Inspection·November 16, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 2's Fall Risk Assessment, dated 9/24/23, it indicated a Fall Risk Score of 10, which is considered a high risk for falls. During a review of Resident 2's MDS, dated [DATE], it indicated Resident 2 used a walker and wheelchair. Resident 2 required partial or moderate assistance (staff assistance- helper does less than half the effort, lifts or holds the trunk [chest] or limbs [arms and/ or legs]) in the following areas: showering/bathing self, toileting, and upper body dressing. The MDS also indicated Resident 2 substantial or maximal assistance (helper does more than half the effort and lifts or holds the trunk or limb) in the following areas: lower body dressing, putting on and taking off footwear, moving from a sitting to standing position, transferring from chair and or bed to chair, toilet, and tub or shower. The MDS also indicated the resident does is cognitively intact. During a review of Resident 2's undated Care Plan, it indicated to follow facility's fall protocol which was initiated on 3/13/22. During a concurrent observation outside Resident 1 and 2's room and interview on 11/16/23, at 12:45 p.m., with Registered Nurse (RN) 1, there were no signs next to the residents' names posted on the wall before entering their rooms to identify both Resident 1 and 2 were high risk for falls. RN 1 stated there were no resident's name written in a red paper indicating Resident 1 was a high risk for fall. RN1 stated that on 10/30/23, Resident1 fell out of bed and sustained a left 7th rib fracture (partial or complete break in the bone). RN 1 stated resident's name written on a red paper should be posted right before entering the resident's room and a red star sticker was usually placed on the resident's wheelchair to indicate the resident was at a high risk for falls. RN 1 stated the identifiers is completed by the Director of Nursing (DON). During an observation and interview of Resident 1 on 11/16/23 at 12:56 p.m., Resident 1 was in his room, lying in bed and stated he fell out of bed twice on 10/30/23. Resident 1 stated he told his daughter the first time he fell out of bed on 10/30/23, in the afternoon (unable to recall exact time) and stated he felt fine so they did not tell the facility staff Resident 1 stated he fell out of bed the second time on 10/30/23 at night (unable to recall exact time) and hit the left side of his abdomen (stomach) on the side table and stated he had pain. During a review of the Interdisciplinary Team (IDT) Notes dated 11/1/23 for Resident 1 indicated Resident 1 notified family member of first fall at 5:30 p.m. During an interview with Certified Nursing Assistant (CNA) 1, on 11/16/23, at 1:49 p.m., CNA 1 stated there are no signs nor red stickers nor resident's name written on a red paper posted before entering the resident's room to indicate residents are at a high risk for falls. During an interview with Licensed Vocational Nurse (LVN) 1, on 11/16/23 at 2:17 p.m., LVN 1 stated LVNs can view residents for high fall risk on PointClickCare (PCC, Electronic Medical Record for residents) but CNAs are not able to access\. LVN 1 further stated is the facility have a falling star program (program created by the facility to prevent resident fall) for high fall risk residents but unaware of details of the program. LVN 1 stated resident's name written on a red paper or other fall risk identifiers are not being used at this time to indicate whether a resident is at a high risk for falls. During an interview with CNA 3, on 11/16/23 at 2:24 p.m., CNA 3 stated staff only find out about falls during huddles (meeting with staff before shift starts). CNA 3 stated red star stickers used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055441 If continuation sheet Page 2 of 3 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 11/16/2023 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be placed on chairs for high fall risk residents but are currently not being used. CNA 3 stated red star stickers or fall identifiers are not used at this time to indicate if a resident is at a high risk for falls. During a review of IDT Progress Note for Resident 2 dated 9/25/23, Resident 2 fell on 9/24/23 with an abrasion (rubbing away of skin by friction) on right buttock. The IDT progress notes also indicated Resident 2 had one to two falls in the past three months the resident declined being moved closer to nurses' station after the fall and refused pad alarm (pad that is placed under sheet and responds to changes in weight and pressure by producing an alarm) to alert staff that resident needs assistance and for safety measures. During a concurrent interview and record review on 11/16/23, at 3:45 p.m. with the DON, the Fall Management Falling Star Program, dated 10/26/23 was reviewed. The DON stated, their program indicated residents in Falling Star Program will have resident's name written in red paper and posted by the resident's door and a red star attached to resident's wheelchair. The DON stated, Resident 2 should be included in the Falling Star Program because of his history of fall and therefore Resident 2 is considered at risk for falling. The DON stated red identifiers are not on doors of residents who are at high risk for. The DON stated there is no excuse to not have risk for fall identifiers for residents at a high risk for falls on doors and wheelchairs and it is the licensed nurse's responsibility in ensuring this is implemented. During a review of facilities QI Plan titled Fall Management Falling Star Program, updated 10/26/23, indicated residents are considered at a high risk for falls if residents have had multiple falls within the last 3 months, falls with major injuries such as a fracture and or traumatic brain injury (violent jolt to the head), or behavior of frequent non-compliance with safety precautions. If a resident refuses to move close to a nursing station, the resident will have red name by the door and red star on their wheelchair to be identified as resident in Falling Star Program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055441 If continuation sheet Page 3 of 3