Health inspection·December 12, 2024

F 0684 - atorvastatin calcium (antilipidemic medication) oral tablet 80 mg, give one tablet one time a day for HLD Level of Harm - Minimal harm or potential for actual harm - escitalopram oxalate (antidepressant medication) tablet 20 mg, give 0.5 mg tablet one time a day for depression Residents Affected - Few - ezetimibe tablet (antilipemic medication) 10 mg, give one tablet by mouth at bedtime for HLD - finasteride tablet (medication to treat enlarged prostate) 5 mg, give one tablet one time a day for BPH - glipizide (anti-diabetic) tablet 10 mg, give one tablet by mouth one time a day for diabetes before meals - losartan potassium (antihypertensive medication)oral tablet 25 mg, give one tablet by mouth one time a day for HTN - protonix tablet (treat high levels of stomach acid) delayed release 40 mg, give one tablet by mouth one time a day for GERD before breakfast - sitagliptin phosphate (anti-diabetic) tablet 50 mg, give one tablet by mouth one time a day for DM - carvedilol (antihypertensive medication) oral tablet 6.26 mg, give 0.5 mg by mouth two times a day for hypertension Review of Resident 2's MAR for November 2024 showed the following medications were coded as 7 (other, see nurses notes). - alfuzosin HCL ER tablet 10 mg one tablet one time a day - aspirin EC tablet delayed release 81 mg one tablet one time a day - atorvastatin calcium oral tablet 80 mg one tablet one time a day - escitalopram oxalate tablet 20 mg 0.5 mg tablet one time a day - ezetimibe tablet 10 mg one tablet at bedtime - finasteride tablet 5 mg one tablet one time a day - glipizide tablet 10 mg one tablet one time a day - losartan potassium oral tablet 25 mg one tablet one time a day - protonix tablet delayed release 40 mg one tablet one time a day - sitagliptin phosphate tablet 50 mg one tablet one time a day (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 2 of 9 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 12/12/2024 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 - carvedilol oral 6.26 mg, give 0.5 mg tablet two times a day Level of Harm - Minimal harm or potential for actual harm Review of Resident 2's eMAR Medication Administration Note for November 2024 showed the following medications were pending delivery: Residents Affected - Few - on 11/26/24 losartan potassium 25 mg pending delivery-new admission - on 11/26/24 protonix delayed release 40 mg pending delivery-new admission - on 11/26/24 sitagliptin phosphate 50 mg tablet pending delivery-new admission - on 11/26/24 glipizide 10 mg tablet pending delivery-new admission - on 11/26/24 escitalopram oxalate 20 mg pending delivery-new admission - on 11/26/24 losartan potassium 25 mg pending delivery-new admission - on 11/26/24 finasteride 5 mg pending delivery-new admission - on 11/26/24 aspirin EC delayed release 81 mg pending delivery-new admission - on 11/26/24 carvedilol 6.25 mg pending delivery-new admission - on 11/26/24 alfuzosin HCl ER 10 mg pending delivery-new admission - on 11/26/24 atorvastatin calcium 80 mg pending delivery-new admission - on 11/27/24 ezetimibe 10 mg awaiting pharmacy delivery - on 11/27/24 carvedilol 6.25 mg pending delivery - on 11/27/24 atorvastatin calcium 80 mg pending delivery - on 11/27/24 alfuzosin HCl ER 10 mg pending delivery - on 11/27/24 protonix delayed release 40 mg pending delivery - on 11/27/24 sitagliptin phosphate 50 mg tablet pending delivery - on 11/27/24 glipizide 10 mg tablet pending delivery - on 11/27/24 finasteride 5 mg pending delivery - on 11/27/24 losartan potassium 25 mg pending delivery - on 11/27/24 escitalopram oxalate 20 mg pending delivery-new admission b. According to the Center for Disease Control and Prevention Managing Blood Sugar dated 5/2024 showed the blood sugar target before a meal range from 80-130 mg/dL and two hours after the start of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 3 of 9 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 12/12/2024 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 meal should be less than 180 mg/dL. Level of Harm - Minimal harm or potential for actual harm According to the Center for Disease Control and Prevention Your Brain and Diabetes dated 7/2024, your brain is your body's command center. To do all its work, your brain uses sugar in your blood for energy. In fact, the brain is the most energy-demanding organ. It needs half of all the sugar energy in the body to function properly. If your blood sugar levels fall outside your normal range, it can throw your command center off balance. In the same way diabetes can damage nerves in other parts of your body, it can damage nerves in your brain. Having frequent episodes of high blood sugar (hyperglycemia) can stress the brain. The effects of high blood sugar happen over time and aren't obvious right away. People often don't know that their brain is being affected. High blood sugar over time damages blood vessels in the brain that carry oxygen-rich blood. When your brain receives too little blood, brain cells can die. This can cause problems with memory and thinking and eventually can lead to vascular dementia. Steps to improve or prevent problems with brain health and diabetes, such as: keep your blood sugars within target levels and to take medicine as prescribed. Residents Affected - Few Review of Resident 2's Care Plan showed the following focus and interventions: - dated 12/2/24, at risk for elevated blood pressure related to HTN. The interventions included to give the antihypertensive medication as ordered, monitor for the medication side effects, and report to MD as necessary. - dated 12/2/24, at risk for hypoglycemia/hyperglycemia r/t diabetes mellitus. The interventions