Inspection visit

Health inspectionDecember 7, 2021

ST. CATHERINE HEALTHCARECMS #05568911 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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 properly obtain the informed consent (permission granted in the knowledge of the possible consequences) from the responsible party/POA (persons designated to make decisions on behalf of the residents) for one of 18 final sampled residents (Resident 22). Residents Affected - Few * A verbal consent for medical treatment and influenza (a contagious respiratory illness caused by flu viruses spread mainly by coughing, sneezing, and close contact) vaccine administration was obtained from Resident 22 who was assessed by the physician as not able to make medical decisions. The facility failed to ensure the consent for medical treatment and influenza vaccination was obtained from Resident 22's responsible party. This failure placed Resident 22 at risk for making health care decisions when she was not able to understand the benefits and reasonable risks of medications or treatment, and reasonable available alternatives based on the resident's medical condition, Findings: Review of the facility's policy titled Advance Directives revised 5/2017 showed it is the policy of the facility that a resident's choice about advance directives will be respected. Medical record review for Resident 22 was initiated on 11/30/21. Resident 22 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 22's H&P examination dated 8/15/21, showed Resident 22 could make needs known but could not make medical decisions. Review of the MDS dated [DATE], showed Resident 22 had moderate cognitive impairment. Review of Resident 22's Advance Directive and Durable Power of Attorney for Health Care dated 12/3/12, showed Resident 22 designated an individual as her POA to make health care decisions on her behalf. Review of the form titled Consent to Treatment-After Hours dated 9/5/21, showed a verbal consent was obtained from Resident 22. The consent showed Resident 22 acknowledged her medical treatment and care from the attending physician. Review of the form titled Influenza Immunization Informed Consent dated 10/6/21, showed a verbal consent was obtained from Resident 22 to receive the influenza vaccine. Resident 22 had given permission to receive the Influenza vaccine. (continued on next page) 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 Page 1 of 17 Event ID: 055689 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0552 Level of Harm - Minimal harm or potential for actual harm On 12/2/21 at 1225 hours, an interview and concurrent medical record review for Resident 22 was conducted with the DON. The DON verified Resident 22 named a friend as POA for her care. The DON stated the person with the POA for care had to be notified about Resident 22's plan of care. The DON stated the physician had assessed Resident 22 as not able to make medical decisions. Resident 22's POA should have been notified to obtain consent for treatment and to receive the influenza vaccine. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 2 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to follow the physician's order for one of 18 final sampled residents (Resident 18). Resident 18 was administered guiafenesin instead of the dextrometorphan guiafenesin ordered by the physician. This failure had the potential for adverse outcomes to the resident. Residents Affected - Few Findings: On 12/2/21 at 0752 hours, a medication administration observation was conducted with LVN 1. LVN 1 was observed administering guaifenesin (a cough medication used to thin secretions) 200 mg to Resident 18. Medical record review for Resident 18 was initiated on 12/2/21. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's physician's orders showed an order dated 11/28/21, to administer Tussin DM Syrup 10-100 mg/5ml dextromethorphan-guaifenesin (a cough suppressant and to thin secretions) 10 ml every 6 hours as needed for cough. On 12/2/21 at 1020 hours, a concurrent observation, interview, and medical record review was conducted with LVN 1. LVN 1 was asked to show the cough medication bottle administered to Resident 18. LVN 1 removed the bottle of Geri-tussin (guaifenesin) from the medication cart and verified it was as the medication bottle used. LVN 1 pulled up Resident 18's electronic Medication Administration Record and compared it with to the medication bottle. LVN 1 stated Resident 18's physician's order was to administer Tussin DM Syrup (dextromethorphan-guaifenesin), and verified only guaifenesin was administered to the resident. LVN 1 stated the dextromethorphan-guaifenesin medication was not in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 3 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 provide the necessary care and services for the GT feeding of one of 18 final sampled residents (Residents 21). * The facility failed to ensure Resident 21 received the accurate amount of enteral feeding as