Health inspection·January 25, 2024

F 0583 to the increase in scammers and for others to know and have access about who took controlled medication. Level of Harm - Minimal harm or potential for actual harm Interview on 01/25/24 at 1:12 pm, the HIM Director stated the facility did not have any issues with the staff leaving their computers unlocked which displayed the resident's information. She stated her expectations for this facility was to be 100% HIPAA compliant and added when the staff walked away from their computers, they were supposed to log off the program and log out of the actual computer. She stated not being HIPAA compliant could affect the residents if the wrong person saw the resident's information which was a breach of their privacy and took their social security, address, shared their diagnoses to family friends' staff. She stated if a HIPAA violation was to happen the staff should get written up and addressed about the non-compliance. She added the Nurse Managers were responsible for ensuring the computer screens were locked to secure the resident's privacy. She stated she was not aware of MA C leaving her medication cart computer unlocked. Residents Affected - Few Interview on 01/25/24 at 1:28 pm, the DON stated HIPAA was the protection of the resident chart information and added there were no issues with the staff leaving the computers unlocked and disclosing resident information. He stated HIPAA trainings were done upon hire and annually and stated HIPAA violations could be used against the resident and allow people to get information about the residents they wanted private. He stated his expectations for HIPAA compliance was for the staff to always press the button for the screen saver before walking away. He stated he was not aware MA C left her medication cart computer unlocked today and would go talk to her about the matter. Record review of the facility's Resident Rights Policy last revised 07/2018 revealed, Policy Statement: It is the policy of [Facility] to promote and protect the rights of resident residing in our ministry .Policy interpretation: 1. Resident Rights are explained to the resident (or responsible party) at the time of move in. A copy is given to him/her, and an acknowledgement of receipt is signed by him/her. A. State specific residents' rights are provided, per state requirements .have community information about you maintained as confidential Record review of the facility's HIPAA policy revision date: June 1, 2023, revealed, Subject: [Facility] is committed to protecting the privacy rights of our patients and residents (Individuals). In compliance with the (HIPAA) Act of 1996, the health information technology for economic and clinical health act (HITECH) .procedure sets forth the HIPAA Privacy Program policies, procedures, and standards .General policy: [Facility] shall implement policy and procedures, and standards that are reasonably designed to ensure compliance with HIPAA rules . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 2 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning for one (Resident #111) of six residents reviewed for PASRR assessments. The facility failed to provide a specialized Customized Wheelchair to Resident #111, after her 11/22/23 IDT meeting, when a request for a CWC was made but the NFSS form was not submitted until 01/16/24. And as of 01/25/24 Resident #111 had not received her Customized wheelchair. SW E failed to notify MDS Coordinator Director H about Resident #111's need for a Specialized Customized Wheelchair. These failures could place PASRR positive residents at risk of not getting medical equipment they were eligible to receive which could cause a decline in their health, resulting in a loss of mobility, falls and decrease in their psycho-social well-being and quality of life. Findings included: Record review of Resident #111's MDS assessment dated [DATE] revealed a [AGE] year-old female who admitted [DATE] with a BIMS score 04 (Severe cognitive impaired). The resident was coded as using a wheelchair. with no psychosis, no upper and lower extremity Impairment, independent and partial/moderate assist with ADL care. And independent and partial/moderate assist with wheelchair mobility. She was frequently incontinent of bladder and diagnoses of anemia (low iron), heart failure, renal insufficiency (kidney failure), hyperkalemia (high potassium level), depression (sadness) .Down Syndrome (developmental delay) .Major Depressive Disorder (persistent sadness) . Record review of Resident #111's Physician Orders dated 01/25/24 revealed orders for, Administer Medication and assist with ADLS at needed, Anti-depressant Behavior monitoring .anti-depressant side effect monitoring, Nortriptyline 50 mg every PM evening for depression . Record review of Resident #111's Care Plan with date start date 04/01/22 and revised 08/10/23 read, Provide habilitation coordination with HC, will hold quarterly SPT meetings at the nursing facility to review/monitor all PASRR services . Record review of Resident #111's PASARR level 1 form dated 03/23/22 revealed yes for Section C: Mental illness, Intellectual disability, and Developmental disability and date of entry 04/01/22 . Record review of Resident #111's PASARR Evaluation dated 05/02/22 revealed she was eligible and coded yes for Intellectual disability, developmental disability and intervention by law