Inspection·December 19, 2025

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 (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 12/19/2025 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 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055441 If continuation sheet Page 3 of 3