St Elizabeth Healthcare Center
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 REDACTED], 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.
Event ID:
Facility ID:
If continuation sheet
ST ELIZABETH HEALTHCARE CENTER in FULLERTON, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FULLERTON, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ST ELIZABETH HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.