enforcement, protective services, or other housing officials in the last two years .recommended services: Habilitation Coordination .Specialized Occupational therapy, specialized physical therapy and Durable Medical Equipment .with mood disorder, sleep disturbance . Record review of Resident #111's Quarterly PASRR Comprehensive Service Plan Form dated 11/22/23 by HC revealed PASRR Evaluation: pending for a Customized Manual Wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 3 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #111's Simple LTC PASRR Nursing Facility Specialized Services (NFSS) form revealed it was submitted 01/16/24 for a Customized Manual Wheelchair and 01/22/24 TMHP: A free form manual alert was created and submitted by HHSC. Check the LTC PASSAR Portal alerts page for details, Record review of Resident #111's Texas Medicaid Healthcare Partnership Form Activity revealed, On 12/17/2023 and 12/29/23: Conduct PASRR Evaluation - First Notification .An individual exhibiting signs of MI and/or IDD requires a PASRR Evaluation. A PASRR Evaluation must be successfully submitted on the TMHP LTC Online Portal within 7 calendar days of this notification . Record review of Resident #111's Texas Medicaid Healthcare Partnership Form Activity revealed, On 01/17/2024: Confirm IDT .The NF has submitted a New or Updated IDT meeting on the LTC Online Portal for an individual for which your LA - IDD/LA - MI is responsible. Please check the IDT Meeting information on the PCSP form for accuracy and confirm . Record review of Resident #111's Physical Therapy Plan of Care dated 11/27/23 by Physical Therapist K revealed, Treatment Diagnosis: Other Abnormalities of gait and mobility .the patient referred due to eligibility for habilitative services under PASRR .current level of function: The patient demonstrates muscle weakness causing ipsilateral (same sided) pelvic drop and step to gait pattern during ambulation with front wheeled walker and stand by assist. Close enough to reach patient if assist needed for 100 feet .The patient's Right lower extremity hip abduction muscle strength 3 -/5 .The patient's Right lower extremity knee extension/flexion muscle strength is 3-/5 . Observation on 01/23/24 at 12:30 pm revealed Resident #111 was in the dining room, sitting in a regular wheelchair (not customized). After eating she was able to unlock the brakes of her wheelchair, then she asked for assistance to leave. A female staff assisted with moving her out of the dining room. Interview on 1/23/24 at 11:13 am, the MDS Coordinator Director H stated they did not have any problems submitting the PASRR forms and added she was responsible for submitting them. She stated the only delay could be if she did not know when a service had been requested in a meeting for her to complete. She stated this happened with Resident #111, she had an IDT meeting on 11/23/23 and she had up until 12/23/23 to get the NFSS form submitted. She stated she just recently submitted the form and added she did not know Resident #111 had a request for a CWC until the HC told her. She stated filling out the NFSS form was all new to her and she did not know the therapist and resident measurements were needed. She stated constant communication with SW E and HC was needed in order to know when they had IDT meetings to start the referral process on specialized services. She stated she submitted Resident #111's NFSS form 01/16/24 and added usually the SW, HC and Nurse Manager were in the Quarterly PASARR meetings, and she was in the Annual ones. She stated she completed the PASARR trainings in the past but did not know how to complete the NFSS forms and had to ask one of the therapists to assist her with filling out Resident #111's NFSS form. She stated she spoke to SW E about informing her about the IDT meetings so that she did not miss what was discussed and referrals she needed to do. Interview on 01/24/24 at 1:10 pm, Nurse Manager D stated, Resident #111 had an IDT meeting last November 2023 and SW E, HC and herself was in the meeting with the resident and her RP and a CWC was requested. She stated SW E notified them about the IDT meetings and documented what was discussed in the meetings and added she was not aware of any issues or delays with submitting Resident #111's PASARR forms. She stated MDS Coordinator Director H was not always in their meetings, and she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 4 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sure if SW E emailed the MDS Coordinator Director H about Resident #111's CWC referral. She stated although she was in Resident #111's IDT Meeting 11/23/23, she did not notify MDS Coordinator Director H of the CWC need because she believed the SW E notified MDS Coordinator Director H. She stated Resident #111 had a wheelchair, but she needed staff assistance to get around in it. She stated if a resident did not have the right type of wheelchair, it could limit their mobility and ability to get around independently. Interview on 1/24/24 at 4:16 pm, PT F stated she never attended the IDT meetings and was aware Resident #111 was in the process of getting a CWC because MDS Coordinator Director H had her fill out part of the NFSS. She stated she evaluated Resident #111 for therapy and noticed her wheelchair was too tall and she needed a shorter wheelchair for her to get around in independently. She