ordered by the physician. This failure had the potential for not meeting the resident's nutritional needs Findings: Review of the facility's P&P titled Enteral Formulas, Administration of Closed System revised 2/2021 showed it is the policy of the facility that all residents requiring tube feedings will be set up on continuous feeding pumps, after appropriate diagnoses have been obtained for justification of pump, administering adequate tube feeding formula according to established criteria outcomes, utilizing closed system products when applicable. The policy provides a means to safely administer a complete nutritional feeding to the resident using a premixed formula in a closed container system protecting formula from exposure to harmful contaminants. Medical record review for Resident 21 was initiated on 11/30/21. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed a physician's order dated 8/25/21, to administer Glucerna 1.5 via GT/EP/Pump kit at 70 ml/hr to provide 1400 ml/2100 kcal over 20 hours or until volume limit completed, restart at 1400 hours. On 12/7/21 at 0840 hours, Resident 21 was observed with an empty bottle of enteral feeding labeled Glucerna 1.5. Resident 21's Glucerna 1.5 feeding bottle label showed a full bottle contained 1.5 L (1500 ml) with a date written as 12/6/21, start time of 1615 hours, and rate of 70 ml/hr. This meant Resident 21 received 1500 ml from 1615 hours on 12/6/21 to 0840 hours on 12/7/21 (a total of 16 hours and 25 minutes) instead of 1400 ml for 20 hours as ordered. On 12/7/21 at 0848 hours, a concurrent observation and interview was conducted with LVN 6. LVN 6 verified the feeding bottle was empty. LVN 6 verified Resident 21's full bottle of Glucerna 1.5 was started on 12/6/21 at 1615 hours at a rate of 70 ml/hr, for a duration of 17 hours. LVN 6 verified Resident 21 should have only have received 1190 ml of the enteral feeding. LVN 6 stated Resident 21's enteral feeding should have 310 ml remaining in the bottle. On 12/7/21 at 0910 hours, a concurrent observation and interview was conducted with the DON and LVN 6. The DON verified Resident 21's enteral feeding bottle of Glucerna 1.5 was already empty. The DON verified Resident 21 should only have received 1190 ml of feeding for the past 17 hours. The DON acknowledged there should have been about 310 ml of enteral feeding left for the remaining three hours. When asked what could potentially happen with the inaccurate administration of feeding, LVN 6 stated Resident 21 may not receive the correct amount of nutrients as prescribed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 4 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **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 provide the necessary respiratory care and services to one nonsampled resident (Resident 36). Residents Affected - Few * Resident 36 was administered oxygen without a physician's order. In addition, Resident 36's oxygen tubing touching the floor. These failures had the potential to put Resident 36 at risk for negative health outcomes and adverse effects of the improper care and administration of oxygen. Findings: According to the facility's P&P title Oxygen Administration revised date 1/2016 showed it is the policy of this facility that oxygen therapy is administered as ordered by the physician. On 11/30/21 at 1117 hours, and 12/1/21 at 0755 hours, Resident 36 was observed being awake in bed and receiving oxygen via nasal cannula (a small, flexible tube that contains two open prongs for oxygen delivery intended to sit just inside the nostril) at two liters per minute. Resident 36's oxygen tubing was observed touching the floor. Resident 36 stated she had been oxygen therapy at two liters per minute. On 12/1/21 at 0755 hours, an observation and concurrent interview was conducted with the IP. The IP verified Resident 36's oxygen cannula tubing was touching the floor. The IP stated it should not be on the floor for infection control reasons. On 12/2/21 at 0735 hours, Resident 36 was observed in bed receiving oxygen via nasal cannula at two liters per minute. Medical record review for Resident 36 was initiated on 12/3/21. Resident 36 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 36 moderate cognitive impairment. Resident 36 needed extensive assistance with her ADL care. Resident 36 was not on oxygen therapy. Review of the Order Summary Report dated 11/5/21, showed a physician's order to administer oxygen at two liters per minute and monitor oxygen saturation level every shift and as needed for Resident 36. Review of the physician's order in the electronic medical record showed an order dated 11/19/21, to discontinue Resident 36's oxygen therapy and oxygen saturation level monitoring. Review of Resident 36's Medication Administration Record dated 12/1/21 to 12/31/21, did not show an order to provide oxygen therapy and monitor oxygen level saturation. Review of the plan of care showed a care plan problem was initiated on 8/25/21, addressing Resident 