Health inspection·April 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few boots were gone. Resident 36 stated she cried and was very upset when she could not find her boots. Resident 36 stated Resident 15 (roommate) informed her that CNA 4 took her boots and brought it to the laundry. Resident 36 said her boots were returned to her two days later. During an interview on 4/14/2025. At 9:30 AM, with Resident 15, Resident 15 stated she was in the room when CNA 4 cleaned Resident 15's closet and bedside table. Resident 15 stated she saw CNA 4 take Resident 36's Moon Pies. Resident 15 stated she did not know why CNA 4 took Resident 36's Moon Pies. Resident 15 stated she was also in the room when CNA 4 took Resident 36's boots. During an interview on 4/15/2025, at 2:52 PM, with CNA 4, CNA 4 stated the residents' closets and bedside tables were cleaned weekly. CNA 4 stated Resident 36 had a history of leaving snacks and food inside her bedside table. CNA 4 stated Resident 36 keeps old cookies from the Activity Room and puts them inside her bedside table. CNA 4 stated Resident 36 informed her that she saves the cookies for the night. CNA 4 stated she took the cookies in Resident 36's bedside table because it had been in there for more than 2 days. CNA 4 stated she did not inform Resident 36 that she was going to take the cookies away. During an interview on 4/15/2025, at 2:52 PM, with CNA 4, CNA 4 stated she was passing out the breakfast tray in Resident 36's room and noticed that Resident 36's boots were wet and smelled bad. CNA 4 stated she asked Resident 36 if laundry could wash her boots but Resident 36 refused. CNA 4 stated she informed the Charge Nurse (CN) that the bad smell in the room came from Resident 36's boots. CNA 4 stated the CN told her to take the shoes to laundry to get it washed quickly. CNA 4 stated she did not inform Resident 36 that she was going to get her boots washed. During an interview on 4/16/2025m, at 9:15 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she remembered seeing Resident 36, on an unknown date, upset while walking in the hallway. LVN 1 stated Resident 36 informed LVN 1 she was upset because her boots were washed without her permission. LVN 1 stated Resident 36 informed her that she was told that her boots needed to be washed because there was an odor that came from her boots after she removed them. LVN 1 stated Resident 36 was also upset the beginning of the week because her bedside table was cleaned, and her Moon Pies were taken. LVN 1 stated facility staff should have asked for Resident 36's permission before taking her boots to get washed and removing her Moon Pies from her bedside table. LVN 1 stated if a resident refuses to have her clothes washed or food inside her bedside table taken away then facility staff should respect that decision, inform the Supervisor, and talk to the resident again later. LVN 1 stated the facility was Resident 36's home and she should be treated with respect. During an interview on 4/16/2025, at 10:28 AM, Activities Director (AD), stated Moon Pies were given out as prices for winning games in the Activity Room. AD stated residents loved the Moon Pies because it reminded them of their childhood. AD stated the expiration dates of the Moon Pies were checked before they were given out as prices to the residents. AD stated none of the Moon Pies were about to expire. AD stated Resident 36 informed her that she accumulated the Moon Pies from winning bingo. AD stated Resident 36 informed her that she was saving the Moon Pies in case she needed to eat them later. AD stated Resident 36 informed her that her Moon Pies were taken from her bedside table and thrown out by CNA 4. AD stated Resident 36 informed her that she only gave CNA 4 permission to clean her bedside table but not to throw away her Moon Pies. AD stated Resident 36 was upset and did not understand why her Moon Pies were taken if the bags were sealed. AD stated not all residents can afford to by snacks like Moon Pies so they should not have been thrown out if the bags were still sealed. AD stated residents will feel horrible if food items that they won are taken away from them without permission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 2 of 30 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 04/17/2025 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm During an interview on 4/16/2025, at 10:34 AM, with LVN 2, LVN 2 stated winning prices in the Activity Room made residents happy and excited. LVN 2 stated taking away prices that residents won from playing games in the Activity Room would be upsetting to residents. LVN 2 stated it was Resident 36's right to be informed that her boots were going to be washed. LVN 2 stated residents would feel violated and disrespected if their belongings were taken away without permission. Residents Affected - Few During an interview on 4/16/2025, at 1:56 PM, with the Director of Nursing (DON), the DON stated facility staff clean the residents' closets and bedside tables once a week to make sure there are no old food and dirty items inside. The DON stated facility staff need to inform the residents and get permission from them before taking their belongings to laundry or throwing their food items. The DON stated the resident's room is their home and taking things from their home without asking will affect their dignity. During a review of the facility's policy and procedure (P&P) titled, Personal Property, revised on 8/2022, the P&P indicated, Resident belongings are treated with respect by facility staff, regardless of perceived value. During a review of the facility's P&P titled, Resident Rights Guidelines for All Nursing Procedures, revised on 10/2010, the P&P indicated the purpose of the P&P was to provide general guidelines for resident rights while caring for the resident. The P&P, under General Guidelines, indicated for any procedure that involves direct resident care to: Explain the procedure to the resident. Answer any questions he/she may have Ask permission to implement the procedure. If the Resident refuses, notify your supervisor. If permission is obtained, proceed with the procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 3 of 30 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 04/17/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a documented evidence that restorative nursing (a program available in nursing homes that helps residents maintain any progress made during rehabilitation therapy treatments, enabling the residents to function at a high capacity) care was provided on 4/1/2025 to 4/8/2025 and 4/10/2025 to 4/13/2025 for one of two sampled residents (Resident 18) with limited range of motion (ROM- the extent of movement of a joint) and limited mobility: This deficient practice placed Resident 18 at risk for further decline in physical function and contractures (condition of shortening and hardening muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included other secondary parkinsonism (movement disorders similar to Parkinson's disease [a movement disorder of the nervous system that worsens over time] caused by factors other than the disease itself, such as medications, brain injuries or other underlying illnesses), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (wasting away or decrease in size of a cell, organ, or tissue). During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool), dated 1/22/2025, the MDS indicated Resident 18 was assessed having moderately impaired (decisions poor, cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 18 had functional limitation in range of motion and impairment on both sides of the lower extremities (hip, knee, ankle, foot). Resident 18 was dependent (helper does all of the effort) with eating, oral/personal hygiene, toileting hygiene, shower/bathe self, lower/upper body dressing, and roll left and right. During a review of Resident 18's Joint Mobility Screening, dated 1/22/2025, the Joint Mobility Screening indicated Resident 18 had severe (greater than 50%) joint mobility loss on his right hip, left hip, right knee, and left knee. The Joint Mobility Screening indicated Resident 18 had minimal to severe loss of LE PROM and Resident 