Health inspection·December 19, 2025

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address the recurrent behavior fluctuations of manic mood (mental state of an extreme highs or depressive lows) of verbally aggressive towards staff/others and diminished interest/pleasure in usual Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), for (1) of two (2) sampled residents (Resident 2) while on Depakote (drug used to calm overactive nerves in the brain). This deficient practice resulted in Resident 1 being hit on the left leg by Resident 2's right hand and had the potential to place Resident 1 at risk for physical and psychosocial harm.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to anxiety (a feeling of fear, dread, and uneasiness that may occur as a reaction to stress) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/13/2025, the MDS indicated Resident 1 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting and shower and required supervision (helper provides cues) with oral and personal hygiene, upper and lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 1 required setup assistance (helper sets up; resident completes activity) with eating. 2. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] and 8/23/2025 with diagnoses that included bipolar and delusional disorder (having false or unrealistic beliefs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's physicians order dated 8/23/2025 timed at 9:59 AM, the physicians order indicated Depakote 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) to give 1 tablet by mouth 2 times a day (BID) for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) manifested by recurrent behavior fluctuations between diminished interest/pleasure in usual ADLs to manic mood of verbally aggressive towards staff/others. During the same review of the physician's order dated 8/23/2025 timed at 9:59 AM, the physicians order indicated to monitor episodes of recurrent behavior fluctuations between diminished interest/pleasure in usual ADLs to manic mood of verbally aggressive towards staff/others. During a review of Resident 2's Care Plan initiated on 11/28/2023, the Care Plan indicated Resident 2 has a behavior problem manifested by recurrent outburst of anger for no reason hitting staff and recurrent behavior fluctuations between diminished interest/pleasure in usual ADLs to manic mood of verbally Residents Affected - Few Page 1 of 3 055441 055441 12/19/2025 Ivy Creek Healthcare & Wellness Centre 115 Bridge St. San Gabriel, CA 91775

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aggressive towards staff/others. The Care Plan approach plan indicated to monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, person involved, and situations. The Care Plan also indicated to document behavior and potential causes. During a review of Resident 2's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of November 2025. The MAR indicated Resident 2 had 11 incidents of behavior disturbances. During a review of Resident 2's Minimum Data Set, dated [DATE], the MDS indicated Resident 2 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 2 required supervision with toileting, shower, upper and lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 2 required setup assistance with eating, oral and personal hygiene. During an interview on 12/18/2025 at 1:41 PM, Licensed Vocational Nurse 1 (LVN 1) stated he heard someone yelling from Room A on 12/8/2025 at around 12:15 AM during the night shift (11PM - 7AM) but did not know who was the resident that was yelling. LVN 1 stated he went towards the room and saw Resident 2 hit Resident 1's left leg with his right hand. During a concurrent interview and record review on 12/18/2025 at 3:30 PM with LVN 2, Resident 2's MAR were reviewed. LVN 2 stated Resident 2 was on Depakote 125 mg BID. LVN 2 also stated Resident 2 was being monitored for verbally aggressive behaviors to staff and others and the MAR indicated Resident 2 did not have behavior from December 1 - 4, 2025 but had 11 episodes of behaviors from December 5 - 7, 2025. LVN 2 stated Resident 2's physician should have been notified of the resident's aggressive behaviors so that the physician would be aware of the resident's increasing behavior. During an interview on 12/18/2025 at 3:50 PM, LVN 3 stated Resident 2's physician should have been notified of the resident's increasing behavior to see if the physician wants to change or increase the dosage of the residents Depakote. LVN 3 also stated Resident 2's increasing behavior should have been reported to the physician so the resident could be re-evaluated to prevent further episodes of aggression. During a concurrent interview and record review on 12/18/2025 at 4:55 PM, Resident 2's MAR on behavior monitoring for the month of December 2025 was reviewed. Registered Nurse 1 (RN 1) stated the licensed staff for day shift should have documented if the non-pharmacological interventions (NPI) for 12/7/25 were effective. RN 1 also stated the licensed staff on 12/7/2025 evening shift should have NPI provided for the resident's behaviors and then documented in the progress notes. RN 1 further stated, NPI should be provided to Resident 2 and then medicated if NPI was not effective to prevent the Resident 2 from getting more agitated and potentially harm self or others. During an interview on 12/19/2025 at 9:30 AM, Certified Nursing Assistant 1 (CNA 1) stated he saw Resident 2 got up and told him What can I do for you? while he was helping another resident in Room A. CNA 1 also stated he proceeded to close the curtain and that's when he heard Resident 1 scream Ahhh!. CNA 1 further stated that when he opened the curtain, he saw Resident 2 standing at the end of Resident 1's bed and hit the left leg of Resident 1 with his hand. During a concurrent interview and review of the Policy and Procedure (P&P) on Behavior/Psychoactive Medication Management revised 10/30/2025 with the ADM, the P&P indicated monitoring and reporting for side effects of psychotropic medication with all complications and side effects should be reported to the healthcare practitioner. ADM stated monitoring and reporting for side effects included behavior monitoring. During a review of the facility's P&P titled, Dementia Care, revised October 2017, the P&P care process indicated that if the resident manifests a change in his/her behavior symptoms, the Licensed Nurse will assess the resident's mood and behavior status utilizing the change in condition process. The policy also indicated that the Licensed Nurse would notify and collaborate with the attending physician, family, resident, resident representative, and/or Inter Disciplinary Team (IDT, comprised of 055441 Page 2 of 3 055441 12/19/2025 Ivy Creek Healthcare & Wellness Centre 115 Bridge St. San Gabriel, CA 91775

F 0744 Level of Harm - Minimal harm or potential for actual harm team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) members regarding the identified contributing factors to the resident's mood/behavior problems and the non-drug intervention s to address the problems, as well as to evaluate the effectiveness of the non-drug interventions for further recommendations. Residents Affected - Few 055441 Page 3 of 3