PASADENA, CA - Federal health inspectors documented a staggering 44.44% medication error rate at Golden Rose Care Center during a July 2024 inspection, raising serious concerns about patient safety and medication management protocols at the 91103 facility.
Critical Medication Timing Failures Put Residents at Risk
The most alarming finding centered on a stroke patient who experienced 12 medication errors out of 27 total opportunities during observation, yielding the 44.44% error rate. Licensed Vocational Nurse 3 failed to administer the resident's medications within the required 60-minute window for both 7:30 AM and 9 AM doses on July 10, 2024.
The resident, who had diagnoses including stroke with left-side paralysis, chest pain, and high blood pressure, was prescribed 12 different medications including critical heart and blood pressure drugs. Two medications specifically ordered to be given with meals at 7:30 AM - Metoprolol Tartrate for blood pressure control and Ranolazine for chest pain prevention - were not administered until 10:27 AM, nearly three hours late.
"If medications were not administered on time, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition," the facility's Director of Nursing told inspectors. The DON further stated that if these medications were not given timely, the resident "can develop uncontrolled high blood pressure and chest pain that can cause complications such as death."
Understanding the Medical Risks of Late Medication Administration
Blood pressure medications like Metoprolol Tartrate work by maintaining steady levels in the bloodstream to keep blood pressure controlled throughout the day. When these medications are given hours late, several dangerous scenarios can occur. Blood pressure can spike to dangerous levels, increasing the risk of stroke, heart attack, or other cardiovascular emergencies.
Ranolazine, prescribed for chest pain prevention, works by improving blood flow to the heart muscle. Delayed administration can leave patients vulnerable to angina attacks and potentially more serious cardiac events. For stroke patients who already have compromised cardiovascular systems, these timing failures create compounded risks.
The facility's policy clearly states that medications may be administered one hour before or after the scheduled time. However, the three-hour delay observed by inspectors far exceeded these parameters and violated basic medication safety protocols.
Systemic Medication Management Failures
Beyond the critical timing errors, inspectors identified multiple systemic failures in the facility's medication management system. A second resident missed two doses of levothyroxine, a thyroid medication, in January 2024. Thyroid medications must be taken consistently to maintain proper hormone levels, and missed doses can lead to serious complications including heart problems, mental health issues, and metabolic dysfunction.
The facility also failed to follow up on pharmacist recommendations from monthly medication reviews. In June 2024, the consulting pharmacist recommended dose reductions for two residents receiving antipsychotic and antidepressant medications, and requested lab work to assess medication levels for a seizure patient. However, the Director of Nursing admitted she had not reviewed these recommendations or relayed them to physicians.
"If MRR result was not reviewed and if there's any irregularities or recommendation in the MRR were not relayed to the doctor and no action has been taken by the facility, it can cause medications overdose or medication misuse which can lead to resident harm serious illness and/or worsening of condition," the DON acknowledged during the inspection.
Dangerous Medication Storage and Security Violations
Inspectors observed a medication cart left unlocked and unattended in the facility hallway with the narcotic key still attached to the lock. This occurred when a Licensed Vocational Nurse responded to a distressed resident call, leaving controlled substances accessible to anyone passing by.
The potential consequences of unsecured medications are severe. Residents with cognitive impairment might accidentally ingest medications not prescribed for them, leading to overdoses or dangerous drug interactions. Visitors or staff could also access and misuse controlled substances, creating liability issues for nursing staff who are legally responsible for narcotic accountability.
Additionally, medication refrigerators contained expired medications from discharged residents, and two refrigerators had significant ice buildup that could affect medication efficacy. Temperature control is crucial for many medications, and improper storage can render treatments ineffective or potentially harmful.
Food Safety and Infection Control Concerns
The inspection revealed multiple food safety violations that could expose residents to foodborne illnesses. In the kitchen walk-in refrigerator, temperatures consistently measured above the required 41°F threshold, with readings as high as 55°F documented on facility logs.
Raw pork chops were stored unlabeled and undated in opened cardboard boxes, violating basic food safety protocols. Dry storage containers holding pasta and flour were left unsealed, creating opportunities for contamination. Multiple food items in the resident refrigerator lacked proper labeling with names and dates.
These violations are particularly concerning for nursing home residents, who often have compromised immune systems and may be more susceptible to foodborne illnesses. Proper food handling and storage protocols are essential safeguards that help prevent outbreaks of gastrointestinal illness in vulnerable populations.
Vaccination and Pest Control Failures
Despite having signed consent from a family member in February 2024, one immunocompromised resident never received the influenza vaccine during flu season. The Infection Prevention Nurse admitted to misplacing the signed consent form and failing to follow up on vaccination requirements.
Inspectors also documented flies in resident rooms, with one fly observed on uncovered food. The facility's pest control program failed to prevent insects from entering through sliding doors that residents and staff left open when accessing patio areas.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain medication error rates below 5%. The 44.44% rate documented at Golden Rose Care Center represents a nearly nine-fold increase above acceptable standards. Industry best practices include multiple verification checks, proper timing protocols, and immediate reporting of medication errors to physicians.
Effective medication management systems typically include bar-code scanning, double-verification for high-risk medications, and real-time documentation of administration times. These safeguards help prevent the types of errors observed during the inspection.
Facility Response and Regulatory Actions
The violations carry minimal harm ratings, indicating that while serious system failures occurred, inspectors did not find evidence of actual resident harm during the survey period. However, the potential for significant injury or death from these practices prompted immediate corrective action requirements.
The facility must develop comprehensive corrective action plans addressing medication timing protocols, staff training, pharmacist review procedures, and storage security measures. Follow-up inspections will verify implementation of these corrections and assess whether the facility has achieved compliance with federal safety standards.
Golden Rose Care Center serves a vulnerable population of residents with complex medical needs including stroke, heart failure, seizure disorders, and cognitive impairment. These patients depend on precise medication management and safe care environments to maintain their health and quality of life. The documented violations represent serious breaches of that trust and highlight the critical importance of rigorous oversight in long-term care facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Rose Care Center from 2024-07-11 including all violations, facility responses, and corrective action plans.
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