Health inspection·September 9, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of one of eight sampled residents (Resident 1). *The facility failed to ensure Resident 1 was provided with assistance in a timely manner. The failure had the potential to negatively impact the resident's physical and psychosocial well- being and result in delayed provision of care. Findings Review of the facility's P&P titled Call Light revised 5/2007 showed to answer the call light within a reasonable time and turn off the call light once the request/ need is met. Review of Resident 1's medical record was initiated on 9/8/25. Resident 1 was admitted on to the facility on 7/28/25. Review of Resident 1's H&P examination dated 7/29/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's care plan dated 7/29/25, showed a care plan for bowel and bladder incontinence related to impaired mobility, general weakness, and overactive bladder. The care plan intervention included to check the resident as required for incontinence, wash, rinse, and dry perineum, and change clothing as needed after incontinence episodes. Review of Resident 1's MDS assessment dated [DATE], showed the resident had a BIMS score of 15 (meaning cognitively intact). On 9/9/25 at 0707 hours, an observation was conducted of Resident 1's call light. The call light included a visual light and a sound to indicate it was turned on. On 9/9/25 at 0712 hours, during an observation, CNAs 4 and 5 responded to Resident 1's call light. Resident 1 stated she had been waiting for almost an hour to be cleaned after having a bowel movement. CNA 4 told Resident 1 to make sure a complaint ws made, and CNA 4 would inform the nurse. Both CNAs 4 and 5 left the room. On 9/9/25 at 0715 hours, an interview was conducted with LVN 1. LVN 1 stated she was not aware Resident 1 had not been attended to. On 9/9/25 at 0720 hours, during an observation, Resident 1 was changed by her assigned CNA (CNA 1). On 9/9/25 at 0938 hours, an interview was conducted with CNA 1. CNA 1 stated as soon as she came to the nurses' station, she was told Resident 1 needed to be changed and went to change Resident 1 immediately. CNA 1 stated Resident 1 had a bowel movement. On 9/9/25 at 1037 hours, an interview was conducted with CNA 4. CNA 4 verified she answered the call light in room [ROOM NUMBER] and was told by Resident 1 she has been waiting for an hour to be changed after a bowel movement. CNA 4 stated she told Resident 1 they just came into the room and would find out what was going on. CNA 4 verified she walked out of the room. CNA 4 further stated I know I'm supposed to take care of Resident 1 right away; it is not an excuse I was not thinking right. CNA 4 verified she turned off Resident 1's call light and walked out of the room to find Resident 1's assigned CNA instead of changing the resident right away. On 9/9/25 at 1050 hours, an interview was conducted with CNA 5. CNA 5 verified she went inside Resident 1's room with CNA 4 to respond to the call light. CNA 5 verified Resident 1 needed to be changed and had been waiting for a reasonable amount of time. CNA 5 verified they turned off the call light then left the room. CNA 5 stated she did not change the resident because she was not assigned to her but should have changed the resident right away. On 9/9/25 at 1105 hours, Residents Affected - Some (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 5 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 09/09/2025 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)