18 had a diagnosis/condition that puts him at risk for contracture development. During a review of Resident 18's Physical Therapy Discharge summary, dated [DATE], the Physical Therapy Discharge Summary under Discharge Status and Recommendations indicated the following: Orthotic Management- Splint/Orthotic Recommendations: It is recommended the patient wear a knee extension splint on left knee and on right knee for four hours in order to maintain joint integrity and maintain joint mobility. Restorative Nursing Program (RNP)- RNP/Functional Maintenance Program (FMP- physical therapy): It is recommended that patient wear a knee extension splint on left knee and on right knee for four hours in order to maintain joint integrity and maintain joint mobility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 4 of 30 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 04/17/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 18's Order Summary Report, dated 4/15/2025, the Order Summary Report indicated a physician order, with a start date of 3/2/2025, for Restorative Nursing Assistant (RNA- a certified nursing assistant [CNA] that focuses on helping residents regain or maintain their ability to perform activities of daily living [ADLs] through therapeutic interventions like ROM and physical therapy) to apply splint (a medical device used to support and prevent a body part from moving) to bilateral (both) knees, everyday (qd) five times a week, for four hours or as tolerated. During a review of Resident 18's Order Summary Report, dated 4/15/2025, the Order Summary Report indicated a physician order, with a start date of 3/2/2025, for RNA to perform passive range of motion (PROM- when the Resident applies to effort to move the joint which moved through a variety of stretching exercises) to bilateral lower extremities (LE- legs) and bilateral upper extremities (UE- arms) qd five times a week as tolerated. During a review of Resident 18's Care Plan for Restorative Nursing, revised on 4/2/2025, the care plan indicated Resident 18 required the RNA program to maintain joint mobility, to prevent further decline in function, and to prevent contracture. The care plan indicated staff interventions included were for RNA to perform PROM to BLE qd 5 times a week as tolerated, PROM exercise to both UE as tolerated qd 5 times a week, and RNA to apply splint to right knee, qd 5 times a week for 4 hours or as tolerated. During an observation on 4/14/2025, at 2:22 PM, in Resident 18's room, Resident 18 was observed lying on his right side in bed. Resident 18 did not have a splint on both knees. During an observation on 4/15/2025, at 11:30 AM, in Resident 18's room, Resident 18 was asleep in bed. Resident 18 did not have a splint on both knees. During an observation on 4/15/2025, at 12:41 PM, in Resident 18's room, Resident 18 was observed being fed his lunch in bed with the assistance of Certified Nurse Assistant 5 (CNA5). CNA 5 stated Resident 18 did not have a splint on both knees. During an interview on 4/15/2025, at 12:50 PM, with CNA 2, CNA 2 stated he also worked in the facility as an RNA and applies the residents' splints and assists the residents with RNA exercises. CNA 2 stated he was working as an RNA today and was assigned to Resident 18. CNA 2 stated Resident 18 was ordered for bilateral knee splints for four hours five days a week. CNA 2 stated he applied Resident 18's bilateral knee splints at approximately 9 AM this morning and removed them at around 11 AM before his shower. CNA 2 stated he did not reapply Resident 18's bilateral knee splints when Resident 18 returned from his shower because he went on his lunch break. CNA 2 stated the knee splint was ordered to prevent Resident 18's contractures from getting worse. CNA 2 stated Resident 18's RNA order to apply the splint to his bilateral knees was not followed. During the same interview on 4/15/2025, at 12:50 PM, with CNA 2, CNA 2 stated Resident 18 was ordered for PROM to his BLE and BUE every day five times a week. CNA 2 stated PROM exercises included moving the joints and stretching the legs and arms by straightening them as tolerated. CNA 2 stated PROM exercises are important to prevent muscle atrophy (condition that causes a progressive loss of muscle mass, strength and power) and contractures. CNA 2 stated he does not document applying the bilateral splints and providing PROM exercises on the Documentation Survey Report. CNA 2 stated he only documents it in the progress notes once a week. During an interview on 4/15/2025, at 12:57 PM, with RNA 1, RNA 1 stated he was assigned to Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 5 of 30 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 04/17/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 18 on 4/14/2025. RNA 1 stated he forgot to put Resident 18's bilateral knee splints on 4/14/2025. RNA 1 stated it was important to put Resident 18's bilateral knee splints to prevent his knees from getting stiffer. During a record review on 4/15/2025, at 3:10 PM, Resident 18's Documentation Survey Report for 4/2025 was reviewed. Resident 18's Documentation Survey Report indicated CNA 2 and RNA 1 documented Resident 18's bilateral knee splints were applied, and PROM exercises were provided as ordered on 4/14/2025 and 4/15/2025. During a concurrent interview and record review on 4/15/2025, at 3:57 PM, with the Director of Nursing (DON), Resident 18's Documentation Survey Report for 4/2025 was reviewed. The DON stated there was no documentation that Resident 18's bilateral knee splints and PROM were done from 4/1/2025 to 4/8/2025 and 4/10/2025 to 4/13/2025. The DON stated if it was not documented then it was not done. The DON stated the RNA treatments should be documented on the Documentation Survey Report right after it was provided to the resident. The DON stated Resident 18 had contractures on both knees and was ordered to wear bilateral knee splints and PROM exercises to prevent the contractions from progressing. During a review of the facility's policy and procedure(P&P), titled, Restorative Nursing Services, revised 7/2017, the P&P indicated Residents will receive restorative nursing care as needed to help promote optimal safety and independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 6 of 30 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 04/17/2025 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate care to prevent complications of a gastrostomy tube (g-tube; a surgical opening fitted with a tube device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one (1) of four (4) sampled residents (Resident 32) in accordance with the facility's policy and procedure (P&P) by not ensuring Licensed Vocational Nurse 2 (LVN 2) checked Resident 32's g-tube placement prior to administering a water flush (the process of gently pushing water through the g-tube to keep it from clogging) and medication administration. This failure had the potential to result in Resident 32 aspirating (when something enters the airway of lungs by accident) which could lead to lung problems such as pneumonia (a lung infection) and result in death. Findings: During a review of Resident 32's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dysphagia (difficulty swallowing) and pneumonia. During a review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 2/12/2025, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 32 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) with going from lying to sitting on the side of the bed, rolling left and right in bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear and personal hygiene. Resident 32 was also assessed to have a feeding tube upon admission and while a resident at the facility. During a review of Resident 32's Order Summary Report, dated 4/16/2025, the Order Summary Report indicated an enteral feed (a method of delivering nutrition directly into the gastrointestinal tract [the organs and system involved in the digestion and absorption of food] through a feeding tube) order on 2/5/2025 to check tube placement before initiation of formula, medication administration, and flushing the tube every shift. During a review of Resident 32's Order Summary Report, dated 4/16/2025, the Order Summary Report indicated an enteral feed order from 2/5/2025 indicated to check tube feeding residuals (the amount of liquid left in the stomach after a feeding) every shift, if residual is greater than 100 ml (milliliters; unit of volume), hold the feeding for 1 hour and then recheck and resume the feeding if the residual is less than 100 ml. The order further indicated to call the physician (MD) if the residual remains greater than 100 ml. During a review of Resident 32's Enteral Feed Care Plan, dated 3/13/2025, the Care Plan indicated a staff intervention to check for tube placement and gastric (stomach) contents/residual volume per facility protocol and record. Hold feed if greater than 10 cubic centimeter (cc; a unit of volume equal to 1 milliliter) aspirate (to draw out). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 7 of 30 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 04/17/2025 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm During an observation of Resident 32's medication pass in Resident 32's room on 4/16/2025 at 9:18 AM with LVN 2, LVN 2 was observed pausing the resident's feeding and then proceeded to give Resident 32 a 50 ml water flush via (by) gravity into Resident 32's g-tube. After the water flush was given, LVN 2 was then observed pushing air into Resident 32's g-tube and listening to their abdomen with her stethoscope to check for g-tube placement. Residents Affected - Few During a concurrent interview and record review on 4/16/2025 at 9:51 with LVN 2, Resident 32's Order Summary Report, dated 4/16/2025 was reviewed. Resident 32's Order Summary Report indicated an enteral feed order on 2/5/2025 indicating to check tube placement before initiation of formula, medication administration, and flushing the tube every shift. LVN 2 stated she did not check Resident' 32's g-tube placement prior to giving the initial water flush. LVN 2 stated that for checking g-tube placement, she was under the impression that she could either check for residual or push air through the g-tube while listening to the resident's abdomen for a whooshing sound. LVN 2 further stated it is important to check for g-tube placement to ensure the resident's tube is in place. During an interview on 4/17/2025 at 10:16 AM with the Director of Nursing (DON), the DON stated prior to giving a resident a flush or medication administration through the g-tube, placement must first be checked with either checking residual or giving 10-20 cc of air through the g-tube and listening with a stethoscope for a whooshing sound. The DON stated that residual should also be checked prior to medication administration because if the residual is greater than 100 cc, the resident's feeding needs to be stopped since checking residual lets staff know if the resident is tolerating their g-tube feeding. The DON further stated it is important to check for g-tube placement to make sure whatever is being administered is going where it is supposed to be going prior to giving a water flush and medication administration. During a concurrent interview and record review on 4/17/2025 at 11:43 AM with the DON, the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, revised November 2018 was reviewed. The P&P indicated its purpose is to ensure the safe administration of enteral nutrition and preventing aspiration, the P&P indicated to check enteral tube placement every four (4) hours and prior to feeding or administration of medication and to check gastric residual volume as ordered. The DON agreed with the policy and stated the way enteral tube placement should be checked is by checking residual. During a review of the facility's P&P titled, Administering Medications through an Enteral Tube, revised November 2018, the P&P indicated the purpose of the procedure was to provide guidelines for the safe administration of medication through an enteral tube. The P&P also indicated: Steps in the Procedure a. Verify placement of feeding tube a. If you suspect improper tube positioning, do not administer feeding or medication. Notify the Charge Nurse of Physician. b. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 8 of 30 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 04/17/2025 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)

F 0693 Stop feeding and flush tubing with at least 15 ml warm purified water (or prescribed amount). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 9 of 30 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 04/17/2025 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 post a No Smoking/Oxygen in Use sign outside of the room entrance door for one of one sampled resident (Resident 98) to indicate the presence of oxygen as indicated in the facility's policy and procedure (P&P). Residents Affected - Few This deficient practice had the potential to place the residents, staff, and visitors at risk for injury in an event of a fire. Findings: During a review of Resident 98's admission Record, the admission Record indicated Resident 98 was admitted to the facility on [DATE] with diagnoses that included respiratory disorders in diseases classified elsewhere, dyspnea (shortness of breath), and atelectasis (complete or partial collapse of a lung or a section of a lung). During a review of Resident 98's Minimum Data Set (MDS- a resident assessment tool), dated 4/2/2025, the MDS indicated Resident 98 was assessed having intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 98 required supervision or touching assistance with eating and oral/personal hygiene. Resident 98 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, and lying to sitting on side of bed. The MDS indicated Resident 98 was on continuous oxygen therapy. During a review of Resident 98's physician's order, dated 4/12/2025, the physician's order indicated an order for oxygen at 2-3 liters per minute (LPM), nasal cannula (a small plastic tube, which fits into the resident's nostrils for providing supplemental oxygen) or face mask, humidification (the process of adding moisture to the air), continuous. During an observation on 4/14/2025, at 10:31 AM, in Resident 98's room, Resident 98 was observed in bed with the head of the bed elevated. Resident 98 was on 3 LPM of oxygen via nasal cannula. Resident 98 did not have an No Smoking/Oxygen in Use sign posted outside his door. During a concurrent observation and interview on 4/15/2025, at 11:23 AM, with Treatment Nurse (TN) outside Resident 98's room, TN stated Resident 98 was ordered for oxygen continuously. TN stated Resident 98 did not have a No Smoking/Oxygen in Use sign posted outside his door. TN stated it was important to have the sign outside Resident 98's door to inform visitors and staff that oxygen was being used in the room and to keep flammables out of the room. TN stated residents, staff, and visitors' safety are placed at risk if a fire breaks out in the facility. During an interview on 4/15/2025, at 3:55 PM, the Director of Nursing (DON), the DON stated the facility's policy to post a No Smoking/Oxygen in Use sign outside a resident on oxygen therapy was not followed. The DON stated it was important to post a No Smoking/Oxygen in Use sign outside Resident 98's door to inform the staff and visitors that oxygen was in use and smoking around the room was a fire hazard. During a review of the facility's P&P titled, Oxygen Administration, revised on 10/2010, the P&P indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 10 of 30 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 04/17/2025 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)

