Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on observation, interview, and record review, the facility failed to ensure to post the accurate and
complete Census and Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of
work performed per patient day by a direct caregiver) in accordance with the facility's policy and procedure
by:
Residents Affected - Some
1.
Facility did not post the DHPPD on 9/16/2024 in a prominent place readily accessible to resident and
visitors.
2.
Facility failed to ensure the posted DHPPD for 9/8/2024 to 9/12/2024 were complete and indicated the total
number and actual hours of licensed and unlicensed nursing staff who worked and directly responsible for
resident care.
These deficient practices had the potential for the Nurse Staffing Information not to be available to the
residents and visitors at any given time.
Findings:
During an observation at the facility entrance on 9/16/2024 at 11:21 AM, there was no DHPPD Form posted
by the entrance.
During a concurrent record review of the DHPPD Form dated 9/11/2024 and interview with the Director of
Staff Development (DSD) on 9/16/2024 at 11:22 AM, DHPPD Projected hours dated 9/11/2024 was the
one posted on the wall at the facility entrance. DSD stated, DHPPD form was not updated, and she was not
able to create and post the DHPPD form for 9/16/2024. DSD stated, she is responsible in posting the
DHPPD form at the facility entrance and not anywhere else in the facility to ensure it is visible to residents
and visitors.
During an observation and record review of the DHPPD Forms dated 9/8/2024 to 9/12/2024 posted at the
entrance of the facility on 9/16/2024 at 11:35 AM, DHPPD forms dated 9/8/2024 to 9/12/2024 in the posting
were incomplete. The DHPPD forms only indicated the projected hours of the DHPPD forms posted on the
wall with the following dates: 9/8/2024, 9/9/2024, 9/10/2024, 9/11/2024, and 9/12/2024.
During a concurrent record review of the DHPPD Forms dated 9/8/2024 to 9/12/2024 and interview with
DSD Consultant (DSDC) on 9/16/2024 at 11:38 AM, DSDC verified the DHPPD Forms dated 9/8/2024 to
(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:
555894
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
555894
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Foothill Heights Care Center
1515 North Fair Oaks Ave
Pasadena, CA 91103
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 0732
Level of Harm - Potential for
minimal harm
Residents Affected - Some
9/12/2024 were incomplete, the actual direct service hours were not added. DSDC stated, The DHPPD
projected forms should be completed within 24 hours, after the staff completed the working hours.
During a concurrent record review of the DHPPD Form dated 9/11/2024 and interview with Accounts
Payable and Payroll Director (APPD) on 9/16/2024 at 11:40 AM, APPD stated, The actual DHPPD dated
9/11/2024 was not completed after 24 hours. I was sick. I was working remotely. I need to get the staff
hours to complete the time for the actual DHPPD. I was not able to do the actual DHPPD form for 9/11/2024
and the other dates (9/8/2024-9/12/2024). I have until today (9/16/2024) to complete it.
During an interview with the DSD on 9/16/2024 at 11:47 AM, DSD stated she is the one responsible for the
posting of the DHPPD Projected hours of staffing, but the APPD is the one who completes the Actual
DHPPD Form because APPD collects the hours of the staff who worked from the previous day.
During a concurrent record review of the facility's policy and procedure titled, Posting Direct Care Daily
Staffing Numbers revised date on 7/2016, and interview with the DSD on 9/16/2024 at 12:35 PM, DSD
stated the DHPPD Form is posted within two (2) hours at the beginning of each shift. DSD stated, I am the
one responsible for posting that (DHPPD form). I was not able to do it today because I was busy to help
with issue in the kitchen. The purpose of the posting was for the staff to see if we have enough staffing for
the whole shift, and for the family/visitors to see and assuring them we have enough staff. If the APPD is
sick, I have to be the one who covers her. She informed us that she was sick, but she did not endorse the
completion of the actual DHPPD form. DSD stated, the DSD was busy with other residents that is why DSD
was not able to complete the DHPPD Form for 9/16/2024.
During an interview with APPD on 9/16/2024 at 1:05 PM, APPD stated, Actual DHPPD Form is part of my
daily responsibility. We complete the actual NHPPD daily unless it is holiday/weekend. If I am sick no one
has access to payroll, they need must have the actual hours. The DSD can do it and they can use the sign
in sheet to compute the actual hours. The purpose of staffing to inform the staff that we have enough
coverage for the staffing.
During a concurrent record review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers
revised on 7/2016 and interview with the DSD on 9/16/2024 at 1:11PM, the policy indicated within two (2)
hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number
of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent
location(accessible to residents and visitors) and in a clear and readable format. Within two (2) hours of the
beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the
Nursing Staff Directly Responsible for Resident Care Form. DSDC stated, the policy indicated the posting
of DHPPD has to be 2 hours at the beginning of each shift and it t is the DSD's responsibility. DSDC stated
we missed it today (9/16/2024) and the purpose of staffing is to inform everyone that we have enough
coverage for the staffing.
During a review of the facility's policy and procedure titled, Posting Direct Care Daily Staffing Numbers
revised on 07/2016, indicated the previous shift's forms shall be maintained with the current shift form for a
total of 24 hours of staffing information in a single location. Once a form is removed, it shall be forwarded to
the director of nursing services' office and filed as a permanent record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555894
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
FAQ · About this visit
Common questions about this visit
What happened during the September 17, 2024 survey of FOOTHILL HEIGHTS CARE CENTER?
This was a inspection survey of FOOTHILL HEIGHTS CARE CENTER on September 17, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FOOTHILL HEIGHTS CARE CENTER on September 17, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Post nurse staffing information every day."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.