Health inspection·January 31, 2024

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to notify the resident's representative regarding the change of condition for one of two sampled residents (Resident 1). This failure posed the risk of violating Resident 1's rights. Findings: Review of the facility's P&P titled Significant Change of Condition, Response dated 12/2023 showed the resident's representative will be notified of the change of condition and any changes in the resident's medical or nursing care. Medical record review for Resident 1 was initiated on 1/29/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical Examination dated 1/3/24, showed Resident 1 did not have the capacity to understand and make medical decisions. Review of Resident 1's eInteract Change in Condition Evaluation dated 1/20/24, showed the resident was noted to have pulled out his indwelling urinary catheter with moderate clotted blood noted in the diaper. The name of family or health care agent notified section showed the resident representative's name and a note showing to endorse to notify in the morning. Review of Resident 1's progress notes of a change of condition notes dated 1/21/24 at 1130 hours, showed while doing the nursing rounds at around 1100 hours, the resident was noted with his catheter in his hand. Upon the assessment, the resident had pulled out his indwelling urinary catheter with slight bleeding noted around the urethral opening. On 1/29/24 at 1115 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 was asked when the family should be notified about the change of condition. RN 1 stated they should be notified immediately, and it should be documented. If they were not able to reach the family, they should endorse and document it. On 1/29/24 at 1330 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 was asked if he had notified the family regarding Resident 1 pulling out the indwelling urinary catheter on 1/21/24. LVN 3 stated he did not notify the resident's family right away but spoke with them when they came to the facility. LVN 3 also stated the family was upset because they were not notified about the resident pulling out the catheter on the previous day. LVN 3 was asked if he (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055570 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055570 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)