F 0695 The purpose of this procedure is to provide guidelines for safe oxygen administration. Level of Harm - Minimal harm or potential for actual harm The following equipment and supplies will be necessary when performing this procedure: No Smoking/Oxygen in Use sign. Residents Affected - Few Place an Oxygen in Use sign on the outside of the room entrance door. Place an Oxygen in Use sign in a designated place on or over the resident's bed FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 11 of 30 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 04/17/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were not used unnecessarily for one of five sampled residents (Resident 35) reviewed for unnecessary medications by failing to: 1. Implement the gradual dose reduction (GDR- is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) recommendation from the consulting pharmacist to decrease Resident 35's Lexapro (medication used to treat depression [mood disorder characterized by a persistent sad, hopeless, or empty mood that can interfere with daily life] and anxiety [a feeling of apprehension, worry, or nervousness, often related to an impending threat of danger]). 2. Monitor and document for efficacy (effectiveness), and specific target behaviors: extreme sadness causing social withdrawal a state of decreased or absent interaction with others, often accompanied by a preference for solitude and a lack of engagement in social activities) and social isolation (a state where an individual experiences a lack of social contact or a minimal number of social interactions with others) for Resident 35's use of Lexapro. These deficient practices had the potential to result in use of unnecessary psychotropic medications for Resident 35 and can lead to adverse effects and consequences such as decline in quality of life and functional capacity. Findings: During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included other specified depressive (depression) episodes, other schizoaffective disorders (a mental illness that can effect thoughts, mood and behavior), and dementia (a progressive state of decline in mental abilities) without behavioral disturbance, psychotic disturbance (a state where an individual experiences a significant disruption in their ability to distinguish between reality and fantasy leading to a loss of contact with reality), mood disturbance, and anxiety. During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 35 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 35 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, upper body dressing, roll left and right in bed, and chair/bed-to-chair transfer. The MDS indicated Resident 35 required substantial/maximal assistance (helper does more than half the effort) with sit to lying, lying to sitting on side of bed, sit to stand, and walk 10 feet (ft- unit of measurement). The MDS indicated Resident 35 was dependent (helper does all of the effort) with toileting/personal hygiene, shower/bathe self, and lower body dressing. Resident 35 was taking antipsychotic (type of drug used to treat symptoms of psychosis) and antidepressant medications. During a review of Resident 35's physician order, dated 2/6/2025, the physician's order indicated for behavior monitoring- antidepressants: document number of episodes per shift of target behavior (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 12 of 30 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 04/17/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (specify m/b extreme sadness causing social withdrawal and social isolation) every shift for behavior monitoring Lexapro use. During a review of Resident 35's physician's order, dated 3/7/2025, the physician's orders indicated, Lexapro oral tablet 5 milligrams (mg- unit of measurement), give 0.5 tablet (2.5 mg) by mouth two times a day for other specified depressive episodes manifested by (m/b- observable or perceptible signs and symptoms of a disease or condition) extreme sadness causing social withdrawal and social isolation. During a review of Resident 35's Progress Note, dated 3/7/2025, under Behavioral Note, the progress note indicated Psychiatrist (Psych- a medical practitioner specializing in the diagnosis and treatment of mental illness) consulted with Resident 35 today (3/7/2925) and reviewed all medications and reports given by nurse and no increase in behaviors have been noted. The progress note indicated, Resident 35's emotional well-being has been stable, and Psych recommends slight GDR and staff to monitor and report any changes in behavior. The progress notes also indicated, Resident 35 currently stable, calm, able to comply with care and medications, some prompting or redirection at times needed. The progress note indicated GDR Lexapro 2.5 mg once daily (qd) (previous order 0.5 mg to twice a day). During a review of Resident 35's Progress Note, dated 3/7/2025, signed at 6:42 PM, by licensed nurse, under Order Note (a note that would document details like the medication's any specific instructions or contraindications related to the order) , the progress note indicated the order for Lexapro oral tablet 5 mg, give 0.5 tablet by mouth two times a day for other specified depressive episodes m/b extreme sadness causing social withdrawal and social isolation was outside of the recommended dose or frequency. The progress note indicated the frequency of 2 times per day exceeds the usual frequency daily. During a review of Resident 35's Care Plan, dated 4/12/2025, the care plan indicated Resident 35 had depression m/b extreme sadness causing social isolation withdrawal and social isolation and was at risk for side effects due to (d/t) medication usage. Resident 35's care plan interventions included to: Administer medications as ordered. Monitor/document for side effects and effectiveness- Lexapro oral tablet 5 mg, give 0.5 tablet by mouth two times a day for other specified depressive episodes m/b extreme sadness causing social withdrawal and social isolation Monitor/document/report as needed (prn) any signs and symptoms (s/sx) of depression, including: hopelessness, anxiety, sadness, insomnia (difficulty falling asleep, staying asleep, or waking up too early), anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness During a review of Resident 35's Documentation Survey Report, dated 04/2025, the Documentation Survey Report indicated Resident 35's behavior symptoms were not monitored on 4/7/2025 during the Dayshift (7 AM to 3PM), 4/10/2025 during the Dayshift, and 4/12/2025 during the Nightshift (11 PM to 7AM). During a concurrent interview and record review on 4/16/2025, at 3:38 PM, with the Director of Nursing (DON), Resident 35's Note to Attending Physician/Practitioner form, dated 2/20/2025 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 13 of 30 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 04/17/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm reviewed. The Resident 35's Note to Attending Physician/Prescriber form indicated Resident 35's psychotropic medications were due for assessment of GDR. The DON stated the form indicated Resident 35 was currently on Lexapro 5 mg daily for depression since 3/2024. The DON stated, according to the form Resident 35's physician agreed to the consultant pharmacist's GDR recommendation to decrease Lexapro to 2.5 mg every day on 3/7/2025. Residents Affected - Few During the same concurrent interview and record review with the DON, on 4/16/2025, at 3:38 PM, Resident 35's Medication Administration Record (MAR) from 3/8/2025 to 3/31/2025 and 4/1/2025 to 4/16/2025 and Resident 35's physician's order, dated 3/7/2025 were reviewed. The physician's orders indicated, Lexapro oral tablet 5 mg, give 0.5 tablet by mouth two times a day. The DON stated the physician order placed on 3/7/2025 did not reflect the physician's response to the pharmacist consultant's recommendation to decrease Resident 35's Lexapro 2.5 mg to once daily. The DON stated the MAR indicated Resident 35's Lexapro order was 2.5 mg twice daily. The DON stated according to Resident 35's MAR, Resident 35 continued to receive 2.5 mg of Lexapro two times a day from 3/8/2025 to 4/16/2025 instead of 2.5 mg of Lexapro once a day. The DON stated it was important to follow the consultant pharmacist's recommendation for GDR to see if the medication can be administered at a lower dose. The DON stated the GDR helps determine if the resident's current dose was still needed or if it can be reduced to a lower dose. The DON stated it was possible for Resident 35 to get more medication than what the resident needed if the GDR was not followed. The DON stated the RN Supervisor was responsible for making sure when the physician agrees to the consultant pharmacist's recommendation it was reflected in the physician's order and MAR. During a concurrent interview and record review on 4/17/2025, at 2:45 PM, with the MDSC and DON, Resident 35's MAR for Behavior Monitoring of antidepressants from 4/1/2025 to 4/30/2025 was reviewed. MDSC stated Resident 35's specific target behavior that needed to be monitored was extreme sadness causing social withdrawal and social isolation. MDSC stated Resident 35's specific target behavior monitoring was not done from 4/1/2025 to 4/16/2025 because the order was not carried over for the 4/2025 MAR from the 3/2025 MAR when the licensed nurses did the medication recap (reviewing the medication administration records for the next month). The DON stated if an action was not documented then it was not done. The DON and MDSN stated it was important to monitor Resident 35's specific target behavior to determine the effectiveness and necessity of his Lexapro medication. During a review of the facility's P&P, titled Psychotropic Medication Use, reviewed on 1/28/2025, the P&P indicated the following: 1) Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition document in the medical record. 2) Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications in [NAME] antidepressant. 3) Psychotropic medication management is an interdisciplinary process that involves the resident, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 14 of 30 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 04/17/2025 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)

F 0758 family, and/or representatives and includes: Level of Harm - Minimal harm or potential for actual harm a) Determining adequate indications for use. Residents Affected - Few b) Establishing appropriate dose (including duplicate therapy) and duration. c) Adequate monitoring for efficacy and adverse consequences. d) Determining appropriateness of gradual dose reduction (GDR); and 4) The prescribed dose and duration are based on the resident's diagnoses, signs and symptoms, current condition, age, existing medication regimen, labs and other test results, the type of medication, manufacturer's recommendation, accepted standards of practice for dosing, and input from the IDT about the resident's goals and preferences. 5) Residents receiving psychotropic medication are monitored and the response to treatment is documented. 6) Monitoring may include progress notes, behavior flow sheets, medication administration records, and the drug regimen review for the consultant pharmacist. 7) Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 15 of 30 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 04/17/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the storage of food was done in a safe and sanitary conditions according to the facility's policy and procedure (P&P) for twelve (12) residents reviewed for kitchen by failing to ensure: 1. Opened container of pancake and waffle syrup and creamy Italian dressing were dated with the use by date. 2. Frozen vegetables stored in the freezer were labeled with the name of the food item and dated with the use by. This deficient practice had the potential to result in residents ingesting expired food which can result in foodborne illnesses (food poisoning) with symptoms including upset stomach, vomiting, diarrhea, and fever and had the potential for the facility to serve food items not included in the scheduled menu. Findings: During a concurrent observation and interview on 4/14/2025, at 7:37 AM, of the facility kitchen, with the Dietary Supervisor (DS), the following were observed: a. One opened container of Creamy Italian Dressing in the refrigerator with a handwritten label on the lid indicating, D 3/18/25. b. One opened container of Pancake & Waffle Syrup on the bottom of the steam table with a handwritten label indicating, R 2/11/25. c. Three stacks of 16 bags of unlabeled frozen green vegetables in Freezer 1 (FR1) DS stated the date written on the opened container of Creamy Italian Dressing was the delivery date. DS stated the Creamy Italian Dressing container did not have a use by date on it. DS stated the date written on the opened container of Pancake & Waffle Syrup was the received date. DS stated the container of Pancake & Waffle Syrup did not have a use by date on it. DS stated the first two stacks of ten (10) bags of unlabeled frozen vegetables were pre-cut green beans. DS stated the third stack of six (6) bags of unlabeled frozen vegetables were pre-cut asparagus. DS stated the sixteen frozen bags were all unlabeled. DS stated the frozen green beans and asparagus looked very similar to each other. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 16 of 30 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 04/17/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 4/17/2025, at 11/22 AM, DS stated it was important that food items stored in the kitchen, refrigerator, and freezer were labeled and dated with the use by date to make sure the food served to the residents were not expired. DS stated the frozen bags of green beans and asparagus looked very similar to each other and should have been labeled with the name of the vegetable. DS stated the kitchen staff can easily pick up and cook the wrong bag of frozen vegetables because there were not labeled. DS stated there was a possibility the wrong ingredient can be added to the menu because of the unlabeled frozen bags of vegetables. DS stated the facility's P&P to label and date food items with the use by date was not followed. During a review of the facility's P&P, titled, Food Receiving and Storage, revised on 10/2017, the P&P indicated the following: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in-first out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 17 of 30 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 04/17/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a bowel and bladder assessment was documented accurately for one (1) of 12 sampled residents (Resident 33) as indicated in the facility policy. This failure had the potential for Resident 33 not to receive the appropriate incontinent (unable to control the blader or bowels resulting in the involuntary release of urine or feces) bowel and bladder care, which could lead to skin breakdown. Findings: During a review of Resident 33's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of metabolic encephalopathy (a brain disorder caused by problems with the body's chemistry and metabolism) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 33's Minimum Data Set (MDS - a resident assessment tool), dated 2/20/2025, the MDS indicated the resident was severely impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 33 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) with chair/bed-to-chair transfers, going from lying to sitting on the sided of the bed, upper and lower body dressing (the ability to dress and undress above and below the waist), putting on/taking off footwear, personal hygiene and eating. Resident 33 was also assessed to be always incontinent of bowel and bladder. During a review of Resident 33's Admission/re-admission Data Tool dated 1/20/2025, Resident 33's bowel and bladder habits were both marked as incontinent. During a concurrent interview and record review on 4/16/2025 at 10:54 AM with Director of Staff Development (DSD), Resident 33's Bowel and Bladder assessment dated [DATE] was reviewed. Resident 33's Bowel and Bladder Assessment indicated Resident 33 always voided appropriately without incontinence. DSD stated this was incorrect since Resident 33 was incontinent of both bowel and bladder DSD further stated since the Bowel and Bladder Assessment was done incorrectly, it could potentially affect the resident receiving the proper care. During a concurrent interview and record review on 4/16/2025 at 11:04 AM with DSD, Resident 33's MDS, dated [DATE] was reviewed. Resident 33's MDS indicated the resident was always incontinent of bowel and bladder. DSD stated Resident 33's Bowel and Bladder Assessment was incorrect since it indicated Resident 33 always voided appropriately without incontinence. During a concurrent interview and record review on 4/16/2025 at 11:04 AM with the Director of Nursing (DON), Resident 33's Bowel and Bladder Assessment, dated 2/20/2025 was reviewed. Resident 33's Bowel and Bladder Assessment indicated Resident 33 always voided appropriately without incontinence. The DON stated Resident 33 was incontinent, bed bound and unable to get up out of bed and therefore the documentation on the resident's Bowel and Bladder Assessment was incorrect. The DON stated that she along with the MDS consultants and Medical Records audit resident's charts weekly to ensure documentation was accurate, however Resident 33's Bowel and Bladder Assessment from 2/20/2025 must have been missed. The DON further stated it was important to ensure a resident's documentation is correct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 18 of 30 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 04/17/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete so that it shows the right status for the resident, and staff are aware of what needs to be done for the resident. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Event ID: Facility ID: 555894 If continuation sheet Page 19 of 30 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 04/17/2025 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)

