Foothill Heights Care Center
FOOTHILL HEIGHTS CARE CENTER in PASADENA, CA — inspection on March 26, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 3/26/2026, at 12:20 PM with CNA 2, CNA 2 stated facility staff supervised the front door to make sure the residents do not leave the facility. CNA 2 stated she last saw Resident 1 in the hallway on 3/14/2026 at approximately 8:40 PM, when she got her lunch. CNA 2 stated at 9 PM, LVN 1 stated Resident 1 was missing and called a Code [NAME] (an emergency code for elopement).
During an interview on 3/26/2026, at 2:19 PM with LVN 1, LVN 1 stated there facility staff always supervised the front door to monitor residents and make sure the residents are safe. LVN 1 stated on 3/14/2026, at around 8:40 PM, Resident 1 was sitting in her wheelchair by the Nurse's Station while CNA 3 supervised the front door. LVN 1 stated she left the Nurse's Station soon after 8:40 PM to administer medications and arrived at Resident 1's room at 9PM to administer her medications. LVN 1 stated Resident 1 was not in her room at 9 PM so she went back to the Nurse's Station because that was the last place where she last saw Resident 1.
LVN 1 stated when she arrived at the Nurse's Station, Resident 1's wheelchair was there but could not find Resident 1. LVN 1 stated the front door was not supervised by CNA 3 when she went to the Nurse's Station to look for Resident 1. LVN 1 stated she was not sure how Resident 1 was able to leave the facility if the front door was locked because Resident 1 was sometimes unsteady when she stood or walked. LVN 1 stated a Code [NAME] was called because they did not find Resident 1 in the facility.
During an interview on 3/26/2026, at 2:31 PM, with Social Services Director (SSD), SSD stated the front door was supervised and monitored by facility staff make sure the residents are safe and do not leave the facility. SSD stated the front door should not be left unattended. SSD stated the residents' safety was the facility's priority.
During a concurrent interview on 3/26/2026, at 2:44 PM, with the Director of Nursing (DON), the DON stated the front door was supervised by staff for the safety of the residents because it opens directly to a busy street.
The DON stated Resident 1 would not have been able to leave the facility if the front door was supervised on 3/14/2026 at around 9 PM.
During a review of the undated facility's policy and procedure (P&P), titled, Wandering and Elopements, the P&P indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
During a review of the facility's P&P, titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated the following:The facility strives to make the environment as free from accident hazards as possible.
Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.Implementing interventions to reduce accident risks and hazards shall include ensuring the interventions are implemented.Resident supervision is a core component of the systems approach to safety.
The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.