stated the wheelchair vendor came out either last month (December 2023) or this month (January 2024) for her measurements for her wheelchair. She stated she would think SW E who coordinated the IDT Meetings would let MDS Coordinator Director H know about all specialized needs requested. She stated if a resident did not have a CWC they may not have appropriate mobile status and could get contractures, fall, and develop pressure ulcers. She stated Resident #111 was getting PT for a better gait pattern and to get her legs stronger by walking a little more smoothly. She stated she was able to walk short distances and could benefit from getting a CWC to strengthen her legs. Interview on 01/24/24 at 9:37 am, HC stated Resident #111 gained weight and it was decided in the Quarterly IDT meeting 11/22/23 for her to get a CWC. She stated Nurse Manager D, SW E and LVN I was at the meeting. She stated after Resident 111's IDT meeting 11/22/23, she emailed MDS Coordinator Director H and it showed she was on vacation on 11/27/23 and emailed her again 11/28/23 and MDS Coordinator Director H replied 11/28/23 that she was working on it and was not sure how to do it then she explained it was a benefit under PASSAR services. She stated on 12/08/23 she asked MDS Coordinator Director H for a status update with Resident #111's PASARR NFSS form, and she said she was working on it and was gathering pertinent information that OTA J assisted her with. She stated on 12/15/23 MDS Coordinator Director H said she was working on it, then on 12/19/23 therapy completed the wrong form and MDS Coordinator Director H gave the therapist the NFSS form and at that point advised MDS Coordinator Director H she was getting close to the deadline the 12/22/23 cutoff date and the form needed to be expedited. She stated MDS Coordinator Director H said she dropped the ball with getting the form submitted by the deadline, then on 1/16/23 it was filled out by the therapist, but it was not signed, she told her to re-submit it. She stated on 01/23/24 MDS Coordinator Director H said the CWC had been approved. She stated the facility had a lack of communication when it came to Resident #111's CWC need. Interview on 01/25/24 at 11:16 am, MDS Coordinator Director H stated MDS G filled in for her while she was out of town November 2023 and went to the IDT meetings and stated SW E nor MDS G told her about Resident #111's CWC referral. She stated either MDS G or SW E should have told her about the referral and said she found out about it on 11/27/23 when HC emailed her about the status of Resident #111's CWC request. She stated she went to therapy to assist with the form and had to get back with therapy for more information on the NFSS form. She stated then a wheelchair vendor came to measure Resident #111 and the time just caught up with her and she was not able to get the NFSS form submitted by 12/21/23. She stated Resident #111's current wheelchair sat up too high, and her feet did not touch the floor and needed a smaller and lower setting wheelchair. She stated today (01/25/24) they had a meeting with the therapy department, and they concluded the SW, Nurse Manager, Therapy Director and MDS Coordinator needed to be in all of their IDT meetings including the quarterly ones. She stated they needed better communication so that the referral process would move a lot faster . She stated if residents did not get specialized services, it could affect the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 5 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few independence and they may not reach their full potential. She stated since 01/07/24 she started checking the PASARR LTC portal daily for any status changes to see what was going on with the resident's forms, instead of checking them weekly. She stated her goal was to follow the processes and policies needed for the PASARR positive residents. Interview on 01/25/24 at 11:50 am, MDS G stated she was the alternate MDS Nurse when her supervisor MDS Coordinator Director H was not at work and last November 2023 she covered for MDS Coordinator Director H but said she was not in Resident #111's IDT Meeting. She stated Unit Manager D said she did not have to attend the meeting and added she was unaware Resident #111 needed a CWC until MDS Coordinator Director H mentioned it to her. She stated she was not sure how the PASARR CWC process worked, and her understanding was that the MDS needed to fill out some paperwork to be approved for the CWC . She stated she had not had any PASARR training in the past. She stated SW E was usually good about taking notes in the IDT meetings and was not sure what happened in Resident #111's case. She stated they were all aware of the delay in getting Resident #111's CWC and was currently working on a plan to prevent this from happening again. She stated if a resident did not get PASARR specialized services timely could cause the residents to decline in health. She stated she was not sure how this got dropped and they were reviewing other PASRR positive residents' records to ensure this was not happening with any other residents. Interview on 01/25/24 at 12:04pm, Nurse Manager D stated, for Resident #111's IDT meeting on 11/22/23, MDS Coordinator Director H and MDS G was not in the meeting. She stated HC mentioned Resident #111 needed a CWC and thought SW E sent an email to therapy herself, and