F 0880 Provide and implement an infection prevention and control program. 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 observe infection control measures for five (5) of nine (9) sampled residents (Residents 9, 40, 42, 150 and 17) as indicated on the facility policy and procedure (P&P) when the facility failed to: Residents Affected - Some 1-4. Ensure facility staff donned (put on) full personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and/or a N95 respirator (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) before entering a Coronavirus (SARS-CoV-2/COVID-19; a disease caused by coronavirus characterized mainly by fever and cough and can progress to severe symptoms) positive room under contact (a type of transmission-based precaution [TBP; infection control measures used in healthcare settings to prevent the spread of pathogens] used for residents with diseases caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact) and droplet (a type of TBP used to prevent the spread of infectious agents that are transmitted through respiratory droplets) isolation for Residents 9, 40, 42, and 150 . 5. Ensure Resident 17's soiled clothes and diaper were not thrown and left on the floor. These failures had the potential to result in the spread of bacteria and virus to other residents in the facility. Findings: 1. During a review of Resident 9's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD; a chronic lung disease causing difficulty in breathing) and contact with and (suspected) exposure to COVID-19. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 3/21/2025, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. The MDS also indicated, Resident 9 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) with chair/bed-to-chair transfers (the ability to transfer to and from bed to a chair or wheelchair), going from lying to sitting on the side of the bed, putting on/taking off footwear (the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility and lower body dressing (the ability to dress and undress below the waist). The MDS indicated Resident 9 needed supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with upper body dressing (the ability to dress and undress above the waist), needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with personal hygiene and was independent with eating. During a review of Resident 9's Physician Order dated 4/7/2025, the Physician Order indicated an order to place Resident 9 on COVID-19 TBP due to COVID-19 exposure. 2. During a review of Resident 40's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of heart failure (a condition where (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 20 of 30 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 04/17/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the heart muscle is weakened or stiff, making it difficult for the heart to pump blood effectively) and COVID-19. During a review of Resident 40's MDS dated [DATE], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. The MDS also indicated Resident 40 needed partial/moderate assistance (helper does more than half the effort) with walking 50 feet and putting on/taking off footwear. The MDS indicated Resident 40 needed supervision or touching assistance with transfers (how resident move to and from bed, chair, wheelchair, chair/bed-to-chair transfers), lower body dressing and personal hygiene and needed setup or clean-up assistance with going from lying to sitting on the side of the bed, upper body dressing and eating. During a review of Resident 40's Physician Order dated 4/7/2025, the Physician Order indicated to place Resident 40 on COVID-19 transmission-based precautions due to being COVID-19 positive. 3. During a review of Resident 42's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of asthma (a chronic lung condition that causes the airways to become inflamed and narrow making it difficult to breathe) and contact with and (suspected) exposure to COVID-19. During a review of Resident 42's MDS dated [DATE], the MDS indicated the resident was cognitively intact with cognitive skills for daily decision making. The MDS also indicated Resident 42 needed supervision or touching assistance with walking 150 feet, chair/bed-to-chair transfers, putting on/taking off footwear and lower body dressing. The MDS indicated Resident 42 needed setup or clean-up assistance with going from lying to sitting on side of bed and personal hygiene and was independent with upper body dressing and eating. During a review of Resident 42's Physician Order dated 4/7/2025, the Physician Order indicated to place Resident 42 on COVID-19 transmission based precautions due to COVID-19 exposure. During a review of Resident 42's Care Plan dated 4/7/2024, the Care Plan indicated Resident 42 was at risk for COVID-19 respiratory infection due to exposure to COVID-19 positive roommate and included an intervention indicated to start on transmission-based precautions. 4. During a review of Resident 150's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of type two (2) diabetes mellitus (DM2; a disorder characterized by difficulty in blood sugar control and poor wound healing) and contact with and (suspected) exposure to COVID-19. During a review of Resident 150's MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. The MDS also indicated Resident 150 needed partial/moderate assistance with walking 10 feet and chair/bed-to-chair transfers. The MDS indicated Resident 150 needed supervision or touching assistance with going from lying to sitting on the side of the bed, putting on/taking off footwear and lower body dressing, needed setup or clean-up assistance with personal hygiene and upper body dressing and was independent with eating. During a review of Resident 150's Physician Order dated 4/7/2025, the Physician Order indicated to place Resident 150 on COVID-19 transmission based precautions due to COVID-19 exposure. During a review of Resident 150's Care Plan dated 4/7/2025, the Care Plan indicated Resident 150 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 21 of 30 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 04/17/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some was at risk for COVID-19 due to COVID-19 positive roommate exposure and included an intervention indicating to start Resident 150 on transmission-based precautions. During an observation on 4/14/2025 at 9:13 AM, in the hallway outside of Residents 9, 40, 42 and 150's room, a contact and droplet precaution sign was observed. The contact precautions sign indicated for everyone entering the room to clean hands and wear a gown and gloves on room entry. The droplet precaution sign indicated everyone entering the room must clean their hands prior to entering the room and to make sure their eyes, nose and mouth are fully covered before room entry. During an observation on 4/14/2025 at 9:19 AM, in the hallway outside of Residents 9, 40, 42 and 150's room, Certified Nursing Assistant 2 (CNA 2) was observed entering the Residents 9, 40, 42 and 150's room wearing an N95 mask and did not don (put on) a gown, gloves or face shield or goggles. During an observation on 4/14/2025 at 10:09 AM, outside of Resident 9, 40, 42 and 150's room, Housekeeping (HK) was observed inside the room wearing only a gown, gloves and a surgical mask (a loose-fitting device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment). HK was not wearing face shield/ goggles and N95 mask. During an interview on 4/14/2025 at 10:22 AM with HK, HK stated she was inside Residents 9, 40, 42 and 150's room wearing a gown, gloves, and surgical mask and did not wear face shield/ goggles and N95 mask. During an observation on 4/14/2025 at 10:25 AM outside of Residents 9, 40, 42 and 150's room, CNA 2 was observed wearing an N95 mask and donning a gown and gloves and entered the room without a face shield or goggles. During an interview on 4/16/2025 at 1:44 PM with Infection Preventionist (IP), IP stated when staff enter a COVID-19 isolation room (Residents 9, 40, 42 and 150's room), they must wear full PPE including an N95 mask, gown, gloves and face shield or eye protection to help minimize the spread or potential of catching COVID-19. During an interview on 4/17/2025 at 10:05 AM with IP, IP stated regardless of what a staff member is doing, prior to entering a COVID-19 isolation room, they need to don full PPE including wearing an N95 mask, gown, gloves and face shield or eye protection. During a review of the facility's P&P titled, Isolation - Categories of Transmission-Based Precautions revised October 2018, the P&P indicated: a. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. Contact Precautions a. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 22 of 30 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 04/17/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. b. Residents Affected - Some Staff and visitors will wear gloves (clean, non-sterile) when entering the room. c. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions a. Droplet precautions may be implemented for an individual documented or suspected to be infected microorganisms transmitted by droplets (large-particle droplets [larger than 5 microns (unit of measurement) in size] that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). b. Masks will be worn when entering the room. c. Glove, gown and goggles should be worn if there is risk of spraying respiratory secretions. During a review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) Infection Prevention and Control Measures revised May 2023, the P&P indicated, This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention (CDC; the nation's leading science-based, data-driven, service organization that protects the public's health) to prevent the transmission of COVID-19 within the facility. The P&P further indicated: a. The infection prevention and control measures that are implemented to address the SARS-CoV-2 (COVID-19) pandemic are incorporated into the infection prevention and control plan. These measures include: i. Implementing universal use of PPE for staff; ii. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 23 of 30 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 04/17/2025 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)

F 0880 Following current environmental infection prevention and control recommendations. Level of Harm - Minimal harm or potential for actual harm During a review of the CDC's guidance titled, Infection Control Guidance: SARS-CoV-2 dated 6/24/2024, the guidance indicated: Residents Affected - Some a. This guidance applies to all U.S. settings where healthcare is delivered, including nursing homes and home health. The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency. a. Implement Source Control Measures i. Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing or coughing. ii. Source control for healthcare personnel (HCP) include: 1. A National Institute for Occupational Safety and Health (NIOSH; the federal institute responsible for conducting research and making recommendations for the prevention of work-related injury and illness) Approved particulate respirator with N95 filters or higher; 2. A well-fitting facemask. a. When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g. [for example] NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during surgical procedure or during care of a patient on droplet precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. b. Source control is recommended for individuals in healthcare settings who: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 24 of 30 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 04/17/2025 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)

F 0880 i. Level of Harm - Minimal harm or potential for actual harm Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g. those with runny nose, cough sneeze); or Residents Affected - Some ii. Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure. c. Implementing Universal Use of Personal Protective Equipment for HCP i. Eye protection (i.e. goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters. d. Personal Protective Equipment i. HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. [that is], goggles or a face shield that covers the front and sides of the face). 5. During a review of Resident 17's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of sequelae (an after effect of a disease, condition or injury) of cerebral infarction (a condition where brain tissue dies due to lack of blood blow and oxygen) and lack of coordination. During a review of Resident 17's MDS, dated [DATE], the MDS indicated the resident was moderately impaired with cognitive skills for daily decision making. The MDs also indicated Resident 17 needed partial/moderate assistance with walking 50 feet, chair/bed-to-chair transfers, going from lying to sitting on side of bed, putting on/taking off footwear, lower body dressing. The MDS indicated Resident 17 needed supervision or touching assistance with personal hygiene, upper body dressing and eating. During a concurrent observation and interview on 4/14/2025 at 9:48 AM inside Resident 17's room with CNA 3, Resident 17's soiled diaper and dirty clothes were observed on the floor along with a plastic bag on the floor with some clothes inside. CNA 3 stated she left it there for a second and stated that the resident's dirty clothes and soiled diaper should not have been left on the floor like that. During an interview on 4/15/2025 at 3:05 PM with CNA 4, CNA 4 stated when assisting a resident with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 25 of 30 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 04/17/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm changing, there should be one plastic bag for the resident's soiled diaper, and one plastic bag for their dirty clothes. CNA 4 stated the resident's soiled diaper should immediately be placed inside the plastic bag and thrown away in the dirty hamper. CNA 4 stated both Resident 1's soiled diaper and clothes should not be thrown onto the floor for infection control especially since some residents like to walk around not wearing any socks. Residents Affected - Some During an interview on 4/16/2025 at 9:45 AM with IP, IP stated soiled diapers, linen and clothes are to be placed in the dirty linen and dirty hamper. IP stated all CNA's have access to clear plastic bags and the dirty linen, dirty clothes and soiled diaper should be thrown into the appropriate receptacle and not on the floor. IP also stated if a resident's dirty clothes and soiled diaper are thrown on the floor, the infection control policy is not being followed and when someone steps on the floor, it could harbor bacteria and cause cross contamination and in turn someone could step on the area and bring that bacteria to another resident's room and potentially take it back to their home. During a review of the facility's P&P titled, Laundry and Bedding, Soiled, revised October 2018, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to the best practices for infection prevention and control. The P&P also indicated: a. All used laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. Contaminated laundry is placed