Health inspection·July 23, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete noted. LVN 1 stated, the hip precaution interventions on the dislocated Right hip should be on TAR. LVN 1 stayed quiet and looked at the surveyor when asked if where was the documentation for Resident 1's hip precaution interventions. During a concurrent interview and record review on 7/23/2025 at 2:40 PM with LVN 1, Resident 1's Nurses' Progress Notes (NPN) dated 5/18/2025 to 7/8/2025 were reviewed. The NPN indicated no documentation for monitoring or interventions for Resident 1's right hip dislocation. LVN 1 just looked at the surveyor and did not answer when asked if she could show the documentation for the hip precaution interventions. During an interview on 7/3/2025 at 3:35 PM with Physical Therapist 1 (PT 1), PT 1 stated, If a resident was transferred back to the facility with hip dislocation, We should update the care plan for hip precautions and follow interventions like using the abduction pillow and flex the leg a bit so the Resident's hip can be placed in proper position so the hip will be in the proper placement. If hip precaution interventions were not followed, the hip dislocation can get worse. During a concurrent interview and record review on 7/23/2025 at 4:14 PM with Director of Nursing (DON), Resident 1 Care Plan (CP) from 4/28/2025-7/8/2025 were reviewed. There was no care plan indicated for Resident 1's right hip dislocation on 5/18/2025. DON stated, there was no care plan for Resident 1's right hip dislocation. We should have a specific CP to Resident 1's hip dislocation to address his problem, what needs to be done, and right interventions can be implemented. During a concurrent interview and record review on 7/23/2025 at 4:16 PM, Resident 1 CP from 5/18/2025-7/8/2025 was reviewed. The CP did not indicate Resident 1's use of 2 antibiotics last May 19-22,2025. DON stated, If Resident 1 was using Antibiotics, we should have formulated a care plan. It is important to have a care plan to see if the problem is resolved, if we reached our goal, we have monitored and implemented the needed interventions. During a concurrent interview and record review on 7/23/2025 at 4:19 PM with DON, Resident 1's NPN dated 5/18/2025 to 7/8/2025 were reviewed. The NPN did not have documentation of hip precautions for Resident 1's Right hip dislocation. DON stated, there was no documentation of Resident 1's Right Hip dislocation interventions implementation like using an abduction pillow, repositioning the Resident. We should have documentation for using abduction pillow, to make sure we monitor placement and Resident 1's right hip. During a review of the undated facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.e. reflects currently recognized standards of practice for problem areas and conditions.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes. Event ID: Facility ID: 555894 If continuation sheet Page 2 of 4 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 07/23/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide the necessary wound care and treatment for one (1) of three (3) sampled residents (Resident1) accordance with facility's policy ( Wound Care) when: a. Licensed Nursing staff did not monitor Resident 1 for signs and symptoms of infection, pain and discomfort of the right hip abscess (collection of pus in any part of the body) on every shift from 6/1/2025 - 6/23/2025.b. Treatment orders were not provided on every shift from 6/1/2025 - 6/23/2025. These deficient practices had the potential to delay in healing Resident 1's right hip abscess which can lead to worsening of the wound and affect the resident's overall well-being and quality of life. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted [DATE]. Resident 1's diagnoses included right hip prosthesis sequela (refers to the long-term consequences or complications arising from a right hip replacement. These can include pain, stiffness, limited range of motion, and issues related to the prosthesis itself, such as loosening or infection), sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection) and right hip dislocation (occurs when the ball (femoral head) of the hip joint is forced out of socket (acetabulum) on the right side). During a record review of Resident 1's History and Physical (H&P) in General Acute 1 (GACH 1) dated 5/15/2025, the H&P indicated Resident 1 presents to the emergency department with a right hip abscess