included to administer the diabetes medications as ordered, monitor/document for the side effects and effectiveness, and educate regarding medications and importance of compliance. - dated 12/2/24, resident has the potential for discomfort, complications related to benign prostatic hyperplasia. The interventions include to administer the medications as ordered. - dated 12/2/24, resident on escitalopram for depression. The interventions included to give the antidepressant medications as ordered. Review of Resident 2's Blood Sugar Summary dated on 12/2/24, showed a result of 514 mg/dL. On 12/12/24 at 1425 hours, a concurrent interview and closed medical record review was conducted with the DON. When asked if Resident 2 was on any blood sugar monitoring, the DON stated per the resident's family member, he was not on the blood sugar monitoring at home. The DON stated for the respite care residents, the facility uses the resident's home medications. When asked what the process was when Resident 2 did not receive his medications on 11/26 and 11/27/24 and if the resident'sblood sugar would have been monitored. The DON stated she was not aware Resident 2 did not receive his medications. The DON stated the resident's family member was supposed to bring the medications for the resident. When asked what the process was if the family member did not bring the medications timely, the DON stated, we will order, and notify the resident's physician. When asked what 7 was in the MAR, the DON stated it meant pending delivery. When asked who was responsible for following up for pending medication delivery, the DON stated the charge nurses. When asked if it was documented the physician was notified regarding Resident 2's medications had not been administered due to pending delivery, the DON stated, no not that I can see. When asked if Resident 2's blood sugars levels were being monitored, the DON stated on 12/2/24, Resident 2's blood sugar was checked prior to being sent out to the acute care facility. When asked why Resident 2 was being sent out to the acute care facility, the DON stated Resident 2 was difficult to arouse, and his oxygen saturation was 88%. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 4 of 9 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 12/12/2024 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 Level of Harm - Minimal harm or potential for actual harm what Resident 2's blood sugar result was on 12/2/24, the DON stated 514 mg/DL. When asked if that was a high reading, the DON stated that's pretty high. The DON verified Resident 2's medications were not administered on 11/26 and 11/27/24 due to pending delivery, and the physician was not notified the medications were not administered as ordered due to pending medication delivery. Residents Affected - Few On 12/12/24 at 1638 hours, the DON and the Administrator Assistant acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 5 of 9 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 12/12/2024 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 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 observation, interview, medical record review, facility P&P review, the facility failed to ensure three of nine sampled residents (Residents 3, 4, and 5) remained free from accident hazards. * Resident 3's fall risk care plan showed the interventions including for the resident's bed to be in the lowest position and for the bilateral floor mats. However, the bed was not in the lowest position and the floor mat was folded up against the wall. * Resident 4's fall risk care plan addressing the resident's actual fall showed interventions including to maintain a clear pathway, free of obstacles, needs a safe environment: floor free from spills and/or clutter. However, the bedside table was placed on top of the floor mat next to the resident's bed. * Resident 5's fall risk care plan addressing the resident's actual fall showed interventions including for the resident's bed to be in the lowest position, for bilateral floor mats, and to maintain a clear pathway, free of obstacles, needs a safe environment: floor free from spills and/or clutter. However, the bed was not in the lowest position, and the bedside table was placed on top of the floor mat. These failures had the potential to place the residents at risk for injury. Findings: Review of the facility's P&P titled Fall Management (undated) showed it is policy of this facility to investigate the circumstances surrounding each resident's fall and implement actions to reduce incidences of additional falls and minimize potential for injury. The care plan or an update to an existing care plan will then be generated. Review of the facility's P&P titled Fall Prevention revised 8/2020 showed toidentify the resident who are high risk for fall, and if appropriate, interventions will be initiated per IDT member recommendation and when necessary, physician's orders (i.e., physical therapy services, initiation, or medication of a device etc.) for any fall related incident. 1. Medical record review for Resident 3 was initiated on 12/6/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 6/28/24, showed Resident 3 had the capacity to understand and make decisions. Review of Resident 3's plan of care showed a care plan problem initiated on 7/5/24, addressing risk for further falls. The interventions included floor mats at bedside and bed in lowest position. Review of Resident 3's Fall Risk Evaluation dated 9/24/24, showed Resident 3's score was 14 which was categorized as high risk for falls. On 12/6/24 at 0955 hours, an observation was made of Resident 3's bed and floor mats. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 6 of 9 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 12/12/2024 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 right-side floor mat was observed folded up against the wall and the bed was not in the lowest position. Level of Harm - Minimal harm or potential for actual harm On 12/6/24 at 1003 hours, a concurrent observation and interview was conducted with the DON. The DON verified Resident 3's right-side floor mat was folded up against the wall and stated Resident 3's care plan interventions included for the bilateral floor mats. Residents Affected - Few On 12/6/24 at 1010 hours, a concurrent observation and interview was conducted with the Administrator. The Administrator acknowledged the right-side floor mat was against the wall. When asked if Resident 3's bed was at the lowest position, the Administrator went to check, and the bed went down another inch. 2. Medical record review for Resident 4 was initiated on 12/6/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 11/14/24,showed Resident 4 had no capacity to understand and make decisions. Review of Resident 4's plan of care addressing the resident's actual fall initiated on 11/13/24, showed interventions including to maintain a clear pathway, free of obstacles, needs a safe environment, floors free from spills, and/or clutter. On 12/6/24 at 1629 hours, an observation was made of Resident 4's bedside table that was placed on top floor mat on the left side of the bed, and one end of the floor mat was observed to be flipped up. On 12/6/24 at 1639 hours, a concurrent observation and interview was conducted with RN 1. RN 1 verified Resident 4's bedside table was on top of the floor mat and stated, feels more like a fall risk because she gets up so much. RN 1 stated she observed the floor mat was flipped up, and the table was on top of the floor mat. 3. Medical record review for Resident 5 was initiated on 12/12/24. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's plan of care showed a care plan problem initiated on 10/24/24,addressing the actual fall. The care plan showed interventions including for thebed to be in the lowest position, bilateral floor mats, maintain a clean pathway, needs a safe environment: floor free from spills, and/or clutter. Review of Resident 5's H&P examination dated 10/26/24. Resident 5 had the capacity understand and make decisions. On 12/12/24 at 0834 hours, Resident 5's bed was observed not in the lowest position and on the left side of the bed, the bedside table was observed on top of the floor mat. On 12/12/24 at 0839 hours, a concurrent observation and interview was conducted with CNA 2. Upon entering Resident 5's room, CNA 2 was asked if Resident 5's bed was in the lowest position. CNA 2 moved the bedside table from off the floor mat to reach the remote control for the bed control. When asked if the bed was in the lowest position, the CNA 2 lowered the bed further with the remote control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 7 of 9 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 12/12/2024 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 CNA 2 stated the bed was not in the lowest position, and acknowledged he moved the bedside table that was on top of the floor mat. On 12/12/24 at 1425 hours, an interview was conducted with the DON. When asked if the bedside table should be placed on top of the floor mats, the DON stated, it shouldn't be there. Residents Affected - Few On 12/12/24 at 1638 hours, the DON and the Administrator Assistant acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 8 of 9 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 12/12/2024 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 - Potential for minimal harm Residents Affected - Some 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, medical record review, and the facility's P&P review, the facility failed ensure the accuracy of the MAR for one of nine sampled residents (Resident 2). This failure had the potential for the resident's care needs not being met. Findings: Review of the facility's P&P titled Documentation dated 5/2007 showed the resident's clinical record is concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident's condition. Closed medical record review for Resident 2 was initiated on 12/6/24. Resident 2 was admitted to the facility on [DATE],for respite care and was transferred to theacute care facility on 12/2/24. Review of Resident 2's H&P examination dated 11/26/24, showed Resident 2 had fluctuating capacity to understand and make decisions. Review of Resident 2's Order Summary Report dated 11/25/24, showed to administer carvedilol oral tablet 6.25 mg-give 0.5 mg by mouth two times a day for hypertension and ezetimibe tablet 10 mg-give one tablet by mouth at bedtime for HLD. Review of Resident 2's eMAR Medication Administration Note for November 2024 showed: - on 11/26/24 carvedilol 6.25 mg was documented as pending delivery-new admission - on 11/27/24 carvedilol 6.25 mg was documented as pending delivery - on 11/27/24 ezetimibe 10 mg showed awaiting pharmacy delivery However, review of Resident 2's Medication Administration Record for November 2024 showed the following medications were administered: - on 11/26/24 at 1700 hours, carvedilol 6.25 mg - on 11/26/24 at 2100 hours, ezetimibe 10 mg On 12/12/24 at 1425, a concurrent interview and closed medical review was conducted with the DON. The DON verified Resident 2's medications that were pending delivery were not administered and were error in the documentation as administered. On 12/12/24 at 1638 hours, the DON and the Administrator Assistant acknowledged the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055689 If continuation sheet Page 9 of 9