Inspection·August 2, 2024

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interviews and record review, the facility failed to ensure two of two facility staff (the Director of Nursing [DON] and the Registered Nurse Supervisor [RNS]) had Infection Prevention (IP) certificates and had completed specialized training in infection prevention and control while covering the Infection Control Preventionist (ICP) role. This failure had the potential to result in the spread of infections throughout the facility. Findings: On 8/2/24 a visit was made to the facility to investigate a facility reported incident regarding a Covid-19 (minor to severe respiratory illness caused by a new virus and spread from person to person) outbreak (a higher-than-expected number of occurrences of a disease in a specific location and time). During an interview with the Administrator (ADM), on 8/2/24 at 11:12 am, the ADM stated the facility's ICP was on medical leave and the acting ICP role was shared between the DON and the RNS. During an interview with the DON, on 8/2/24 at 3:07 pm, the DON stated the DON was the acting ICP at the facility for several months (did not remember start date). The DON stated the ICP role was share between the DON and the part-time RNS. The DON stated the DON was trained in specialized infection control program but was unable to provide a certificate to indicate completion of the training as was required to be an ICP. The DON stated it was important for the facility's ICP to be properly trained because the ICP was responsible for infection control and prevention of the spread of Covid-19 or other diseases to the residents. During an interview with the ADM, on 8/2/24 at 4:50 pm, the ADM stated the facility followed rules and regulations from the Centers for Disease Control and Prevention (CDC, national public health agency of the United States), the California Department of Public Health (CDPH, state department responsible for public health in California), and the Los Angeles County Department of Public Health (LADPH, organization works to protect and improve communities within the county of Los Angeles). The ADM stated the RNS was off and only worked one day a week. The ADM stated the facility was unable to provide RNS's certificate to indicate completion of ICP training. The ADM stated it was important for the facility to have a trained ICP to monitor Covid-19 outbreaks and other infections and to prevent exposure to residents and staff. During a review of an undated document from the CDPH, titled, State and Federal Regulatory Requirements: Infection Preventionist Training for SNF Healthcare-Associated Infections Program Center for (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: 055261 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 055261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pilgrim Place Health Services Center 721 Harrison Ave Claremont, CA 91711 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)