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Complaint Investigation

Foothill Heights Care Center

March 26, 2026 · Pasadena, CA · 1515 North Fair Oaks Ave
Citations 1
CMS Rating 3/5
Beds 49
Provider ID 555894
Healthcare Facility
Foothill Heights Care Center
Pasadena, CA  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies

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.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PASADENA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FOOTHILL HEIGHTS CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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