St. Catherine Healthcare

F 0552

Ensure that residents are fully informed and understand their health status, care and treatments.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven final sampled residents (Resident 1) was informed of the indication for the use of medications affecting brain activities associated with mental processes and behavior. * The facility failed to ensure Resident 1's informed consent was obtained when the indication for the use of Ativan (lorazepam, a benzodiazepine class of medication used to treat anxiety) was changed in frequency in administration from every six hours to every eight hours. * The facility failed to ensure Resident 1's informed consent was obtained for the use of Depakote (an anticonvulsant medication for labile mood). These failures had the potential for Resident 1 not to be informed of the medications and potential side effects of the use of Ativan and Depakote medications.Findings: Review of the facility's P&P titled Psychotropic (medication affecting brain activities associated with mental processes and behavior) Drug Use revised 1/2023 showed upon initiation of a new order for psychoactive medications, the Licensed Nurses shall complete the Verification of Informed Consent form prior to the initiation of the new medication. Closed medical record review for Resident 1 was initiated on 9/2/25. Resident 1 was admitted to the facility on [DATE REDACTED]. 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.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Catherine Healthcare

245 E Wilshire Avenue Fullerton, CA 92832

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)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Residents 1) was free from unnecessary psychotropic (medication affecting brain activities associated with mental processes and behavior) medications. * The facility failed to ensure Resident 1 was adequately monitored for the Depakote medication. This failure posed risk for Resident 1 to cause potential harm from adverse consequences and a significant decline in functioning. Findings: Review of the facility's P&P titled Psychotropic Drug Use revised 1/2023 showed it is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure: a.

Psychotropic medication was prescribed to treat a specific diagnosed condition, asdocumented in the clinical record;b. Not in excessive dosage;c. Behavior is not related to Delirium or other reversible conditions;d. Monitoring for adverse consequences and effectiveness of medications are in place;e. PRN medications are within guidelines;f. Informed consent was obtained prior to medication use;g. Review of plan of care shows individualized, person-centered care approaches tomanage behavior with non-pharmacological interventions;h. Attempt/consider a GDR (Gradual Dose Reduction), if appropriate, with consent ofphysician/psychiatrist. Closed medical record review for Resident 1 was initiated on 9/2/25.

Resident 1 was admitted to the facility on [DATE REDACTED]. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Catherine Healthcare

245 E Wilshire Avenue Fullerton, CA 92832

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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 5) reviewed for falls received the necessary care and services for the resident at risk for fall. * The facility failed to monitor and initiate a care plan when Resident 5 reported a fall on 9/1/25. This failure had the potential for the delay in providing the necessary care and services and posed a risk for Resident 5 to sustain serious injury.Findings: Review of the facility's P&P titled Psychotropic Drug Use not dated showed it is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. If the resident sustains a fall, a Risk Management Assessment is completed to determine the cause of the fall, and an IDT meeting is also completed to identify internal and external factors that might have contributed to the fall. The care plan or

an update to an existing care plan will then be generated. The Licensed Nurse will complete the documentation as follows:1. Briefly describe the fall2. Identify medications, environmental conditions, equipment involved, contributingmedical factor, and any other factors that may be related to the fall3.

Identify fall patterns such as, time of day, location, and activity at time of fall, otherresident involvement that may have contributed to the fall4. Complete the conclusion section of the form and make a determination if possible as tothe cause of the fall5. Identify an action plan or approaches to be taken in an attempt to prevent further fallsbased on newly identified facts or risk factors6. If there is an existing plan of care in the resident's medical record pertaining to falls itshould be updated to reflect newly identified risk factors and approaches7. If there is no existing care plan entry pertaining to falls, a new entry must be developedSignificant information obtained as a result of the IDT should be reported to the physician andfamily and documented in the Medical Records. Medical record review for Resident 5 was initiated on 9/10/25. Resident 1 was admitted to the facility on [DATE REDACTED]. 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 REDACTED], 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.

Event ID:

Facility ID:

If continuation sheet