Inspection·January 24, 2024

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 infection control (methods used to prevent, control, or stop the spread of infections) precautions by having expired alcohol hand sanitizer bottles available and used throughout the facility. Residents Affected - Some This failure had the potential to result in the spread of bacteria, viruses and pathogens (harmful microorganisms) to residents, visitors and staff while increasing the risk of infections. Findings: During an observation on [DATE] at 12:28 pm at the front lobby, two visitors seen using bottled alcohol sanitizer with an expiration date of 6/2022. During a concurrent observation and interview on [DATE] at 12:31 pm with Central Supply Manager (CSM) at the indoor facility supply cabinet, seven bottles of alcohol hand sanitizer found with expiration dates of 6/2022. CSM stated these bottles should not be used and should have been thrown away. During a concurrent observation and interview on [DATE] at 12:36 pm with Licensed Vocational Nurse (LVN) in the [NAME] Nurse's Station, one bottle of alcohol hand sanitizer found with the expiration date of 6/2022. LVN stated, he along with other staff use this bottle for hand hygiene (a way of cleaning one's hands that substantially reduces potential pathogens on the hands). During an observation on [DATE] at 12:40 pm in the facility hallway, one bottle of alcohol hand sanitizer with expiration date of 6/2022 seen on top of isolation cart for Room A. During a concurrent observation and interview on [DATE] at 12:46 pm with the Director of Nursing (DON) in Nurse's Station 3, three bottles of alcohol hand sanitizer found with the expiration dates of 6/2022. The DON stated the expired bottles of hand sanitizer should not be I the nurse's station and should have been thrown away. During an interview on [DATE] at 2:07 pm with CSM, CSM stated he is responsible for the restocking and ordering supplies as well as checking the expiration dates of facility's supplies. CSM also stated the facility protocol is to throw away all supplies 2 months before the supply expires. During a concurrent interview and record reviews on [DATE] at 3:07 pm with CSM, the facility's Covid 19Inventory and the Order Supply Summary for [DATE], [DATE] and [DATE] were reviewed. The inventory list and order summaries did not include any ordering or quantity amounts for the facility's alcohol sanitizer bottles. CSM also stated the facility does not currently have a supply of unexpired (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 5 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 01/24/2024 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)