36's hypoxia (condition where the tissues are not oxygenated adequately) and hypercapnia (too much carbon dioxide (CO2) in the blood), with a goal to to display optimal breathing pattern. Interventions were to continue oxygen as ordered by the physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 5 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 12/7/21 at 0924 hours, an interview and concurrent medical review was conducted with LVN 5. LVN 5 verified Resident 36 was on oxygen therapy. When asked if Resident 36's physician had ordered to administer oxygen for Resident 36, LVN 5 verified there was no current order. LVN 5 stated there should be an order obtained from the physician prior to administering oxygen. On 12/7/21 at 1001 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. Event ID: Facility ID: 055689 If continuation sheet Page 6 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the appropriate pain management for one of 18 final sampled residents (Resident 280). Residents Affected - Few * The facility failed to ensure Resident 280's pain was addressed when she reported a pain level of 7 (severe pain) on a pain scale of 0-10 (with 0=no pain and 10=worst pain). Resident 280 had reported severe pain with a pain level of 7 multiple times but was only provided a pain medication prescribed by the physician for moderate pain (pain level of 4-6). This failure had the potential to affect the resident's well-being and unnecessary pain. Findings: Medical record review for Resident 280 was initiated on 11/30/21. Resident 280 was admitted to the facility on [DATE]. Review of Resident 280's H&P examination dated 11/23/21, showed Resident 280 had sustained an ankle fracture with pending surgical intervention. Review of Resident 280's Order Summary Report dated 12/7/21, showed the following pain management orders: - Monitor pain level every shift using the following pain scale: 0 for no pain, 1-3 for mild pain, 4-6 for moderate pain, and 7-10 for severe pain, ordered on 11/22/21. - acetaminophen (an over-the-counter pain medication) 650 mg every 4 hours as needed for mild pain, ordered 11/22/21. - hydrocodone-acetaminophen (an opioid pain medication) 5-325 mg every 6 hours as needed for moderate pain, ordered on 11/22/21. There were no orders to treat severe pain. Review of the Medication Administration Record for November 2021 showed Resident 280 was administered hydrocodone-acetaminophen for a pain level of 7 (severe pain) on 11/26/21 at 2331 hours, and 11/30/21 at 1832 hours. Review of the Medication Administration Record for December 2021 showed Resident 280 was administered hydrocodone-acetaminophen for a pain level of 7 (severe pain) on 12/1/21 at 1630 hours, and 12/3/21 at 0715 and 2030 hours. However, the hydrocodone-acetaminophen medication was ordered for moderate pain, a pain scale of 4-6. On 12/7/21 at 1034 hours, an interview and concurrent medical record review were conducted with LVN 2. LVN 2 stated moderate pain was for pain levels of 4-6 and severe pain was for levels of 7 and higher on the 0-10 pain scale. LVN 2 verified Resident 280 had reported pain levels of 7 and was administered one tablet of hydrocodone acetaminophen 5-325 mg which was prescribed for moderate pain on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 7 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0697 five different occasions. LVN 2 stated the physician should have been notified to obtain the orders to address Resident 280's severe pain. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 8 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and medical record review, the facility failed to ensure the assessment for entrapment, alternative for the use of side rails and the care plan was completed for one of 18 final sampled residents (Resident 59). * Resident 59 was observed with bilateral side rails. The facility failed to ensure the entrapment assessment, physician's order, and care plan problem were initiated prior to its use. Failure to establish a comprehensive approach for the use of bed rails posed a potential risk for residents including entrapment and/or injury due to lack of proper installation and preventive maintenance, and not meeting resident needs by informing them of risk and benefits. Findings: According to FDA.gov, Bed Rail Safety dated 8/30/18, deaths and serious injuries related to side rail entrapment have occurred with the use of side rails. Review of the facility's P&P titled Guidance: Bed Rails dated 1/2021 showed the facility would assess the resident for the use of bed side rails, grab bars as needed and with a change of condition that may warrant the use of bed rails or grab bars. Bed rail use for treatment of a medical symptom or condition should be accompanied by a care plan (treatment program) designed for that symptom or condition. Bed rail use for patient's mobility and/ or transferring, for example turning and positioning within the bed and providing a handhold for getting into or out of bed, should