in a bag or container at the location where it is used and not sorted or rinsed at the location of use. During a review of the facility's P&P titled, Infection Prevention and Control Program, revised 1/28/2025, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 26 of 30 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 04/17/2025 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)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 13 of 21 resident rooms (rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21) met the square footage requirement of 80 square feet (sq. ft., unit of measurement) per resident in a multiple resident room. This failure had the potential to affect the residents' personal space, decrease freedom of mobility, and could compromise the provision of care. Findings: During an observation on 4/14/2025 from 9 AM to 1 PM , Rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21 did not meet the minimum requirement of 80 sq. ft. per resident. The residents in these rooms were able to ambulate and/or move around in their wheelchairs freely. Nursing staff were observed to have enough space to provide safe quality care and there was enough space for beds, side tables, dressers, and other medical equipment. During a review of the facility's room waiver request, dated 4/7/2025, the facility's room waiver indicated the 10 rooms with 2 beds and 3 rooms with 4 beds are in accordance with the needs of the residents with adequate space and do not have any adverse effects on the residents' health and safety. The facility's room also indicated the following: Room Sq. Ft. Beds: room [ROOM NUMBER] - 137.61 sq. ft. - 2 beds room [ROOM NUMBER]- 142.50 sq. ft. - 2 beds room [ROOM NUMBER] -142.50 sq. ft. - 2 beds room [ROOM NUMBER] 142.50 sq. ft. - 2 beds room [ROOM NUMBER] - 142.50 sq. ft. - 2 beds room [ROOM NUMBER] - 142.50 sq. ft. - 2 beds room [ROOM NUMBER] - 142.50 sq. ft. - 2 beds room [ROOM NUMBER] - 142.50 sq. ft. - 2 beds room [ROOM NUMBER] - 142.50 sq. ft. - 2 beds room [ROOM NUMBER] - 142.50 sq. ft. - 2 beds The minimum square footage for a 2-bedroom is 160 sq. ft. room [ROOM NUMBER] - 283.40 sq. ft. - 4 beds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 27 of 30 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 04/17/2025 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)

F 0912 room [ROOM NUMBER] - 294.70 sq. ft. - 4 beds Level of Harm - Potential for minimal harm room [ROOM NUMBER] - 294.70 sq. ft. - 4 beds The minimum square footage for a 4-bedroom is 320 sq. ft. Residents Affected - Some During an interview on 4/15/2025 at 12:24 PM with Certified Nursing Assistant 1 (CNA1), CNA 1 stated she has enough room to provide care to the residents to ensure safely in all the resident's rooms including Rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21. During an interview on 4/15/2025 at 1:31 PM with Licensed Vocational Nurse 1 (LVN1), LVN 1 stated that all the resident's rooms including Rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21 have enough room for her to provide proper and safe care to the residents. During interviews with residents in Rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21 both individually and collectively, the residents did not express any concerns regarding the size of their rooms. The Department would be recommending the room waiver for Rooms 1, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, and 21 as requested by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 28 of 30 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 04/17/2025 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)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 the call light (a visible and audible alarm activated by a call button) for one of 12 sampled residents (Resident 23) was within reach as indicated on care plan and facility's policy. Residents Affected - Few This failure placed Resident 23 at risk for experiencing a delay in receiving assistance from facility staff which could lead to a fall or accident. Findings: During a review of Resident 23's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of rhabdomyolysis (a serious medical condition where muscle tissue breaks down, releasing harmful substances into the bloodstream) and lack of coordination. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 1/24/2025, the MDS indicated the resident was severely impaired (difficulty with or unable to make decisions, learn, remember things) with cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 23 was dependent (helper does all of the effort; resident does none of the effort to complete the activity) for lower body dressing (the ability to dress and undress below the waist) and needed substantial/maximal assistance (helper does more than half the effort) with walking 10 feet, chair/bed-to-chair transfers, and going from a sitting to standing position. Resident 23 also needed partial/moderate assistance (helper does less than half the effort) with putting on/taking off footwear, upper body dressing (the ability to dress and undress above the waist) and eating. During a review of Resident 23's Care Plan, dated 11/2/2024, Resident 23's Care Plan indicated Resident 23 was at risk for unavoidable declines related to current medical diagnosis. The staff interventions included were to ensure call light was within reach and attend to resident's needs promptly. During a review of Resident 23's Care Plan, dated 10/29/2024, Resident 23's Care Plan indicated Resident 23 was at risk for falls related confusion, gait/balance problems, incontinence (a condition where a person experiences involuntary loss of bodily fluids, such as urine or stool), poor communication/comprehension, psychoactive drug (a chemical substance that alters brain function and produces changes in perception, mood, consciousness, cognition or behavior) use, unaware of safety needs and vision problems. The staff interventions included were to ensure the resident's call light is within reach and encourage resident to use it for assistance as needed. The care plan indicated Resident 23 needs prompt response to all requests for assistance. During a review of Resident 23's Care Plan dated 10/29/2024, Resident 23's Care Plan indicated Resident 23 has a communication problem related to a diagnosis of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). The staff interventions included was to ensure/provide a safe environment: call light in reach. During a concurrent observation in Resident 23's room and interview on 4/14/2025 at 9:27 AM with Resident 23, Resident 23's call light was observed hanging against the wall to the left side of his head of bed. Resident 23 stated he did not know where his call light was. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 29 of 30 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 04/17/2025 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)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview on 4/14/2025 at 9:34 AM with Certified Nursing Assistant 4 (CNA 4) in Resident 23's room, Resident 23's call light was observed hanging against the wall to the left side of his head of bed. CNA 4 stated Resident 23's call light was hanging behind his head of bed and out of reach. During an interview on 4/15/2025 at 11:53 AM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated the purpose of a call light was for residents to use to get in touch with anyone on the floor to ask for help and assistance. LVN 2 stated if a call light is out of reach, the resident would be at risk for not being able to get the attention and help they need. During an interview on 4/15/2025 at 3:33 PM with the Director of Nursing (DON), the DON stated the purpose of a call light was for residents to ask for help when they need it and if a call light is not within reach, it could result in the resident not being able to get the assistance needed and could possibly fall. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised March 2021, the P&P indicated, The purpose of this procedure is the ensure timely responses to the resident's requests and needs, and indicated under General Guidelines: When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 30 of 30