Other·March 24, 2017

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during the investigation of an entity self-reported incident. Entity reported incident: CA00494123 Highest S/S=G Categories: - Transfer - Substantiated with no regulatory violations - Quality of Care - Substantiated with regulatory violations- Refer to F309 Representing the Department: 36290 The inspection was limited to the specific component(s) investigated and does not represent the findings of a full inspection of the facility.

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 03/30/2017 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055261 (X3) DATE SURVEY COMPLETED 03/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PILGRIM PLACE HEALTH SERVICES CENTER 721 Harrison Ave Claremont, CA 91711 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to provide appropriate care and intervention for 1 of 4 sampled residents (Resident 1), by failing to: 1. Notify Resident 1's physician of the resident's multiple hypoglycemic (blood glucose less than 70 mg/dl [milligrams/deciliter) attacks promptly. 2. Implement the facility's "Nursing Care of the Resident with Diabetes Mellitus" policy and procedure. As a result of these deficient practices, Resident 1 was transferred to an acute hospital due to an altered state of consciousness, difficulty breathing, and low blood sugar. Findings: A review of the face sheet indicated Resident 1 was admitted to the facility on 06/26/16 with diagnoses that included: pneumonia (infection that inflames the air sacks in the lungs), difficulty walking, muscle weakness, pressure ulcer (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/ friction), Type 2 diabetes mellitus (too much sugar in the blood), endstage renal disease (kidneys no longer able to work), renal dialysis (artificial process of eliminating waste from the blood), heart failure, chronic obstructive pulmonary disease (a group of lung diseases that block airflow), and heart pacemaker (device placed in the chest to help control abnormal heart rhythm). A review of the Minimum Data Set (MDS, standardized assessment and care screening tool), dated 06/28/16 indicated Resident 1 was able to understand and be understood by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055261 (X3) DATE SURVEY COMPLETED 03/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PILGRIM PLACE HEALTH SERVICES CENTER 721 Harrison Ave Claremont, CA 91711 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE others. A review of the admission care plan dated 06/26/16 indicated that Resident 1 was a diabetic alert. The care plan's goal for Resident 1 indicated: no hypoglycemic complications. The staff was to observe for signs and symptoms that indicated hypoglycemia. A review of Resident 1's care plan for the risk of blood sugar fluctuations related to Diabetes Mellitus dated 06/26/16 indicated that the goal for Resident 1 was for blood sugar to be within normal limits of 70-110 mg/dl. The interventions for the nursing staff were: - Monitor for hypoglycemic reactions: headache, sweating, tachycardia (abnormally rapid heart rate), nervousness, and change in level of consciousness to coma. - Check blood sugar as ordered or as needed. - Give medications as ordered and note its effectiveness. The physician's order dated 06/26/16 indicated Resident 1's medications included Glipizide (oral medication which reduces blood sugar levels) 10 milligrams (mg) taken daily for diabetes mellitus. A review of Resident 1's 6/27/16 Medication Administration Record (MAR) indicated the following: 1. At 6:30 a.m. = the blood sugar was 103 mg/dl. 2. At 11:30 a.m. = the blood sugar was 81 mg/dl. 3. At 4:30 p.m. =the blood sugar was not done due to the resident was still out to dialysis appointment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055261 (X3) DATE SURVEY COMPLETED 03/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PILGRIM PLACE HEALTH SERVICES CENTER 721 Harrison Ave Claremont, CA 91711 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Dialysis Assessment Sheet dated 06/27/16, completed by the dialysis center, indicated Resident 1 arrived at the dialysis center (time not indicated) with a blood sugar of 49 mg/dl (low). Resident 1 was given dextrose (a form of glucose- time, and route of medication administration were not documented). Resident 1's blood sugar increased to 170 mg/dl. Resident 1 returned to the facility at 8:45 p.m., the blood sugar was checked at this time with the result of 61 mg/dl. There was no documented evidence the facility staff reviewed the dialysis assessment sheet from the dialysis center identifying Resident 1 was treated with hypoglycemia (low blood sugar). A review of the licensed nursing progress notes dated 06/27/16 at 9:51 p.m. indicated Resident 1 drank 100% of Ensure (nutritional shake). No blood sugar result documented. Vital signs were taken with normal results. A review of Resident 1's MAR and licensed nursing notes dated 06/28/16, indicated: 1. At 6:30 a.m. - Blood sugar check - 59 mg/dl (Low). There was no documented evidence the staff administered orange juice for the low blood sugar as ordered by the physician. 2. At 7:00 a.m. - Resident 1 refused breakfast. 3. At 8:15 a.m., 2 ounces of orange juice was given to Resident 1, Resident 1 was awake, alert, and oriented. There was no evidence the blood sugar was checked 15 minutes after the orange juice administration in accordance to the facility's policy and procedure. 4. At 8:30 a.m., Resident 1 complained of shortness of breath stating, "Lord I can't FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055261 (X3) DATE SURVEY COMPLETED 03/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PILGRIM PLACE HEALTH SERVICES CENTER 721 Harrison Ave Claremont, CA 91711 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE breathe." Oxygen saturation was 94 %. Albuterol (breathing treatment) 2 puffs were administered. There was no documented evidence Resident 1's physician was notified. 5. At 9:00 a.m. = Glipizide 10 mg medication was given by mouth. According to "drugs.com" dated 10/15/15, Glipizide should be taken 30 minutes before breakfast. Glipizide may cause low blood sugar levels that make you anxious, sweaty, weak, dizzy, or drowsy. The risk of low blood sugar may be increased by skipping meals. https://www.drugs.com/glipizide.html Review of the nursing notes dated 06/28/16 indicated: - At 11:00 a.m., 2 Certified Nursing Assistant's (CNAs) noticed Resident 1 was restless. The CNAs called for help and vital signs were taken: blood pressure 138/86, heart rate 118, respirations 18, temperature 97.9, and oxygen saturation of 95 % with oxygen administration. - At 11:10 a.m., Resident 1's blood sugar was 39 mg/dl (low=last blood sugar check was at 6:30 a.m. [59 mg/dl]). Resident 1 was given 1 mg Glucagon (medication used for severe low blood sugar) injection in the muscle. There was no evidence the physician was notified of the resident's low blood sugar. - At 11:20 a.m., Resident 1's blood sugar was 51 mg/dl (low). - At 11:25 a.m., RN 1 called 911 paramedics. - At 11:30 a.m., two blood sugar readings were documented, 59 mg/dl and 65 mg/dl (low). - At 11:35 a.m., 911 paramedics arrived at the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055261 (X3) DATE SURVEY COMPLETED 03/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PILGRIM PLACE HEALTH SERVICES CENTER 721 Harrison Ave Claremont, CA 91711 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility. - At 12:15 p.m., Resident 1's Secondary Contact (SC) was called by the facility and made aware that Resident 1 had a change of condition due to an episode of nonresponsiveness (not able to speak, minimal movement, and sluggish). - At 12:30 p.m., SC arrived at facility and told Resident 1 "Hey you're not looking good." Resident 1 responded, "No not good." - At 12:50 p.m., Resident 1 was taken to the hospital via 911 paramedics. A review of the hospital notes dated 06/30/2016 indicated Resident 1 was admitted with low blood sugar of 68 mg/dl, possible sepsis (life threatening complication of infection), severe malnutrition, hypertension (high blood pressure), and elevated troponin (proteins found in heart muscle). Resident 1 was administered various emergency medications to help increase the blood sugar but could not be stabilized, Resident 1 also "had dialysis and continued to be hypoglycemic [low blood sugar]." A review of the Nursing Care of the Resident with Diabetes Mellitus policy and procedure with a revision date of December 2015 indicated the management of hypoglycemia: 1. For asymptomatic (no symptoms) and responsive residents with hypoglycemia (less than 70 mg/dl or less than the physicianordered parameter): a) Give the resident an oral form of rapidly absorbed glucose (4 ounces of juice or 5 to 6 ounces of soda). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055261 (X3) DATE SURVEY COMPLETED 03/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PILGRIM PLACE HEALTH SERVICES CENTER 721 Harrison Ave Claremont, CA 91711 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b) Recheck blood glucose in 15 minutes: i) If blood sugar is less than 70 mg/dl repeat oral glucose and recheck blood glucose in 15 minutes. ii) If no improvement, notify physician for further orders. 2. For symptomatic (lethargic, drowsy) but responsive (conscious) residents with hypoglycemia (less than 70 mg/dl or less than the physician-ordered parameter): a) If unable to swallow: i) Immediately administer oral glucose paste to the buccal mucosa, intramuscular glucagon, or 50 % dextrose in the vein. ii) Recheck blood glucose in 15 minutes. On 07/18/16 at 12:35 p.m., an interview was conducted with Registered Nurse 1 (RN 1). RN 1 stated on 06/28/2016 at 8:30 a.m., the Licensed Vocational Nurse 1 (LVN 1) informed her Resident 1 was having difficulty breathing. On the same date at 11:00 a.m., LVN 1 informed RN 1 that Resident 1 was "not really responsive." RN 1 stated she tried to arouse Resident 1 by speaking to him but Resident 1 was only able to open his eyes, not able to speak, and had minimal movement. RN 1 stated Resident 1 was "lethargic" (drowsy). On 7/18/16 at 3:56 p.m., an interview was conducted with the Director of Nursing (DON). DON stated that when a resident's blood sugar reaches 59 mg/dl, the doctor should be notified and that nurses should reassess residents who are given orange juice for hypoglycemia; she stated that the nurse should have rechecked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055261 (X3) DATE SURVEY COMPLETED 03/07/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PILGRIM PLACE HEALTH SERVICES CENTER 721 Harrison Ave Claremont, CA 91711 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the blood sugar for the low blood sugar episode (59 mg/dl) that occurred at 6:30 a.m., on 06/28/16 to make sure Resident 1 was better. The DON stated that the doctor should have been notified about the notes written by the dialysis center staff that was on the Dialysis Assessment sheet (Resident 1's arrival to the dialysis center with a blood sugar of 49 mg/dl). DON stated that the staff failed to provide Resident 1 with enough interventions to reverse the hypoglycemic state and that the staff should not have administered Glipizide because it lowers the blood sugar. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YYJZ11 Facility ID: CA950000084 If continuation sheet 8 of 8