St. Catherine Healthcare
ST. CATHERINE HEALTHCARE in FULLERTON, CA — inspection on September 16, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 1's Facility Verification of Informed Consent form dated 8/9/25, showed Ativan 1 mg orally every eight hours as needed anxiety signed by the physician on 8/10/25.
Review of Resident 1's H&P examination dated 8/10/25, showed the resident had no capacity to understand and make decisions.
Review of Resident 1's Order Summary Report dated 8/20/25, showed the following orders: - dated 8/14/25, lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax for 14 days, and - dated 8/13/25, Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood.
Review of Resident 1's MAR for August 2025 showed Resident 1 had received the following medications on the following dates/times: - Depakote 250 mg delayed release tablet by mouth two times a day since 8/14/25, and - lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax since 8/14/25. On 9/2/25 at 1120 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON.
The DON verified the Resident 1's Facility Verification of Informed Consent form dated 8/9/25 showed Ativan (lorazepam) 1 mg orally every eight hours as needed anxiety.
The DON additionally verified Resident 1's medical record failed to show an informed consent was obtained for the use of the Depakote 250 mg medication.
The DON stated the informed consent should have been obtained upon the change in the physician's order to indicate the lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax and for use of the Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Catherine Healthcare
245 E Wilshire Avenue Fullerton, CA 92832
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident 1's H&P examination dated 8/10/25, showed the resident had no capacity to understand and make decisions.
Review of Resident 1's Order Summary Report dated 8/20/25, showed the following orders: - dated 8/14/25, for lorazepam 1 mg tablet by mouth every six hours as needed for anxiety manifested by inability to relax for 14 days, and - dated 8/13/25, for Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood.
Further review of Resident 1's medical record failed to show documented evidence Resident 1 was adequately monitored for the use of Depakote. On 9/2/25 at 1120 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON.
The DON stated the residents taking psychotropic medications were monitored for adverse consequences and behavior manifestation for use of the medication.
The DON verified Resident 1 was prescribed with Depakote 250 mg delayed release tablet by mouth to administer two times a day for mood disorder manifested labile mood.
The DON verified the resident's medical records failed to show the resident was monitored for the behavior labile mood and for adverse reactions for use of the Depakote medication.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Catherine Healthcare
245 E Wilshire Avenue Fullerton, CA 92832
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident 5's H&P examination dated 9/1/25, showed the resident had no capacity to understand and make decisions.
Review of Resident 5's Nursing Notes dated 9/1/25 at 1227 hours, showed Resident 5 was observed with a bandage to his right hand.
The resident claimed had a fall the night before on 8/31/25.
Review of Resident 5's MDS assessment dated [DATE], showed resident had a BIMS score of 14, indicating the resident was cognitively intact.
Review of Resident 5's eInteract SBAR Summary for Providers dated 9/7/25 at 0930 hours, showed the resident had a fall outside in front of the facility.
Further review of the resident's medical record failed to show the following: follow up care or monitoring for the resident, a care plan or an update to an existing care plan, and an IDT meeting to identify internal and external factors that might have contributed to the fall after the resident's fall on 9/1/25. On 9/10/25 at 1515 hours, an observation and concurrent interview was conducted with Resident 5. Resident 5 stated he fell the night before he went to the acute care hospital and sustained a scab on the left knee. Resident 5 showed the scab on his left knee. On 9/11/25 at 1053 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 verified Resident 5 reported he fell the night before on 9/1/25. RN 1 stated she did not complete a change of condition to monitor the resident. RN 1 verified a care plan for the fall was not updated, a Fall Risk Assessment and an IDT meeting was not completed. On 9/11/25 at 1245 hours, an interview was conducted with the DON.
The DON stated she expected the licensed nurses to monitor the resident, update the resident's care plan, a fall Risk Assessment and an IDT meeting should be completed after each episode of a fall.
The DON was informed and acknowledged the findings.
Facility ID: