Other·November 25, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an investigation of two complaints. Complaint Intake Number: CA00707189 and CA00708050. Representing the Department of Public Health: REHS: #43230. The inspection was limited to the specific complaint(s) investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint numbers CA00707189 and CA00708050.

F921 SS=F Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 10/01/2020 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain its centralized air conditioning (A/C) units in working condition and maintain comfortable room temperature for 37 of 37 residents and staff. Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 and Staff 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: CVGL11 Facility ID: CA970000174 If continuation sheet 1 of 7 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 10/27/2020 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 1 complained the room temperature was hot for them and made them feel uncomfortable. This deficient practice placed all residents and staff 1 at risk for dehydration (excessive loss of body water) and possible heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). Findings: A review of the facility's census dated October 1, 2020 indicated there were 37 residents in the facility. The facility's floor plan indicated 17 of 20 resident rooms were occupied. During an observation of the facility's roof, on October 1, 2020, at 1:10 p.m., there were 2/3 of shingles missing from the roof, and 5 centralized AC units were removed. There were multiple holes on the roof exposing plywood with ducts, and roofing materials stored on top of the roof. During an observation and a concurrent checking of resident rooms temperature on October 1, 2020 from 1:30 p.m. to 4:05 p.m., the following temperatures were obtained: a. Outside temperature = 98 degrees Fahrenheit (F). a. Resident 1's room (# 16) = 89 F b. Resident 2's room (# 15) = 88 F c. Resident 3's room (# 20) = 87 F d. Resident 4's room (#17) = 91 F e. Resident 5's room (#22) = 86 F f. Resident 6's room (#5) = 83 F According to the Accu-Weather Forecast for California citifies, dated October 1, 2020, at 3:30 p.m., indicated the outside temperature was at 101 F. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVGL11 Facility ID: CA970000174 If continuation sheet 2 of 7 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 10/27/2020 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 on October 1, 2020, at 1:30 p.m., Resident 1 was wearing a thin shirt and a pair of shorts. There was 1 fan in the room, it was turned on. During a concurrent interview, Resident 1 stated for about 2 days, the facility "had been hot." Resident 1 stated the administrator had put a fan in the room for about a month, but it did not help. Resident 1 stated the administrator knows the AC was not working and her room was hot. During an observation on October 1, 2020, at 2:05 p.m., Resident 2 was sitting on her bed, there was a fan running and facing to the resident's roommate. A concurrent interview was conducted with Resident 2; Resident 2 stated it had been warm and uncomfortable in the facility for couple of days. Resident 2 stated she did not want a fan or portable AC in her room, and preferred central air that not directly forcing air to her face. During an observation on October 1, 2020, at 2:10 p.m., Resident 3 was lying in bed. A concurrent interview was conducted with Resident 3; Resident 3 stated it had been hot in the facility for 2 days. Resident 3 stated the facility put a fan and portable AC in her room, but it did not cool off. During an observation on October 1, 2020, at 3:45 p.m., Resident 4 was walking around her bed and used her hands to fan off. A concurrent interview was conducted with Resident 4; Resident 4 stated the room is warm and would like the room to be cooler. During an observation on October 1, 2020, at 3:47 p.m. Resident 5 was lying in his bed, wearing T-shirt and short. During a concurrent interview, Resident 5 stated the room was hot and uncomfortable. The resident stated the administrator had put fans and 2 portable AC FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVGL11 Facility ID: CA970000174 If continuation sheet 3 of 7 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 10/27/2020 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 units but it is still hot. During an observation on October 1, 2020, at 3:48 p.m., Resident 6 was lying in her bed, wearing a thin dress; her dress was pulled up to her thigh and blush on both cheeks. During a concurrent interview, Resident 6 stated it was hot in her room for 3 days and would like some ice to cool off. During an observation on October 1, 2020 at 3:56 p.m., Certified Nursing Assistant 1 (CNA1) was sweating while walking