be accompanied by a care plan. Reassess the patient's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. On 11/30/21 at 1540 hours, and 12/6/21 at 1341 hours, Resident 59 was observed lying on his bed with bilateral side rails elevated. On 12/7/21 at 1009 hours, a concurrent observation and interview was conducted with Resident 59. Resident 59 was observed lying on his bed with bilateral side rails elevated. Resident 59 stated was not able to use the side rails. Review of Resident 59's medical record was initiated on 11/30/21. Resident 59 was admitted in the facility on 9/17/21, with a diagnosis of physical debilitation (a gradual sinking and wasting away of mind or body). Review of the History and Physical Examination dated 9/17/21, showed Resident 59 had the capacity to understand and make decisions. Review of Resident 59's Order Summary Report dated 12/6/21, showed no documented evidence of physician's order for the use of side rails. Review of the Resident 59's care plan did not show a care plan problem addressing the use of grab bars. Review of the Restraint/ Enabling Device/ Safety Device Evaluation dated 12/7/21, showed no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 9 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0700 documented evidence Resident 59 was assessed for entrapment for the bilateral side rails use. Level of Harm - Minimal harm or potential for actual harm On 12/7/21 at 1021 hours, an interview was conducted with the DON. The DON acknowledged Resident 59 was not assessed for the risk for entrapment. Residents Affected - Few On 12/7/21 at 1206 hours, an interview was conducted with LVN 1. LVN 1 verified there was no physician's order for the use of bilateral side rails and stated it was missed. On 12/7/21 at 1212 hours, an interview was conducted with the MDS Coordinator. The MDS Coordinator acknowledged a care plan was not initiated for the use of bilateral side rails and an assessment for entrapment for bilateral grab bars was not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 10 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. Residents Affected - Some * The facility failed to ensure the measuring buckets used for food portioning were air dried prior to storing. * The facility failed to ensure the kitchen utensils were clean, free of food particles, and not worn out. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the form CMS-672 Resident Census and Conditions of Residents completed by the facility dated 11/30/21, showed 69 of 77 residents residing in the facility received food prepared in the kitchen. 1. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. On 12/2/21 at 1301 hours, during a tray line observation, three measuring container buckets were observed stacked on top of each other and two measuring buckets were observed being wet. The DSS verified the finding and stated the measuring buckets were used for food portioning. 2. According to the USDA Food Code 2017, 4-601.11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils, the food- contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 12/2/21 at 1028 hours, an observation and concurrent interview was conducted with the RD. One metal spatula with dry food particles was observed being stored inside a plastic bin for ready to use clean utensils. The RD verified the findings. 3. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 12/2/21 at 1028 hours, an observation and concurrent interview was conducted with the RD. One worn out basting brush with the bristles coming off was observed inside a plastic bin for clean utensils. The RD verified the finding. The RD stated these should have been discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 11 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in one of three garbage dumpster. The lid of the one garbage dumpster was left partially open. This failure had the potential to harbor pests or rodents which carry diseases. Residents Affected - Some Findings: According to the US Food Code 2013, 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. On 12/2/21 at 0935 hours, an observation and concurrent interview was conducted with the Maintenance Director. One dumpster located adjacent to the kitchen was observed with the lid partially propped open. A garbage bag filled with used boxes was observed sticking out of the dumpster, preventing the garbage lid from closing completely. The Maintenance Director verified the findings. The Maintenance Director stated the lids had to be fully closed to prevent flies, rats, and other animals from getting to it and to prevent contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 12 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 59's) medical record was complete. * Resident 59's medical record did not include the physician's progress notes. This failure had the potential for the physician's plan of care for the resident to not be effectively communicated to the interdisciplinary team. Findings: Medical record review for Resident 59 was initiated on 11/30/21. Resident 59 was admitted to the facility on [DATE]. Review of Resident 59's medical record failed to include Resident 59's physician's progress notes. On 12/7/21 at 1459 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the physician documented Resident 59's progress on the paper records. The DON verified the progress notes were not found in Resident 59's medical records. On 12/7/21 at 1537 hours, an interview was conducted with the Medical Records Director. The Medical Records Director was not able to locate any physician progress notes for Resident 59. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 13 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 2. Review of the facility's P&P titled Laundry Personnel revised 5/2007 showed no eating, drinking, or smoking except in designated areas. Residents Affected - Some On 12/1/21 at 1445 hours, a laundry area inspection was conducted with the Maintenance Director. A water bottle and two used faceshields were observed on the table in the laundry clean area where the clean linens were stored. The Maintenance Director verified the findings. Based on observation, interview, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections during a COVID-19 facility outbreak. * The facility failed to follow timely reporting of a COVID-19 outbreak to local and state health agencies. * The facility failed to follow the infection control practices in the clean linen area. These failures had the potential to delay response time and containment of a COVID-19 outbreak. Findings: 1. Review of the County of Orange Health Care Agency - Public Health Services' document for Reportable Disease Conditions revised March 2020, showed to report COVID-19 immediately by telephone. The document showed the contact numbers for reporting, including a number for reporting on holidays, weekends, and after hours. Review of the facility's P&P titled Surveillance of Infections and Reporting revised September 2017 showed any resident or staff with suspected or diagnosed as having a reportable communicable/infectious disease shall be promptly reported to the appropriate local and/or state health department officials. On 12/2/21 at 0956 hours, an interview was conducted with the IP. The IP stated the following: - On the evening of 11/25/21, an acute care hospital staff notified the facility that a resident who was transferred from the facility on 11/24/21, tested positive for COVID-19. - On 11/25/21, the facility initiated the COVID-19 response-driven testing of residents and staff. - On 11/28/21, the test results from the 11/25/21 testing showed one resident and three staff members were tested positive for COVID-19. The resident was transferred to a nursing facility with a COVID-19 unit. - On 11/29/21 at 0830 hours, the IP attempted to notify their local health department contact and did not receive a response. - On 11/29/21 at around 1900 hours, the IP electronically notified the CDPH of a failure to report the four positive COVID-19 cases on the COVID-19 dashboard (a dashboard for daily facility reporting of COVID-19). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 14 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - On 11/30/21 at 0930 hours, the IP was able to get in contact with their local health department contact. The IP stated they did not call the outbreak reporting line or email to notify the local health department. - On 12/2/21, a positive COVID-19 test result for another resident was received. The resident was transferred to a nursing facility with a COVID-19 unit. The local health department instructed the facility to consider all residents as potentially exposed to COVID-19 and placed the residents in quarantine with appropriate COVID-19 PPE. The facility was instructed to close for new admissions and encourage outside visits (between residents and visitors). - On the morning of 12/3/21, three residents and one staff member were tested positive for COVID-19, from the response-driven testing completed on 12/2/21. Approximately half of the test results were still pending. The facility opened a COVID-19 Unit. On 12/3/21 at 1303 hours, the Administrator stated the remaining COVID-19 test results were received showing a total of 11 residents and three staff members tested positive for COVID-19. The facility was in the process of relocating their COVID-19 Unit to a more appropriate location in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 15 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document review, and facility P&P review, the facility failed to accurately and timely identify and report CAI and HAI cases. This failure had the potential of not accurately identifying infections and timely notification to the health care provider resulted in inaccurate data being reviewed by the Infection Control Committee. Residents Affected - Some Findings: According to the CDC, repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. Review