St Elizabeth Healthcare Center: Call Light Ignored - CA
Resident 1, a woman at St. Elizabeth Healthcare Center on North Harbor Boulevard, pressed her call light at 6:30 a.m. on the morning of September 9, 2025. Two certified nursing assistants, identified in the inspection report as CNA 4 and CNA 5, responded to the room. They turned off the call light and left.
Nobody changed her.
She had last been changed after 5:00 a.m. She lay there for the next hour and fifty minutes, soiled, waiting.
"It was not a good morning," she told inspectors later that day. "I had a bowel movement, I hit the call light at 6:30, and they showed up at 7:20 and changed me." She said she was very upset. "They were supposed to change me before the shift ends — but no one changed me."
The facility's own director of nursing, interviewed by inspectors the same morning, didn't dispute any of it. The director said a reasonable response time for a call light was three to five minutes. She confirmed that Resident 1's call light had not been answered in anything close to that window. She confirmed that CNA 4 and CNA 5 should not have switched off the light and walked out.
"This was not acceptable," the director told inspectors. "CNAs 4 and 5 should have just changed the resident right away."
The inspection was a complaint survey, meaning someone had reported a concern to regulators before inspectors arrived. The deficiency was cited under F0558, which covers residents' rights to have their needs met within a reasonable time. Inspectors rated the level of harm as potential for minimal harm, the lowest tier on the federal scale, and noted that some residents were affected.
That classification reflects a regulatory judgment about the severity of a single documented incident. It does not change what the woman said when inspectors asked how the situation made her feel. She had been very upset. She had been waiting since before the morning shift began. She had pressed the button that was supposed to bring someone, and two people came, saw it was lit, and turned it off.
St. Elizabeth Healthcare Center is a licensed skilled nursing facility operating at 2800 North Harbor Boulevard in Fullerton. The inspection was completed September 9, 2025.
The director of nursing's confirmation was unambiguous. The aides' conduct was not a miscommunication or a documentation gap. Two staff members entered a room, found a call light on, switched it off, and left a resident in soiled bedding. Their supervisor told federal inspectors that was wrong and that they should have acted immediately.
Resident 1 told inspectors it was not a good morning. That was the full weight of her description, and it was enough.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Elizabeth Healthcare Center from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
ST ELIZABETH HEALTHCARE CENTER in FULLERTON, CA was cited for violations during a health inspection on September 9, 2025.
Elizabeth Healthcare Center on North Harbor Boulevard, pressed her call light at 6:30 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.