Inspection·August 29, 2023

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 ensure infection control practices (a set of practices that prevent or stop the spread of infections and or diseases in healthcare settings) were followed for six (6) of seven (7) sampled resident (Residents 1, 2, 3, 4, 5, and 6) in accordance with the facility's policy and procedure when: Residents Affected - Some 1. The facility failed to ensure indwelling catheter (is a closed sterile system with a catheter and retention balloon that lets urine leave your bladder and your body to allow for bladder drainage) bag for Resident 1 was not touching the floor. 2. The facility failed to follow standard precautions (a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin, and mucous membranes) by failing to remove soiled gloves and failed to perform hand hygiene (the act of cleaning one's hands with soap and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) before and after resident contact with Resident 2, 3, 4, 5, and 6 . was not used. These deficient practices had the potential to spread infection to all residents, staff and visitors in the facility and the potential for development of catheter associated urinary tract infection (a bacterial infection of the bladder and associated structures) to Resident 1. Findings: 1. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure (an ongoing condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and anoxic brain damage (caused by a complete lack of oxygen to the brain). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/1/23, indicated Resident 1 brief interview of mental status (BIMS, a standardized assessment and care screening tool) was not conducted due to resident was rarely /never understood. Resident 1's required total dependence (full staff performance every time during the entire 7-day period) on bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. During an observation on 8/29/23 at 11:10 a.m., Resident 1's indwelling catheter bag was seen touching the floor. During a concurrent observation and interview on 8/29/23 at 11:15 a.m. with the Director of Nursing (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: 055441 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 055441 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ivy Creek Healthcare & Wellness Centre 115 Bridge St. San Gabriel, CA 91775 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)