Health inspection·September 16, 2025

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]. 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 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 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)