Other·October 9, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Amended date 5-25-2021 per IIDR decision The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA00701853 Representing the Department of Public Health: 16279, REHS, HFE I This inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint number: CA00701853

F584 SS=L Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 11/21/2020 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow its policy and keep the centralized air conditioning (A/C) units in working condition to maintain comfortable and acceptable temperature ranging from 71 to 81 degrees Fahrenheit (F, unit of temperature) for 31 of 31 residents residing in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE As a result, Residents 1, 2, 3 and 9 complained the room temperature was hot and uncomfortable. This deficient practice placed Residents 1, 2, 3 and 9 and other residents at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). On August 20, 2020, at 6:25 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was declared. The facility's Administrator was notified regarding 12 resident rooms temperatures were ranging from 84.4 F to 91.1 F affecting 31 residents in the facility. On August 27, 2020, at 4:03 p.m., the IJ was lifted in the presence of the Administrator after the implementation of the Plan of Action (POA, the action to correct the deficient practices) was verified and confirmed onsite through observation, interview and record review. The Administrator provided an acceptable POA as follow: 1. Facility's Licensed Staff and Certified Nursing Assistants offered water and cold drinks to the residents and keep all 32 residents hydrated (providing plenty of fluid/water) during the daytime. 2. Facility's Licensed Staff checked resident rooms temperature hourly and ensure the residents are comfortable with the temperature. 3. On August 27, 2020, Electrician 1 (ET 1) completed the installation of five extra electrical outlets in Rooms 4, 5, 12, 16, and 20 for five additional portable AC units. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of the facility's Certification Information, dated June 15, 2015, indicated the facility was initially certified on June 15, 2015 and was recommended for certification on July 29, 2015. According to https://www.nia.nih.gov/health/hot-weathersafety-older-adults "National Institute on Aging," under Hot Weather Safety for Older Adults, dated June 15, 2016, indicated older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F to put the residents at risk for a heat-related illness. Headache, confusion, dizziness, or nausea could be a sign of a heatrelated illness. High environmental temperatures can be dangerous to the body. In the range from 90 F to 105 F, residents can experience heat cramps (painful, involuntary muscle spasms that usually occur during heavy exercise in hot environments) and exhaustion (a state of extreme physical or mental fatigue). A review of Resident 1's Face Sheet indicated the facility admitted the resident on February 16, 2020 with diagnoses including congestive heart failure (heart muscle could not pump enough blood), pulmonary edema (extra fluid/water in the lungs) and hypertension (high blood pressure). Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/18/2020 indicated the resident had mild impairment in cognition (ability to think and process information). Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for bed mobility and walking. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 2's Face Sheet indicated the facility admitted the resident on October 4, 2020 with diagnoses including malnutrition (not enough protein and nutrition) and anxiety disorders (excessive and persistent worry about everyday situations). Resident 2's MDS, dated July 23, 2020 indicated the resident had intact cognition. Resident 2 required supervision for bed mobility, walking and personal hygiene. A review of Resident 3's Face Sheet indicated the facility admitted the resident on February 1, 2019 with diagnoses including hypertension. Resident 3's MDS dated July 13, 2020 indicated the resident had impairment in cognition. Resident 3 required supervision with bed mobility, toilet use and personal hygiene. A review of Resident 9's Face Sheet indicated the facility admitted the resident on February 4, 2020 with diagnoses including hypertension (high blood pressure) and Parkinson disease (a progressive nervous system disorder that affects movement). Resident 9's MDS, dated June 16, 2020 indicated the resident had moderate impairment in cognition. Resident 9 required supervision with bed mobility, walking and eating. A review of the facility's floor plan, undated, indicated there were 21 resident rooms with 16 occupied rooms and 5 empty rooms. A review of the facility's census dated August 19, 2020 indicated there were 32 residents in the facility, but one resident left against medical advice (32 residents). A review of the Accu-Weather Forecast for California cities dated August 19, 2020, at 5 p.m., indicated the outside temperature was at 98 F. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation and a concurrent checking of Residents' room temperature on August 19, 2020 from 5:45 p.m. to 6:25 p.m., the following temperatures were obtained: a. Outside temperature =97.6 F a. Residents 4's and 5's room (# 3) = 91.5 F b. Residents 2's and 6's room (# 11) = 92.9 F c. Residents 1's, 7's, 8's and 10's room (# 19) = 95.4 F d. Residents 11's, 12's, and 13's room (# 22) = 93.4 F During an observation on August 19, 2020, at 5:50 p.m., Resident 1 was wearing a T-shirt, a pair of shorts, with blush on both cheeks. During a concurrent interview, Resident 1 stated for about one week now, the facility "had been hot." Resident 1 stated the Administrator had put a fan in the room a couple of days ago, but it did not help. Resident 1 stated the Administrator knows the AC is not working and his room is hot. During an observation on August 19, 2020, at 6:05 p.m., Resident 2 was lying down in bed. A concurrent interview was conducted with Resident 2; Resident 2 stated it had been hot in the facility for a week. Resident 2 stated the facility put a fan in the room, but it did not cool off. During an interview on August 20, 2020, at 8:35 a.m., the Administrator stated the current owners purchased the facility about two years ago and knew that the facility's central AC system needed to be repaired or replaced. The Administrator stated at the beginning of this year when the weather was getting hot, she purchased some portable AC units and recently purchased some electric fans. The Administrator stated that the facility does not have a maintenance supervisor for one month FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE but did not explain why or who will fix the central AC system. During an interview on August 20, 2020, at 2:32 p.m., the Administrator stated she does not have the temperature log. The Administrator did not provide the temperature log for the month of July and August 2020 for review as requested. During an observation and a concurrent checking of Residents' room temperature with the Administrator using the digital (temperature-sensing instruments) and razor thermometers (instrument for determining temperature by laser) on August 20, 2020 from 2:35 p.m. to 3:05 p.m., the following temperatures were obtained: a. Outside temperature: 96.8 F b. Residents 27's room (# 2) = 90 F c. Residents 4's and 5's room (# 3) = 88.6 F d. Residents 25's and 26's room (# 4) = 88.6 F e. Residents 24's room (# 5) = 84.4 F f. Residents 16's and 17's room (# 9) = 88.9 F g. Residents 14's and 15's room (# 10) = 89.3 F h. Residents 2's and 6's room (# 11) = 91.1 F i. Residents 18's room (# 14) = 88.7 F g. Residents 9's and 19's room (# 15) = 89.4 F k. Residents 20's room (# 16) = 89.4 F l. Residents 21's and 22's room (# 17) = 90.1 F m. Residents 23's room (# 18) = 90.7 F During an interview on August 20, 2020, at 3:30 p.m., Resident 3 stated that it was "too hot." The resident stated she had been in the same room for four days; and her room had been this hot the whole time. During an observation and a concurrent checking of the Residents' room temperature with the Administrator on August 21, 2020 from 1:45 p.m. to 2:05 p.m., the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE temperatures were obtained: a. Outside temperature: 97.1 F b. Residents 4's and 5's room (#3) = 88.5 F c. Residents 9's and 19's room (# 15) = 86.2 F d. Residents 20's room (#16) = 87.5 F f. Residents 21's and 22's room (#17) = 88.1 F g. Residents 23's room (#18) = 88.7 F During an interview with the Administrator on August 21, 2020, at 3:30 p.m., she stated she would purchase additional portable A/C units and place them inside the resident rooms (did not identify which room) to lower the room temperature. During an observation on August 21, 2020, at 9:10 p.m., the portable A/C units arrived at the facility and were placed in the resident rooms that did not have an A/C unit (Rooms 5, 6, 9, 10, 16 and 20). The circuit breaker boxes tripped the safety switches because the outlets were overloaded as soon as the A/C units were plugged into the electrical wall outlet. The Administrator could not use these outlets to power the additional A/C units in Rooms 5, 6, 9, 10, 16 and 20. During an interview on August 21, 2020, at 9:30 p.m., the Administrator stated she would try to have an electrician come to the facility to add more outlets for the five portable AC units. The Administrator stated it may be difficult to get an electrician to fix the electrical issue since some electricians refuse to work on the weekend and in a nursing home. During an interview on August 22, 2020, at 11:10 a.m., the Administrator stated she will transfer some residents to other rooms so the residents would not be in rooms with temperature above 81 F. During an observation and a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE checking of the Residents' room temperatures on August 22, 2020 from 3:15 p.m. to 3:30 p.m., the following room temperatures were obtained: a. Outside temperature: 96.8 F b. Residents 26's room (#4) = 88.1 F c. Residents 24's room (#5) = 87.9 F d. Residents 9's and 18's room (#15) = 85 F e. Residents 21's and 23's room (#17) = 85.6 F f. Residents 23's room (#18) = 86.3. F g. Resident 1's, 7's, 8's, 10's room (#19) = 86.6 F h. Resident 3's and 28's, room (#20) = 89 F i. Resident 30's, 31's, and 32's room (#21) =87.6 F j. Resident 11's, 12's and 13's room (#22) = 88.5 F During an interview on August 23, at 1:35 p.m., the Administrator stated she was able to contact an electrician and he (ET 1) would come to the facility today to fix the circuit breakers for the five additional portable AC units. During an observation and a concurrent checking of Residents' room temperatures on August 23, 20020 from 3:40 p.m. and 3:55 p.m., the following room temperatures were obtained: a. Outside temperature: 92.7 F b. Residents 24's room (#5) = 96.8 F c. Residents 21's and 23's room (#17) = 86.3 F d. Residents 23's room (#18) = 87.1 F h. Resident 3's, 27's, and 28's, room (#20) = 89 F i. Resident 30's, 31's, and 32's room (#21) =86.3 F j. Resident 11's, 12's and 13's room (#22) = 89.6 F During an observation and interview on August 24, 2020 at 12:07 p.m., ET 1 came to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility. The Administrator instructed ET 1 to install five additional electrical outlets and ET 1 started to install the outlets. During a concurrent observation and interview on August 24, 2020 at 1:50 p.m., ET 1 stated he had to stop working and buy more parts to complete installing five electrical outlets. ET 1 stated he would come back today, or tomorrow morning, to continue with his work. Five minutes later, ET 1 left the facility. During an observation and the concurrent checking of Residents' room temperatures on August 24, 20020 from 3:42 p.m. and 4 p.m., the following room temperatures were obtained: a. Outside temperature: 89 F b. Residents 9's and 18's room (#15) = 85 F c. Residents 3's 21's and 23's room (#17) = 84 F d. Resident 1's, 7's, 8's, 10's room (#19) = 84 F f. Resident 30's, 31's, and 32's room (#21) = 85 F g. Resident 11's, 12's and 13's room (#22) = 84 F During an interview with Resident 9 on August 24, 2020, at 4 p.m. Residents 9 stated the room was warm. During an interview with Residents 1 on August 24, 2020, at 4:05 p.m., Resident 1 stated "they need to fix the AC." During an observation and a concurrent checking of the Residents' room temperatures on August 25, 20020 from 2:02 p.m. and 2:17 p.m., the following room temperatures were obtained: a. Outside temperature: 93 F b. Residents 9's and 18's room (#15) = 82 F c. Resident 11's, 12's and 13's room (#22) = FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 83.9 F During a telephone conference with the Administrator and the facility's Licensee, the District Supervisor and Manager on August 25, 2020 at 3:40 p.m., had informed them the surveyor would not be able to lift the IJ if ET 1 could not complete installing the 5 additional electrical lines for the five portable AC units. During an observation on August 26, 2020 at 5:35 p.m., ET 1 was installing the additional electrical wires and outlets. A concurrent interview was conducted; ET 1 stated he would not be able to complete installing five additional electrical wires and outlets for the portable AC units. During an observation and the concurrent checking of the Residents' room temperatures on August 26, 2020 from 5:40 p.m. and 6 p.m., the following room temperatures were obtained: a. Outside temperature: 90 F b. Residents 23's room (# 18) = 88 F c. Resident 1's, 7's, 8's, 10's room (# 19) = 85 F d. Resident 30's, 31's, and 32's room (# 21) = 87 F e. Resident 11's, 12's and 13's room (# 22) = 90 F During an observation and the concurrent checking of the Residents' room temperatures on August 27, 2020 at 2:57 p.m., ambient temperatures (surrounding temperatures) for all resident rooms were at or below 81 F. Outside temperature was at 97 F. Five additional outlets were installed and functioning properly. A review of the ET 1's report indicated "Job is completed on 8/27/20." The report did not contain the description of what was being done to complete the job. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555894 (X3) DATE SURVEY COMPLETED 08/27/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FOOTHILL HEIGHTS CARE CENTER 1515 N Fair Oaks Ave Pasadena, CA 91103 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy and procedure, undated, titled, "Maintenance Department," indicated the facility is to provide a clean and safe facility and grounds are maintained through preventive maintenance, corrective maintenance and a comprehensive program of scheduled inspections. A review of the facility's policy and procedure, titled, "Air Temperature," indicated prompt response to air temperature complaints is essential for maintaining acceptable levels of temperature, humidity and ventilation. The policy indicated the acceptance range for air temperature is 71 F to 81 F. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NQG011 Facility ID: CA970000174 If continuation sheet 12 of 12