of the facility's P&P titled Infection Control and Control Program revised September 2017 showed the following: * Ongoing monitoring for infections with subsequent documentation of infections. Surveillance tools are used to recognize the occurrence of infections, record their number and frequency, and monitor outbreaks. * Reports of infections are presented to the Infection Control Committee, and data is used to inform the committee of potential issues and trends. * The Infection Preventionist will review and report findings to facility staff and the Quality Assurance Committee. Review of the facility's P&P titled Infection Control and Control Program - Antibiotic Stewardship revised September 2017 showed the Infection Control Program will promote appropriate use of antibiotics and to limit antibiotic resistance while mproving treatment efficacy and resident safety. Review of the facility's P&P titled Surveillance and Reporting revised September 2017 showed the Infection Preventionst will review the surveillance log during their morning routine to ensure all potential or actual infections are being identified. 1. On 12/3/21 1002 hours, an interview, facility document review, and concurrent medical record review was conducted with the IP. The IP stated her process for antibiotic stewardship was the following: * Trying to run a report on the electronic health record (EHR) every Friday for new antibiotic orders. * Entering the resident data and antibiotic information on the Infection Prevention and Control Surveillance Log. * Conducting a more detailed review to determine if criteria is met for infection using the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 16 of 17 Printed: 05/15/2026 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 055689 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/07/2021 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 0881 Surveillance Data Collection Form or the Infection Surveillance form in the EHR. Level of Harm - Minimal harm or potential for actual harm The IP further stated the CAI was an infection which the resident had an antibiotic order for at the hospital prior to being admitted to the facility. Residents Affected - Some When asked how weekly monitoring of antibiotic affected timely antibiotic review, for example, if an order was written on Saturday and the antibiotic order report was reviewed every Friday, the Infection Preventionist verified it would result in a delay of antibiotic review. 1. On 12/3/21 at 1002 hours, an interview and concurrent medical record review was conducted with the IP. a. Review of the Surveillance Data Collection forms located in the IP's binder showed Resident 63 started antibiotics on 11/13/21, for a UTI (urinary tract infection). The form showed the resident was admitted to the facility on [DATE], and the infection was classified as a CAI. When asked why Resident 63's infection was classified as CAI, the IP stated they classified it incorrectly. b. Review of the Surveillance Data Collection forms located in the IP's binder showed Resident 31 started antibiotics on 11/3/21, for an abnormal UA (urine analysis). The form showed the resident was admitted to the facility on [DATE], and the infection was classified as a CAI. When asked why Resident 63's infection was classified as CAI, the IP stated they classified it incorrectly. 2. Review of the Monthly Infection Surveillance Report for October 2021 showed seven HAIs with infection rate of 2.73%, and 11 CAI with an infection rate of 4.3% were reported to the infection control committee. On 12/3/21 at 1002 hours, an interview and concurrent facility document review was conducted with the IP. When asked to clarify why the IP misidentified HAI and CAI infections for the above residents (Residents 31 and 63), the IP stated when completing the surveillance data, she thought HAI meant the resident transferred from the hospital with an antibiotic order and CAI referred to a new infection acquired while at the facility. The IP stated she was recently told otherwise and had not corrected the data. The IP stated the October's data presented at the infection control committee meeting in November 2021 was based on the inaccurate HAI and CAI reporting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 17 of 17

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Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0814GeneralS&S Bno actual harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Epotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0552GeneralS&S Dpotential for harm
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.

FAQ · About this visit

Common questions about this visit

What happened during the December 7, 2021 survey of ST. CATHERINE HEALTHCARE?

This was a inspection survey of ST. CATHERINE HEALTHCARE on December 7, 2021. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at ST. CATHERINE HEALTHCARE on December 7, 2021?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 7, 2021