Health inspection·December 19, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 implement the care plan interventions for two of eleven sampled residents (Residents 2 and 3). * The facility failed to ensure Residents 2 and 3's care plan interventions to monitor the signs and symptoms of hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose) were implemented. These failures posed the risk of the residents not receiving services that were person-centered to meet the specific needs of each resident.Findings: Review of the facility's P&P titled Comprehensive Person-Centered Care Planning revised April 2025 showed it is the policy of this facility that the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. 1. a. Medical record review for Resident 2 was initiated on 11/18/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's care plan for DM dated 6/9/25, showed the following interventions:- monitor/document/report to MD PRN for signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait.- monitor/document/report to MD PRN for signs and symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, and coma. Review of Resident 2's H&P examination dated 11/22/25, showed the resident had DM Type 2 with hyperglycemia. Review of Resident 2's MDS assessment dated [DATE], showed the resident was cognitively intact. Further review of Resident 2's medical record failed to show documented evidence the resident was monitored for the signs and symptoms of hypoglycemia and hyperglycemia. On 12/19/25 at 1303 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 2 was not monitored for the signs and symptoms of hypoglycemia and hyperglycemia. RN 2 stated the licensed nurse should have monitored Resident 2's signs and symptoms of hypoglycemia and hyperglycemia. RN 2 stated Resident 2 had diabetes and high risk of blood sugar fluctuations. On 12/19/25 at 1400 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 2 was not monitored for the signs and symptoms of hypoglycemia and hyperglycemia. The DON stated the licensed nurse should have identified there was no monitoring and should have initiated a way of monitoring Resident 2's signs and symptoms of hypoglycemia and hyperglycemia. b. Closed medical record review for Resident 3 was initiated on 11/18/25. Resident 3 was admitted to the facility on [DATE], and discharged on 11/21/25. Review of Resident 2's care plan for DM dated 10/30/25, showed Page 1 of 2 055570 055570 12/19/2025 St Elizabeth Healthcare Center 2800 N. Harbor Blvd. Fullerton, CA 92835

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the following interventions:- monitor/document/report to MD PRN for signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait.- monitor/document/report to MD PRN for signs and symptoms of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath, stupor and coma. Review of Resident 2's H&P examination dated 10/31/25, showed the resident had DM Type 2 with diabetic chronic kidney disease. Review of Resident 2's MDS assessment dated [DATE], showed the resident was cognitively intact. Further review of Resident 3's medical record failed to show documented evidence the resident was monitored for the signs and symptoms of hypoglycemia and hyperglycemia. On 12/19/25 at 1320 hours, an interview and concurrent closed medical record review was conducted with RN 2. RN 2 verified Resident 3 was not monitored for the signs and symptoms of hypoglycemia and hyperglycemia. RN 2 stated the licensed nurse should have monitored Resident 3 for the signs and symptoms of hypoglycemia and hyperglycemia. RN 2 stated diabetic residents were at high risk for blood sugar fluctuations. On 12/19/25 at 1420 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have notified Resident 3's physician the resident was diabetic with no blood sugar checks. The DON stated the licensed nurse should have monitored Resident 3 for signs and symptoms of hyperglycemia and hypoglycemia at least every shift. 055570 Page 2 of 2