Inspection·February 25, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document the administration of the two (2) doses of intravenous (IV, directly into the blood stream) antibiotics (medicines that treat bacterial infections by killing or stopping the growth of bacteria0 medication on to the Medication Administration Record (MAR) for one (1) of five (5) sampled residents (Resident 4) in accordance with the Medication Administration policy. This deficient practice had the potential to result in the doubling up of medications (taking the dose twice). Findings: During a review of Resident 4's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of pneumonia (an infection/inflammation in the lungs). During a review of the Physician ' s Order dated 2/6/2024 at 8 PM, the Physicians order indicated cefepime HCL (antibiotics used to treat pneumonia) 1 gram (gm, unit of measurement), IV to be given 2 times a day until 2/10/2025 10:24 PM. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 2/13/2025, the MDS indicated Resident 4 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 4 required partial assistance (helper does less than half the effort) with oral, toileting and personal hygiene, shower, upper and lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 4 required supervision (helper provides verbal cues) with eating. During a review of Resident 4 ' s February 2025 MAR, the MAR did not indicate a signature for the medication administration for cefepime HCL 1 gm for the 9 PM doses on 2/9/2025 and 2/10/2025. During an interview on 2/25/2025 at 3:34 PM, Registered Nurse 1 stated administering the 9 PM dose of Resident 4 ' s cefepime HCL on 2/10/25. RN 1 stated she should have signed the MAR right after administering the medication for accuracy and to indicate that the medication was administered. During an interview on 2/25/2025 at 3:45 PM, RN 2 stated administering Resident 4 ' s cefepime HCL IV antibiotic to Resident 4 on 2/9/2025 at 9 PM. RN 2 also stated that he should sign after the medication was administered as proof that the medication was administered. (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 2 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 02/25/2025 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)