Inspection·July 2, 2025

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, the facility failed to ensure the protocols were followed for oxygen administration for four of four sampled residents (Residents 1, 2, 3, and 4). Residents Affected - Few * Residents 2, 3, and 4 were administered with more than the liters per minute ordered by the physician. * Resident 1's MAR failed to show documentation of the administration of the oxygen PRN. These failures had the potential for adverse respiratory outcomes and resulted in inaccurate administration records for the residents. Findings: Review of the facility's P&P titled Oxygen Administration reviewed 2/2023 showed the oxygen shall be administered as ordered by the physician. Review of the facility's P&P titled Guidelines For Medication Administration (undated) showed the medication administration shall be recorded on the appropriate documentation record. 1. Medical record review for Resident 1 was initiated on 6/6/25. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed a physician's order dated 11/30/24, for continuous oxygen to be administered at 2 LPM via nasal cannula or mask. On 6/6/25 at 1348 hours, Resident 2 was observed lying in bed with the supplemental oxygen being administered via nasal cannula. The regulator dial showed 5 LPM was administered to the resident. On 6/6/25 at 1455 hours, an observation and concurrent interview was conducted with LVN 1 at Resident 2's bedside. LVN 1 observed Resident 2's oxygen regulator and verified the resident was currently receiving the oxygen at 5 LPM. On 6/6/25 at 1459 hours, a follow-up interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 reviewed Resident 2's physician's orders and verified the order for the oxygen administration was for 2 LPM. On 6/6/25 at 1502 hours, an interview was conducted with LVN 2. LVN 2 she was Resident 2's nurse (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 3 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 07/02/2025 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)