Inspection·November 20, 2024

F 0609 that a staff broke her arm. Resident 1 stated that never happened. Level of Harm - Minimal harm or potential for actual harm During a concurrent record review and interview on 11/19/24 at 4:25 pm, the care plan dated 10/30/24 regarding an allegation of someone hurting and breaking Resident 1's arm was reviewed with the Administrator. The Administrator stated that statement was an allegation of abuse and it needed to be reported within two hours to him and to the reporting agencies. The Administrator stated no one reported the abuse allegation involving Resident 1 and he was not aware of the allegation of abuse. Residents Affected - Few During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prohibition Protocols, dated 6/17/23, the P&P indicated the first duty of any associate who becomes aware of suspected or alleged abuse is to protect the resident(s) from future potential harm. The P&P indicated after assuring resident safety, the second duty of an associate aware of suspected or alleged abuse is to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made (if the events that cause the allegation involve abuse or result in serious bodily injury) to: Administrator, [NAME] State Survey Agency, Claremont Police, Adult Protective Services, LTC Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055261 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 055261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) did not develop pressure ulcers-injury [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against the others]) as indicated in the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention and Management, by failing to ensure: Residents Affected - Few 1.A comprehensive care plan (CP) was developed to address the risk for PIs after Resident 1's readmission to the facility on [DATE]. 2.A pressure injury wound risk assessment was conducted for Resident 1 upon readmission on [DATE]. 3. Resident 1's physician order that indicated the use of a low air loss (LAL, a mattress designed to distribute body weight and prevent and treat pressure wounds) mattress for Resident 1 included a mattress setting. Additionally, the LAL did not have the correct setting when the LAL was set on static (a firm mattress surface that makes it easier for the resident to transfer or reposition and prevents from bottoming out when in a sitting position) mode instead of alternating (used for pressure relief and circulation, a surface that regularly redistributes the pressure under the body) mode. These deficient practices resulted in the development of a stage 3 PI (full-thickness loss of skin in which adipose/fat is visible in the ulcer/open sore) on Resident 3's sacrococcyx area (sacral [a triangular shaped bone at the bottom of the spine] coccyx [tailbone]) and had the potential to lead to further skin breakdown and delayed wound healing to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 3/14/24, with diagnoses that included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) myocardial infarction (heart attack). During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/16/24, the MDS indicated Resident 1 had moderate cognitive (ability to understand and process information) impairment. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with bed mobility including rolling left and right, sit to lying, and lying to sitting. During a review of Resident 1's Radiology Interpretation (RI), date of exam 11/2/24, the RI indicated a pathologic fracture (a break in a bone caused by an underlying disease) to the left and right humerus (long bone that runs from the shoulder and shoulder blade to the elbow). During a review of Resident 1's Resident Transfer Record, the record indicated Resident 1 was transferred to General Acute Hospital 1 (GACH 1) on 11/2/24. 1.During a review of Resident 1's CPs. There were CPs in Resident 1's medical record for risk for developing PIs and alteration in skin integrity, dated 3/15/24, revised 6/17/24 and on 9/18/24. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055261 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 055261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few CPs were not revised upon Resident 1's readmission on [DATE] and there were no active CPs that addressed Resident 1's redness on the sacrococcyx area or addressed Resident 1 being at risk for developing PIs. During a review of Resident 1's Nurse's Admitting Record, dated 11/3/24, the record indicated redness on the sacrococcyx area. During a review of Resident 1's Order Summary Report (OSR), active physician orders as of 11/19/24, the OSR included an order, dated 11/3/24, the order indicated to Lift for care, minimal turning due to further fractures every shift. During a review of Resident 1's OSR, active physician orders as of 11/19/24, the OSR included an order, dated 11/13/24, that indicated treatment for Resident 1's sacrococcyx area for a stage 3 PI, the order indicated to cleanse with normal saline (solution, mixture of water and salt and used to cleanse wounds), pat dry, and apply santyl ointment (medicine used to remove dead tissue form wounds so they can start healing), then cover with dry dressing every day and as needed for 21 days. During a review of Resident 1's OSR, active physician orders as of 11/19/24, the OSR included an order, dated 11/14/24, the order indicated Resident 1 may have LAL mattress to aid [with] wound maintenance. The order did not indicate a setting for the LAL mattress. During a review of Resident 1's Preliminary Wound Report dated 11/14/24, the report indicated a wound located on the sacrococcyx that measured 4.8 centimeter (cm, unit of measurement) in length, 4.9 cm in width, and 0.1 cm in diameter. The wound report indicated 20% slough (a layer of dead tissue) and 80% granulation tissue (reddish connective tissue that forms on the surface of a wound when the wound is healing). During an interview on 11/19/24 at 3:01 pm, with the Treatment Nurse (TN), the TN stated the MDS Nurse was responsible for developing a plan of care for a resident's (in general) risk for developing PIs. The TN stated the TN developed plans of care for resident's that had actual skin integrity issue [like PIs]. The TN stated when Resident 1 was readmitted to the facility on [DATE] with sacrococcyx redness. The TN stated the TN did not develop a CP that addressed the redness on Resident 1's sacrococcyx and the TN needed to develop a plan of care to prevent the progression of the redness. During an interview on 11/19/24 at 4:59 pm, with Registered Nurse 1 (RN 1) stated when residents (in general) were readmitted from a hospitalization, RN 1 stated the licensed nurse needed to perform a head-to-toe assessment. RN 1 stated if the resident had a significant change upon readmission, the licensed nurse needed to develop or revise the CP. RN 1 stated we [the facility] needed to do an interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) CP meeting and involve other departments such as rehabilitation, dietary, and nursing. RN 1 stated the rehabilitation department needed to be involved since there was an order that indicated minimal turning for Resident 1. During an interview on 11/20/24 at 10:40 am, with the Director of Staff Development (DSD), the DSD stated [when Resident 1 was readmitted on [DATE]] there was no CNA who asked the DSD how to reposition Resident 1. The DSD stated we really did not want to turn Resident 1 too much, we would just prop up the buttocks area instead of turning to Resident 1 to the sides. 