Health inspection·May 31, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegation of sexual abuse for one of three sampled residents (Resident 2) to the California Department of Public Health (CDPH), the Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility ' s policy and procedure. This deficient practice potentially delays the investigation and prevention of abuse, and put Resident 2 and other residents in the facility at risk of further abuse. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that including but not limited to sequelae of cerebral infarction (long-term effects of a stroke {damage to the brain from blood supply interruption}), anxiety disorders (feelings of worry , anxiety, or fear that interfere with daily living), and depressive episodes (loss of interest in activities). During a review of Resident 2 ' s History & Physical (H&P), dated 12/7/24, the H&P indicated Resident 1 had fluctuating mental status/capacity (periods of capacity followed by periods of cognitive {ability to understand and process thoughts}). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/7/25, the MDS indicated Resident 1 was cognitively intact and required substantial/maximal assistance with shower/bathe self and partial/moderate assistance with toileting. During an interview on 5/31/25, at 5:54 pm with FAM1, FAM1 stated Resident 2 made allegations of sexual abuse when Resident 2 first came to the facility. FAM1 spoke with DON asked DON to keep him aware when Resident 2 makes abuse allegations. During an interview, on 5/31/25, at 7:23 p.m., with the Director of Nursing (DON), the DON stated there were no sexual inappropriate allegations made by Resident 2 or sexual abuse that the DON was aware of. The DON stated we have something for fabrication of stories, that ' s it. During a record review of the interview with the Administrator (ADM), the ADM stated Resident 1 ' s abuse allegations are all part of Resident 1 ' s past history. During a record review of the facility ' s Policy and Procedure (P&P), titled, Abuse, Neglect, Page 1 of 3 555894 555894 05/31/2025 Foothill Heights Care Center 1515 North Fair Oaks Ave Pasadena, CA 91103

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Exploitation, or Misappropriation- Reporting and Investigating, dated April 2021, indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and agencies (as required by current regulations), and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Immediately is defined as a) whthin two hours of an allegation involving abuse or result in serious bodily injury; b) within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 555894 Page 2 of 3 555894 05/31/2025 Foothill Heights Care Center 1515 North Fair Oaks Ave Pasadena, CA 91103

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 system was functioning for one out of three sampled residents (Resident 1). Residents Affected - Few This deficient practice at risk in delay response to resident's requests, ensure resident's safety and fulfill the needs of resident's care. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility readmitted to the facility on [DATE] with diagnoses that including but not limited to Parkinson's disease (affects movement often including tremors), chronic obstructive pulmonary disease (lung disease), and schizophrenia (disorder that affects ability to think, feel, and behave clearly). During a review of Resident 1's History & Physical (H&P), dated 4/27/24, the H&P indicated Resident 1 had fluctuating mental status/capacity (periods of capacity followed by periods of cognitive {ability to understand and process thoughts}). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/21/25, the MDS indicated Resident 1 was moderately cognitively impaired (ability to understand and process thoughts), and was independent for personal hygiene and required supervision/touching assistance with toileting hygiene. During a concurrent observation and interview, on 5/31/25, at 4:25 p.m., with Resident 1, Resident 1 stated Resident 1 needed a Certified Nurse Assistant (CNA). Resident 1 was observed sitting on the side of Resident 1's bed and Resident 1 was wearing no diaper. Resident 1 stated Resident 1's diaper was wet, and Resident 1 took Resident 1's diaper off. Resident 1's diaper was observed on Resident 1's bedside table. Resident 1 stated Resident 1 had been awake and waiting for help for about an hour. Resident 1 stated Resident 1's call light was not working. Resident 1 was observed pressing Resident 1's call light from Resident 1's bed and there was no audible sound and there was no visual light observed illuminating above bed and above door. During a concurrent observation and interview, on 5/31/25, at 4:27 p.m., with the Director of Nursing (DON), Resident 1 pressed Resident 1's call light while seated on the side of Resident 1's bed and no audible sound was heard, and there was no visual light observed. The DON stated the call light came out of the wall. During an interview, on 5/31/25, at 5:35 p.m., with the Maintenance Supervisor (MS), the MS stated it is important to check the residents' call light to ensure it functioning properly for the care and safety of residents and for emergency. During an interview, ON 5/31/25, at 7:27 p.m., the DON stated it is important for the residents' call light to be working for the patient and patient needs. During a record review of the facility's Policy and Procedure (P&P), titled, Answering the Call Light, indicated be sure that the call light is plugged in and functioning at all times. 555894 Page 3 of 3