MDS Coordinator Director H. She stated after a PASARR referral, they needed to get therapy to evaluate the resident for the new medical equipment requested and they needed to follow up on the requests to make sure everyone involved did their part. Interview on 01/25/24 at 12:24 pm, SW E stated they had Resident #111's IDT meeting on 11/22/23 and HC put in a suggestion about the resident getting a CWC. She stated she spoke to the former Rehabilitation Director and MDS Coordinator Director H sometime in November 2023 and said she would get Resident# 111 assessed by the therapist. She stated Resident #111 currently had a regular wheelchair and said she did not know there was a deadline on when to submit the PASARR NFSS form. She stated today (01/25/24) she asked MDS Coordinator Director H what could be done differently and was told to put the referral requests in an email and also ensure the MDS Coordinator H was notified to attended the IDT Meetings. She stated she did not know this needed to be done and thought they were just considering getting Resident #111 a CWC. She stated she spoke to therapy today (01/25/24) about what processes could be put in place to get the referrals done timely and was told to just follow up with MDS and therapy. She stated she did not know the MDS, and therapy department had a part in doing the NFSS forms and timelines to submit the form. She stated there was definitely a breakdown in communication and now knew they had 30 days to get the NFSS form submitted for CWC specialized service requests. She stated not getting resident's DME timely could cause fall risks and skin breakdown. She stated she had a PASARR training last year online but now knew when they discussed things in the IDT meeting, she needed to email MDS Coordinator Director H and therapy about the requested DME if they were not in the meeting, Interview on 01/25/24 at 1:28 pm, the DON stated he was unaware of Resident 111's CWC referral was delayed and causing her a delay in getting her CWC. He stated the Nurse Managers attended the IDT meetings and MDS Coordination Director H had not informed him about any issues with submitting the PASARR forms. He stated they had PASARR meetings with HC and added he needed to be involved in the IDT meetings and he thought SW E forwarded the CWC requests to MDS and therapy. He stated residents not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 6 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few getting PASARR specialized services and equipment, could potentially affect the resident's mobility with how they moved around. He stated MDS Coordinator Director H was responsible for submitting the resident's PASARR documents. He stated his expectations for PASARR referrals was for them to be done timely and if not done timely, MDS needed to let him or another MDS Coordinator know to assist. He stated he was not sure why this issue was not brought to his attention about MDS Coordinator Director H not knowing how to complete and submit the PASARR NFSS form and with the communication issues amoung the Directors. Interview on 01/25/24 at 3:50 pm the DON stated they did not have a PASARR policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 7 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5(Residents #3, #71, #83, #84 and #94) of 8 residents reviewed for infection control in that: Residents Affected - Some MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #3, #71, #84 and #94. LVN B failed to disinfect the stethoscope prior to and after use during g-tube (feeding tube) medication administration for Residents #84. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #3's EHR on 01/24/24 revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertension, with diagnoses of CVA (Stroke), essential hypertension (increased blood pressure), hemiplegia (partial weakness on same side of the body) and hemiparesis (partial weakness on one side of the body) effecting the right side. Review of Resident #3's quarterly MDS assessment, dated 01/15/24, reflected a BIMs score of 01, indicating the resident was severely impaired, unable to make decisions. Her functional status indicate he needed one staff to complete his activities of daily living. Review of Resident #3's physician orders dated 01/15/24 reflected, Amiodarone HCL tabs 500 mg one time a day for arrhythmia and Digoxin 25mg two times a day for pulse control. Take Blood pressure every day. Review of Resident #71's EHR on 01/24/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertension (increased blood pressure) and Hypertensive chronic kidney disease (kidney affected by uncontrolled blood pressure). Review of Resident #71's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating she was alert and oriented not impaired for decision making. Her functional status indicated she needed assist of one staff with her activities of daily living. Review of Resident #71's physician orders dated 01/03/24 reflected, Amlodipine 5 mg tablet [generic] 5 mg by mouth one time a day for hypertension (increased blood pressure). Review of Resident #83's her on 01/24/24 revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnosis including dementia, aphagia, dysphasia, cerebral infraction, and gastro-tube (feeding tube). Review of Resident #83's quarterly MDS, dated [DATE] revealed a BIMs score of 0, indicating she was severely impaired for decision