noted 3 days ago. Resident 1 appeared systemically ill with signs of sepsis, including fever, tachycardia (heart rate [HR] faster than normal, over 100 beats per minute at rest), tachypnea (respiratory rate [RR] exceeding normal, more than 20 breaths per minute), and hypotension (low blood pressure). Laboratory studies reveal leukocytosis (high white blood cell [WBC], a condition characterized by an elevated number of white blood cells {leukocytes} in the bloodstream, often a response to various stimuli, including infections, inflammation, or other immune system challenges) of 11.6 (normal range 4.5-11.0) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/23/2025, the MDS indicated Resident 1 has intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) in eating, oral hygiene, toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, sit to lying, and lying to sitting on the side of bed. During a record review of Resident 1's Physician's Order indicated, 1. On 5/18/2025, a. Treatment: Monitor for signs and symptoms of pain/discomfort to right hip every shift b. Treatment: Monitor wound for any signs and symptoms of infection such as increase in drainage, odor, color of drainage, swelling, redness to surrounding area, then notify MD if observed every shift.2. On 5/20/2025, Treatment: Cleanse with Normal Saline (NS), Pat dry, paint with Betadine on outer side of wound allow to dry, apply dry extra absorbent every shift for right hip abscess.3. On 6/3/2025, Treatment: Cleanse with NS, pat dry, apply A&D ointment, and cover with foam dressing and as needed (PRN) when soiled or dislodged every shift for right hip abscess. During a concurrent interview and record review of Treatment Administration Record (TAR) on 7/23/2025 at 2:44 PM with Licensed Vocational Nurse 2 (LVN 2), Resident 1's TAR dated 6/1/2025-6/30/2025 was reviewed. There was no signature on 6/1/2025, 6/3/2025, 6/6/2025-6/8/2025, 6/11/2025, 6/13/2025-6/15/2025, 6/23/2025. LVN 2 stated, the empty spaces meant they were not done, because they were not signed. During a concurrent interview and record review of TAR on 7/23/2025 at 2:45 PM with LVN 1, Resident 1's TAR dated 6/1/2025-6/30/2025 was reviewed. There was no signature on 6/1/2025, 6/3/2025, 6/6/2025-6/8/2025, 6/11/2025, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555894 If continuation sheet Page 3 of 4 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 07/23/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 6/13/2025-6/15/2025, 6/23/2025. LVN 1 stated, the dates that were not signed were mostly registry staff. I cannot answer that question if what was the reason that it was not signed. I just work here. I am not responsible for other people's work. During a concurrent interview and record review of TAR on 7/23/2025 at 4:04 PM with Director of Nursing (DON), Resident 1's TAR dated 6/1/2025-6/30/2025 was reviewed. There was no signature on 6/1/2025, 6/3/2025, 6/6/2025-6/8/2025, 6/11/2025, 6/13/2025-6/15/2025, 6/23/2025 for Resident 1's wound treatment on the right hip. DON stated, I am sure the staff did the treatment, but they just forgot to sign the TAR. If it was not signed, it means we did not do it. It is an inaccurate documentation. During a concurrent interview and record review of TAR on 7/23/2025 at 4:06 PM with DON, Resident 1's TAR dated 6/1/2025-6/30/2025 was reviewed. There was no signature on 6/1/2025 (AM and PM shift), 6/6/2025-6/8/2025 (AM shift), 6/10/2025 (NOC shift), 6/11/2025 (AM shift), 6/13/2025(AM shift), 6/14/2025-6/15/2025(AM and PM shift), 6/23/2025 (AM shift) for Resident 1's right hip wound monitoring for infection, pain and discomfort. DON stated, The staff did not sign the wound monitoring and assessment which indicates it was not done. There were no assessment and monitoring performed on Resident 1 if those dates and shifts were not signed. During a review of the undated facility's Policy & Procedure (P&P) titled, Wound Care, The P&P indicated, the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation: The following information should be recorded in the resident's medical record:1. The type of wound care given.2. The date and time-the wound care was given.4. The name and title of the individual performing wound care.5. Any change in the resident's condition.6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.1 0. The signature and title of the person recording the data Event ID: Facility ID: 555894 If continuation sheet Page 4 of 4