Health inspection·July 31, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 2's Plan of Care showed a care plan problem initiated on 4/27/24, addressing the resident demonstrated verbally inappropriate behaviors towards the staff related to ineffective coping skills and poor impulse control. The interventions included to document the observed behaviors and attempted interventions. Review of Resident 2's Change in Condition Evaluation dated 7/28/24, showed a CNA witnessed Resident 2 sitting in his wheelchair at the bedside of Resident 1 and his right hand was inserted into Resident 1's briefs and was touching his genital area. Resident 1 was confused and disoriented. Review of Resident 2's Change in Condition Note dated 7/28/24 at 1350 hours, showed after witnessing the incident, CNA 1 called Resident 2's attention to stop and wheeled Resident 2 away from Resident 1. CNA 1 immediately covered Resident 1 with a blanket and immediately reported to the DON. The DON immediately went to the room and found Resident 2 had already wheeled himself close to Resident 1's bed again. The DON called attention of Resident 2's inappropriate behaviors towards Resident 1. Resident 1 was unaware of the situation or unable to account for the incident due to confusion. Resident 2was moved temporarily to the facility'sconference room. Review of Resident 2's Psychological Consult and Progress Note dated 7/29/24, showed Resident 2 reported being cognitively intact and purposeful in his actions. The Progress Note also showed Resident 2's actions were likely due to the need for general sexual gratification and curiosity with fluctuating impulse control. On 7/30/24 at 1237 and 1305 hours, an interview was conducted with Resident 2 in his private room. When asked about his prior roommates (Resident 1), Resident 2 stated Resident 1 takes off his diaper and has exposed his penis, and that's what got me interested. Resident 2 stated he had never had these behaviors in the past. Resident 2 stated,I wanted to look at his penis, and behind me was a nurse and I didn't care .I wheeled over to him, touched his penis with my right hand. Resident 2 stated when the staff saw, he let go and the DON came over. On 7/30/24 at 1356 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she was there on 7/28/24, and left right before 1300 hours. Family member 1 stated she received a call from the Administrator before 1500 hours and was told Resident 1's roommate had touched Resident 1 in the private parts. Family Member 1 stated she visited Resident 1 on 7/29/24, and his hands were folded at his stomach, he was very quiet and staring at the wall. Family member 1 stated Resident 1 seemed very distant and was not as talkative as before. On 7/30/24 at 1406 hours, an interview was conducted with Resident 3 with Family Member 2 who assisted with translation. Resident 3 stated he saw Resident 2 moving and rubbing his hand in massaging motions on Resident 1's stomach and whatever he could reach underneath Resident 1's diaper. On 7/31/24 at 1005 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 2 was verbally inappropriate towards him when he changed him. CNA 3 stated whenever he would change Resident 2, Resident 2 told CNA 3 to wipe his genital area more because it felt good. CNA 3 stated he had reported this and had not been scheduled to work with Resident 2 afterwards. On 7/31/24 at 1108 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 2 had been verbally inappropriate towards him and had asked during brief changes if CNA 1 could clean his genitals again. CNA 1 had reported this to his supervisor in the past. CNA 1 stated on 7/28/24, at 1345 hours, he was walking to get some supplies for another room, peaked into the room, and observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 2 of 3 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 07/31/2024 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 2 touching and shaking Resident 1's penis with his right hand. CNA 1 stated Resident 1 was awake, had a blank facial expression, and was not saying anything. CNA 1 stated he immediately pulled Resident 2's hand out, told Resident 2 that he could not do that, fixed Resident 1's brief, covered Resident 1 with a blanket, pulled Resident 2's chair away, and then reported to the DON. On 7/31/24 at 1351 hours, an interview and concurrent medical record review was conducted with the DON and Administrator. The DON and Administrator verified the above findings. The DON stated Resident 2 has had inappropriate verbal behavior towards the staff. The Administrator stated Resident 2 had not had any inappropriate behavior towards the residents and did not have any indicators that they should be extra cautious with putting Resident 2 in a roommate situation. When asked about the incident, the DON stated CNA 1 reported to her that he saw Resident 2 touching Resident 1 in his genital area. The DON stated she went to the room right away and found Resident 2 close to Resident 1's bed and Resident 2's hand was in his brief. The DON stated she put Resident 2 in the conference room to keep him separated from Resident 1. Review of the facility document titled Allegation of Abuse – Investigation Report dated 8/1/24, showed the facility substantiated the alleged incident of Resident 2 inappropriately touching Resident 1 because there were two eyewitnesses and Resident 2 acknowledged his actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055570 If continuation sheet Page 3 of 3