Health inspection·March 7, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of alleged sexual abuse (the act of engaging in sexual activity with someone without their consent, or by using force or coercion) for one (1) of three sampled residents (Residents 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement when OMB and local law enforcement went to the facility to investigate the allegation of sexual abuse made by Resident 1 on 3/5/2025. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect resident's physical, emotional, and mental wellbeing. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus type 1 (DM type 1 , is a life-long autoimmune disease that prevents the pancreas from making insulin), schizoaffective disorders a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), and anxiety disorders (a group of mental health conditions that cause excessive fear and worry). During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 2/28/2024, the MDS indicated Resident 1 had modified independence (some difficulty in new situations only) of cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) in shower/ bathe self, lower body dressing, and putting on/taking off footwear, lying and sitting on the side of the bed, sit to stand position, toilet transfer and tub/shower transfer. During an interview with Licensed Vocational Nurse (LVN) on 3/7/2025 at 10:33 AM, LVN stated she is a mandated reporter, she must report any abuse incident or allegation of abuse to the ADM as soon as possible, she can also call police, ombudsman to report the abuse. LVN stated there is a form of SOC 341 (form used by Californian to report suspected dependent adult or elder abuse) that needs to be filled out in case of any abuse and suspected abuse happened to residents. During an interview with the Director of Nursing (DON) on 3/7/2025 at 10:43 AM, The DON stated (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 3 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 03/07/2025 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)