making. Her functional status indicated she needed assist of two (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 8 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 staff with her ADLs. Level of Harm - Minimal harm or potential for actual harm Review of Resident #83's physician orders dated 01/11/24 reflected, all medications must be given per (by) G-tube (feeding tube). Auscultation ( to listen with stethoscope) for G-tube placement, in the stomach. Residents Affected - Some Review of Resident #84's her on 01/24/24 revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including hypertension(elevated blood pressure), and atrial fibrillation (unusual heart beat). Review of Resident #84's quarterly MDS, dated [DATE] revealed a BIMs score of 12, indicating she was alert and oriented, not impaired for decision making. Her functional status indicated she needed assist of one staff with her ADLs. Review of Resident #84's physician orders dated 12/01/23 reflected, Lisinopril 2.5mg every day (blood pressure), Metoprolol ER 50mg every day(for increased blood pressure, and digoxin 25mg two times a day (increased pulse). Checking blood pressure prior to administration. Review of Resident #94's her on 01/24/24 revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including essential hypertension (elevated blood pressure), and heart disease. Review of Resident #94's quarterly MDS, dated [DATE] revealed a BIMs score of 8, indicating he was confused and impaired for decision making. His functional status indicated he needed assist of one staff with his ADLs. Review of Resident #94's physician orders dated reflected, Metoprolol 25mg by mouth two times a day (blood pressure) and Cardizem 180mg by mouth every day (blood pressure) . Checking blood pressure prior to administration. Observation on 01/23/24 at 10:01 a.m. revealed MA A performing morning medication pass, during which time she checked the blood pressure of Resident #3. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #3. Observation on 01/23/24 at 10:08 a.m. revealed MA A performing a medication pass, during which time she checked the blood pressure of Resident #71. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #71. Observation on 01/23/24 at 10:10 a.m. revealed MA A performing a medication pass, during which time she checked the blood pressure of Resident #84. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #8. Observation on 01/23/24 at 10:22 a.m. revealed MA A performing morning medication pass, during which time she checked the blood pressure of Resident #94. MA A failed to sanitize the same blood pressure cuff before or after using it on Resident #94. Observation on 01/23/24 at 01:27 p.m. revealed LVN B performing afternoon medication pass, during which time she checked the g-tube (feeding tube) for placement of Resident #83. LVN B failed to sanitize the stethoscope before or after using it on Resident #83. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 9 of 10 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 455983 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Catherine Center 300 West Highway 6 Waco, TX 76712 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 Interview on 01/23/24 at 10:30 a.m., MA A stated she always cleaned the blood pressure cuff with the purple top before and after each use. MA A stated she had used the purple top wipes that were on her medication cart to clean the blood pressure cuff before and after use She stated there had been in-services on infection control and cleaning equipment, but she could not recall when that had occurred. MA A stated that if the cuff was not cleaned appropriately, it could spread germs. Residents Affected - Some Interview on 01/23/24 at 1:45 p.m., LVN B stated stethoscopes should be sanitized with purple top wipes between each resident use to prevent transmitting an infection from one resident to another. She stated she was supposed to cleanse the stethoscope in-between each usage. LVN B stated she had been nervous because she had never had to perform her medication pass in front of a state surveyor. LVN B stated that if the equipment that was used on the residents was not cleaned correctly it could cross contaminate causing a spread of infection. Interview on 01/25/24 at 11:45 a.m. with the DON, he stated that his expectation was that staff would sanitize all reusable equipment between each resident use. He stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. He stated there was plenty of supplies for the nursing staff to have the sanitization wipes that were EPA-registered disinfectant, on all the medication carts. He stated that should be basic nursing to understand you should practice appropriate infection control. Review of facility's Policies and Procedure titled: Infection Prevention and control Program, dated November 2023, reflected the following: The infection control prevention and control program is a facility -wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . The program will be carried out by the facility infection control preventionist Policies/Procedures 1. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the community . b. maintain a safe, sanitary , and comfortable environment for personnel, residents, visitors, and the general public .e. provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455983 If continuation sheet Page 10 of 10