2.During a concurrent interview and review of Resident 1's medical record on 11/20/24 at 12:27 pm, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055261 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 055261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the TN, there was no readmission wound risk assessment completed for Resident 1 in Resident 1's medical record. The TN stated there was no readmission skin risk assessment done and the skin risk assessment could trigger if there was a need to develop a specific plan of care for Resident 1. The TN stated, if a skin risk assessment was completed for Resident 1 and if the risk assessment placed Resident 1 at risk for the development of PIs, the TN could have suggested to put Resident 1 on an alternating pressure pad (APP mattress pad, system that utilizes air-filled cells within a mattress, the pump regulates the inflation and deflations of the cells to alternate pressure between different areas of the body). The TN stated, the TN examined Resident 1 on 11/12/24, it was difficult to put Resident 1 in a position to examine the skin on Resident 1's buttock area well. The TN stated at that time they were still figuring out a plan on how to turn Resident 1. The TN stated, the TN discussed with the acting Director of Nursing (DON) how difficult it was to get Resident 1 in a position to clearly assess Resident 1's buttock area. The TN stated when staff turned Resident 1, Resident 1 pushed back, Resident 1 was hesitant to allow [staff] to move Resident 1 because Resident 1 did not want to be in pain. The TN stated the physician's order that indicated minimal turning meant not to turn Resident 1 too many times, but [staff] did not how many times to turn Resident 1. The TN stated the TN did not clarify the order that indicated minimal turning for Resident 1 with Resident 1's physician and the order needed to be clarified. The TN stated staff needed clear interventions involving Resident 1's care that involved Resident 1, Resident 1's family, and the rest of the care team. During an interview on 11/20/24 at 1:27 pm, RN 2 stated Resident 1's bilateral (both) arm fractures impaired Resident 1's mobility (movement) because pain led to Resident 1 refusing repositioning and Resident 1 not wanting to be touched. RN 2 stated a pressure ulcer risk assessment when completed, identified Resident 1 as high risk for the development of a PI. RN 2 stated when risk assessments were completed, the care team proceeded and conducted an IDT meeting to plan evidence-based interventions for the prevention of PIs such as using a sliding sheet or using an APP mattress. During an interview on 11/20/24 at 3:46 pm, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated on the day of 11/3/2024 (Resident 1's readmission), the licensed nurse (unidentified) had informed CNA 2 Resident 1 had limited movement because of Resident 1's bilateral arm fractures. CNA 2 stated Resident 1 was in so much pain that to check if Resident 1's adult brief, CNA 2 inserted CNA 2's hand, pressed the mattress downward [to help change the adult brief] and Resident 1's mattress got deep. The next day on 11/4/24, CNA 2 stated the previous shift had informed CNA 2 Resident 1 refused to turn. CNA 2 stated CNAs (in general) limited moving Resident 1 because that was the direction CNAs received from the licensed nurses. 3. During a concurrent observation and interview on 11/19/24 at 2:10 pm, with the TN. Resident 1's LAL mattress was set at static. The TN stated the LAL mattress was set at static and the company who delivered the mattress was responsible for setting up the mode on the LAL mattress to static. During an interview on 11/19/24 at 5:06 pm, RN 1 stated the LAL mattress needed to be set at alternating mode and not static mode because alternating pressure provided pressure relief to a resident [who was at risk for developing PIs] on a LAL mattress. During an interview on 11/20/24 at 10:40 am, with the DSD, the DSD stated when the LAL mattress was set at static mode, this made the mattress firm for staff to do patient care. The DSD stated when the LAL mattress was on alternating mode, there was air movement on the mattress. The DSD stated the DSD did not know what the setting needed to be for Resident 1 and for prevention of PIs, the DSD did not know if the LAL setting for Resident 1 needed to be in alternating or static mode. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055261 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 055261 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's P&P, titled Pressure Injury Prevention and Management date reviewed 9/26/2022, the P&P indicated the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. The P&P indicated licensed nurse will conduct a pressure injury risk assessment on all residents upon admission/readmission, weekly X 4 weeks, then quarterly or whenever the resident's condition changes significantly. The P&P indicated interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications included: changes in resident's degree of risk for developing a pressure injury, new onset or recurrent pressure injury development, resident non-compliance and changes in the resident's goals and preferences, such as at end-of life or in accordance with his/her rights. During a review of the undated LAL Manufacturer's manual, the manual indicated to turn the switch to alternating to turn on the alternating pressure function. Turn the switch to static to turn on the static mode. The manual indicated, in static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition and prevents the patient from bottoming out when in a sitting position. The manual indicated the mattress was designed for bed sore (PIs) and wound care therapy treatment and prevention, which may occur during an extended hospital stay and nursing home/long term care environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055261 If continuation sheet Page 6 of 6