Inspection·February 5, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with Certified Nursing Assistant 1 (CNA 1) on 2/5/2025 at 6:20 AM, CNA 1 stated she was with Resident 1 on 1/22/2025 when Resident 1 refused blood draw. During an interview with CNA 3 on 2/5/2025 at 7:01 AM, CNA 3 stated that on Thursday (1/23/2025) morning (time not specified), CNA3 saw Licensed Vocational Nurse 1 (LVN 1) come out from Resident 1's room. CNA3 stated LVN 1 looked stressed. CNA3 stated after LVN 1 came out of Resident 1's room, LVN 1 told CNA3 that Resident 1 accused CNA 1 of hurting her. During an observation on 2/5/2025 at 7:21 AM, Resident 1 was observed in bed awake but refused to discuss the abuse allegation against CNA1. During an interview with the Director of Nursing (DON) on 2/5/2025 at 8:49 AM, the DON stated that on Thursday (1/23/2025) morning at 7AM, LVN 1 assessed Resident 1's skin discoloration on the right hand. The DON stated on 1/23/2025 at 3:45PM, the DON assessed Resident 1's right hand. The DON stated Resident 1 had a swollen, reddish discoloration on the right hand. The DON added that according to Resident 1, it happened during transfer but could not identify the staff. During an interview with the DON on 2/5/2025 at 9:09 AM, the DON stated, We need to report abuse allegation within 2 hours per our policy. If abuse incident was not reported on time, we might have delay in care, and there will be delay of investigation. We need to make sure the resident was safe. During an interview with the Director of Staff Development (DSD) on 2/5/2025 at 10:04 AM, DSD stated, If we cannot report within 2 hours, there is a possibility that the resident involved might get abused, resident might feel scared, and there will be a possible issue of resident safety. During an interview with the DON on 2/5/2025 at 10:06 AM, the DON stated she received a text message from LVN 1 on 1/23/2025 at 9:15 AM that Resident 1 had informed LVN 1 regarding allegation of being hit by CNA (CNA1) on Wednesday (1/22/2025) morning. The DON stated the text message indicated that according to LVN 1, LVN 1 did not work on Wednesday morning so was not sure on what actually happened that day. LVN 1 added that she had asked CNA1 who reported that Resident 1 was agitated and kicked CNA 1 on Wednesday morning. The DON stated, It was my fault, I was not reading the text carefully. I must have misread it. I would have reported it right away. Every abuse allegation should be reported right away. We need to report abuse allegation timely, so we can conduct the investigation and make sure the resident involved was safe. The DON stated Resident 1's abuse allegation against CNA1 was reported to the California Department of Public Health (CDPH) on 1/23/25 at 5 PM. During an interview with LVN 1 on 2/5/2025 at 10:50 AM, LVN 1 stated On 1/23/2025, Thursday morning before resident (Resident 1) went for dialysis (process of removing waste products and excess fluid from the body), I took the resident's vital signs on the right arm because she has a left arm arteriovenous shunt (AVS, is the most commonly used vascular access in resident's receiving regular hemodialysis [a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to work adequately]). I saw a discoloration to the back of the resident's (Resident 1) right hand. LVN 1 stated, I sent a text message to the DON on Thursday morning after 8 AM and was able to speak with the DON at 9 AM about the resident's (Resident 1) hand discoloration. During an interview with LVN 1 on 2/5/205 at 11:01 AM, LVN 1 did not give any information regarding Resident 1's allegation of abuse against CNA 1 but stated, If there is an allegation of abuse, we should report it as soon as possible to the DON. We should also inform the physician and Responsible Party. The DON will follow up with the other stuff needed to be submitted such as reporting the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055441 If continuation sheet Page 2 of 6 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 02/05/2025 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 0609 abuse to the agencies. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Management, revised 5/30/2024, the P&P indicated the facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies. Reports of resident abuse, mistreatment, neglect, exploitation, injuries of unknown source and any suspicion of crimes are promptly reported and thoroughly investigated. The P&P indicated the Administrator, or designated representative will notify law enforcement, by telephone immediately, or as soon as practicably possible, but no longer than two (2) hours of an initial report and send a written SOC 341 report (report of suspected dependent adult/elder abuse) to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within 2 hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055441 If continuation sheet Page 3 of 6 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 02/05/2025 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for two (2) of three (3) sampled residents (Residents 1 and 2) that was readily accessible with the language the residents were able to understand in accordance with the facility's policy. Residents Affected - Some This failure had the potential for Residents 1 and 2 to experience a delay in receiving appropriate care and treatment and feeling lonely and isolated due to the staff not being able to properly communicate with the residents. Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 1's diagnoses included metabolic encephalopathy (ME, occurs when problems with your metabolism cause brain dysfunction), diabetes mellitus (DM, is a metabolic disease, involving inappropriately elevated blood glucose levels), chronic kidney disease (CKD, is a condition in which the kidneys are damaged and cannot filter blood as well as they should) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, the MDS indicated Resident 1 was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required partial/ moderate assistance (Helper does less than half the effort, helper lifts, hold, or supports trunk or limbs but provides less than half the effort) in toileting hygiene, shower/ bathe self, lower body dressing, putting on and taking off footwear, personal hygiene and tub/ shower transfer. Resident 10 needed supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) in oral hygiene, upper body dressing, roll left and right, sit to lying, sit to stand, chair/ bed-to-chair transfer, toilet transfer, walk 10, 50,and 150 feet. During a record review of Resident 1's care plan (CP) dated 4/21/2022, the CP indicated Resident 1 was at risk for ineffective communication manifested by impaired ability to make self-understood and understand others. Primary language is not English. Communication: Resident 1 prefers to communicate with her primary language. During an observation in Resident 1's room on 2/5/2025 7:23 AM. Resident 1 was laying on her bed. The Communication board was hanging on top of Resident 1's bedside table and was not in the language that Resident 1 speaks. The Communication board was also observed not within Resident 1's reach. During a concurrent observation in Resident 1's room and interview with Licensed Vocational Nurse 2 (LVN 2) on 2/5/2025 at 7:34 AM, LVN 2 took the communication board from the resident's bedside table. LVN 2 stated the communication board does not have the language Resident 1 speaks so it will be difficult to communicate her needs with the staff if using the communication board. During a concurrent observation in Resident 1's room and interview with Certified Nursing Assistant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055441 If continuation sheet Page 4 of 6 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 02/05/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm 2 (CNA 2) on 2/5/2025 at 7:36 AM, CNA 2 stated the communication board hanging on top of Resident 1's bedside table did not have the language Resident 1 speaks. CNA 2 stated, I do not speak the Resident's (Resident 1) language. I just do hand gestures to communicate with the Resident. The communication board had incorrect language. If we have the wrong communication board, the Resident will not be able to communicate her needs with the staff. Residents Affected - Some During an interview with the Director of Nursing (DON) on 2/5/2025 at 12:59 PM, the DON stated The communication board hanging on top of the Resident's (Resident 1) bedside table had a different language from what the resident was speaking. There is a possibility of miscommunication. The resident (Resident 1) will not be able to communicate her needs, and staff will not be able to address the resident's needs. During a concurrent record review of Resident 1's care plan and interview with DON on 2/5/2025 at 1:01 PM, the DON stated, Communication Board should be included in the care plan because it was the communication tool used by the resident (Resident 1). 2. During a review of Resident 2's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re- admitted on [DATE]. Resident 2's diagnoses included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in roll left and right, sit to lying, sit to stand, chair/ bed-to-chair transfer, toilet transfer, and walk 10 feet. Resident 2 needed partial/ moderate assistance in toileting hygiene, shower/ bathe self, upper/lower body dressing, putting on and taking off footwear, and personal hygiene. During a record review of Resident 2's CP, dated 4/17/2023, the CP indicated Resident 2 has communication deficit due to inability to understand and make herself understood at times. Resident 2's primary language is not English. Resident 1 prefers to communicate with her primary language. During a concurrent observation in Resident 2's room and interview with CNA 2 on 2/5/2025 at 8:17 AM, Resident 2 was laying on her bed. There was no communication board on the bedside or hung on the head part of the bed. Resident 2 was observed crossing her arms across her chest. CNA 2 pulled the blanket and covered Resident 2's shoulders and neck. CNA 2 stated, Resident (Resident 2) might be cold. We just communicate with the resident (Resident 2) by doing hand gestures, or the rsident will point at the bathroom or the overhead light. But if there was communication board, the resident (Resident 2) might be able to communicate her needs with the staff. During a concurrent observation in Resident 2's room and interview with LVN 2 on 2/5/2025 at 8:19 AM, LVN 2 stated, There was no communication board for the resident (Resident 2). I was just about to get it right now. If there was no communication board at the bedside, it can delay care because resident (Resident 2) cannot communicate with the staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055441 If continuation sheet Page 5 of 6 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 02/05/2025 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview with the Director of Staff Development (DSD) on 2/5/2025 at 10:12 AM, DSD stated, Communication board'ss purpose was to communicate the Residents' needs with the staff if Residents' do not speak English. If communication board had the wrong language, the residents' needs might not be met. There was a barrier in the communication between the staff and it should be replaced right away. During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Residents' Communication Needs, revised 3/2017, the P&P indicated the facility provides assistance to residents with communication challenges through a number of adaptive services. Staff will provide adaptive devices as needed to enable the resident to communicate as effectively as possible. The following are examples of adaptive devices the staff may provide the resident: Communication Boards/Charts. Any accommodation identified and provided by facility staff will be reflected in the residents' plan of care and updated as appropriate. Event ID: Facility ID: 055441 If continuation sheet Page 6 of 6