in the hallway. During a concurrent interview, CNA1 stated it was hot, and it was challenged for her to work in this condition. During an interview on October 1, 2020 at 4:00 p.m., the administrator stated the room temperature was hot because the shingle roofing materials were removed and exposing plywood and holes on the roof. The administrator also stated she purchased some portable AC units, electric fans, covered resident windows with linen drapes and used ice baths to keep the room temperature down. The administrator added the roof installation will be done by the end of the day of October 5, 2020 and there was nothing that can be done at the time. She stated she had exhausted all of her options. During an observation and a concurrent checking of the resident rooms temperature with the administrator using the digital (temperature-sensing instruments) and laser thermometers (instrument for determining temperature by laser) on October 1, 2020 at 5:30 p.m. The following temperatures were obtained: a. Outside temperature = 99 F b. Resident's room (# 1) = 88 F c. Resident's room (# 2) = 84 F FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVGL11 Facility ID: CA970000174 If continuation sheet 4 of 7 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 10/27/2020 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 d. Resident's room (# 3) = 84 F e. Resident's room (# 4) = 85 F f. Resident's room (# 5) = 84 F g. Resident's room (# 6) = 84 F h. Resident's room (# 7) = 86 F i. Resident's room (# 9) = 91 F g. Resident's room (# 10) = 88 F k. Resident's room (# 11) = 89 F l. Resident's room (# 12) = 90 F m. Resident's room (#15) = 91 F n. Resident's room (#16) = 91 F o. Resident's room (#17) = 91 F p. Resident's room (#18) = 90 F q. Resident's room (#19) = 92 F r. Resident's room (#20) = 89 F s. Resident's room (#21) = 86 F t. Resident's room (#22) = 87 F u. Resident's room (#23) = 89 F During an interview on October 1, 2020, at 5:36 p.m., Resident 8 stated that it was "too hot." Resident 7 stated it was warm, Resident 1 stated it was warm, Resident 2 stated it was hot. Resident 6 stated it was too hot to eat and she could only drink water at this time. On October 1, 2020, at 6:23 p.m., the administrator was informed that the facility would be depopulated immediately (removal of all residents from the facility). On October 1, 2020, at 7:00 p.m., the local fire department captain informed the administrator that all the residents in the facility would be transferred to another skilled nursing facility. During an observation and a concurrent checking of the residents' room temperature on October 1, 2020 at 7:15 p.m., the following temperatures were obtained: a. Outside temperature = 97 F b. Resident's room (#12) = 86 F c. Resident's room (#11) = 86 F FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVGL11 Facility ID: CA970000174 If continuation sheet 5 of 7 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 10/27/2020 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 d. Resident's room (#10) = 87 F e. Resident's room (#9) = 88 F f. Resident's room (#14) = 89 F g. Resident's room (#15) = 90 F h. Resident's room (#16) = 90 F i. Resident's room (#17) = 90 F j. Resident's room (#18) = 88 F k. Resident's room (#19) = 91 F l. Resident's room (#20) = 89 F m. Resident's room (#21) = 85 F n. Resident's room (#22) = 87 F o. Resident's room (#23) = 88 F p. Resident's room (#7) = 87 F q. Resident's room (#6) = 83 F r. Resident's room (#5) = 83 F s. Resident's room (#4) = 87 F t. Resident's room (#3) = 81 F u. Resident's room (#2) = 84 F v. Resident's room (#1) = 92 F During an interview on October 1, 2020, at 7:21 p.m., Resident 6 stated it was too hot to eat and she could only drink water to cool off. During an interview on October 1, 2020, at 7:43 p.m., the administrator stated SNF 2 located in Temple City had one empty unit that could accommodated all 37 residents and the facility would provide transportation. During an observation between 9:20 p.m. and 11:11 p.m., the facility's 37 residents were transferred out of the facility. Numerous ambulances transported the residents to SNF 2 with the assistance from the local fire department, the local public health nurse, and the police department. During an observation between 11:15 p.m. and 11:30 p.m., Surveyor 1, 2, 3 and 4, a Public Health Nurse (PHN 1), and Fire Chief conducted a walk-through of the facility to verify FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CVGL11 Facility ID: CA970000174 If continuation sheet 6 of 7 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 10/27/2020 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 that there were no residents left in the facility. 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: CVGL11 Facility ID: CA970000174 If continuation sheet 7 of 7