PASADENA, CA — Federal inspectors documented multiple respiratory care violations at Golden Rose Care Center during a July 2024 survey, including findings that staff administered oxygen therapy to at least two residents without any physician order on file. The 67-page inspection report also revealed catheter care lapses that created infection risks, a resident consistently receiving less oxygen than prescribed, and staff who were entirely unaware of a resident's post-traumatic stress disorder diagnosis.
Oxygen Administered Without Physician Authorization
The most significant finding involved two residents receiving oxygen therapy without documented physician orders, a direct violation of federal regulations governing medical treatment in skilled nursing facilities.
Inspectors observed Resident 260 — a patient with acute respiratory failure, end-stage renal disease, and paralysis on one side of the body — receiving oxygen at 3 liters per minute via nasal cannula on July 8, 2024. When surveyors reviewed the resident's Order Summary Report, no physician order for oxygen administration existed anywhere in the record. A subsequent review of the electronic chart spanning nearly a full year, from August 2023 through July 2024, confirmed the absence of any authorization.
The facility's Director of Nursing acknowledged the gap during an interview with inspectors, stating that "oxygen is considered a treatment and needs to have a doctor's order before it can be given." The DON further noted that administering oxygen without a physician's order meant "treatment was not validated by the doctor and the resident can be given unnecessary or unmonitored treatments."
A nearly identical situation was documented with Resident 54, who had been admitted with a malignant mass between the lungs and difficulty swallowing. On July 10, 2024, inspectors observed Resident 54 receiving oxygen at 3 liters per minute. When Licensed Vocational Nurse 3 checked the resident's electronic health record and hospice binder, she confirmed she could not locate any physician order for oxygen therapy.
Oxygen therapy, while commonly used, is a medical treatment that requires careful physician oversight. Administering oxygen without proper authorization means there is no prescribed rate, no monitoring parameters, and no clinical framework to evaluate whether the therapy is appropriate, effective, or potentially harmful. For patients with conditions like COPD, excessive oxygen can actually suppress the respiratory drive, making the absence of physician-directed parameters a serious clinical concern.
Golden Rose's own policy on oxygen administration, revised in 2017, explicitly states that "a physician's order is required to initiate oxygen therapy, except in an emergency situation." No emergency circumstances were documented in either case.
Resident Received Less Oxygen Than Prescribed
In a separate but related finding, inspectors documented that Resident 161 — a patient with chronic obstructive pulmonary disease, pneumonia, and congestive heart failure — was consistently receiving less oxygen than his physician had ordered.
The resident's physician had prescribed 5 liters per minute of continuous humidified oxygen via nasal cannula for his COPD, with a care plan reflecting that same rate. However, inspectors observed the resident receiving only 4.5 liters per minute on July 8, and when they returned the following day on July 9, the rate remained at 4.5 liters per minute. By July 10, the oxygen had dropped further to just 4 liters per minute — a full liter below the prescribed rate.
During the July 9 observation, Resident 161 told inspectors directly: "I cannot receive less than 5 LPM of oxygen at any time." The resident explained that oxygen was critical for him because he experienced periods of anxiety that caused shortness of breath.
Registered Nurse 1, upon checking the resident's oxygen on July 10, confirmed the rate was set at 4 liters per minute and acknowledged the order called for 5 liters per minute. RN 1 stated that Resident 161 "can get sick, have difficulty breathing, desaturate, and end up in the hospital for respiratory distress if he does not get enough oxygen."
The DON reinforced the severity of the finding, telling inspectors that insufficient oxygen for a COPD patient could result in "shortness of breath, oxygen desaturation, COPD exacerbation, and end up in the hospital." The DON stated it was the responsibility of licensed nurses to verify the oxygen rate every shift and during medication administration.
For patients with COPD, maintaining the prescribed oxygen flow is essential to preventing hypoxemia — dangerously low blood oxygen levels. Even a difference of one liter per minute can be clinically meaningful, potentially leading to increased heart rate, confusion, respiratory distress, and in severe cases, organ damage. The fact that this discrepancy persisted across multiple days and multiple nursing shifts suggests a systemic failure in routine monitoring rather than an isolated oversight.
Catheter Bag Found on Floor, Creating Infection Risk
Inspectors also documented failures in urinary catheter care that created preventable infection risks. On July 8, 2024, surveyors observed Resident 167 — a patient with seizure disorder, diabetes, and severely impaired cognitive function — asleep in bed with an indwelling catheter collection bag resting directly on the floor.
The collection bag also lacked a dignity cover, leaving the resident's urine visible to anyone entering the room.
A Certified Nursing Assistant acknowledged during the observation that the collection bag "should not touch the floor" and should have been covered and placed in a bucket. Treatment Nurse 2 was more explicit about the clinical risk, stating: "The floor was dirty and Resident 167's indwelling catheter collection bag should not touch the floor for infection control purposes." TN 2 added that the resident "can get sick and end up in the hospital if she gets an infection."
The DON explained the mechanism of harm: bacteria from the floor can travel up the catheter tubing and cause a urinary tract infection. Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections in long-term care settings. They can lead to sepsis, hospitalization, and in vulnerable elderly populations, can be life-threatening. Standard infection prevention protocols universally require that catheter drainage bags remain below the level of the bladder and never contact the floor — a basic measure that was not followed here.
The facility's own catheter care policy, dating to 2017, states clearly: "Take care to ensure the collection bag does not touch the floor at any time."
Staff Unaware of Resident's PTSD Diagnosis
A separate deficiency revealed a breakdown in psychosocial care. Resident 9, who had been diagnosed with PTSD, bipolar disorder, depression, and partial paralysis, was being cared for by staff members who did not know about the PTSD diagnosis and had no knowledge of the resident's triggers or trauma-informed care interventions.
Licensed Vocational Nurse 1, who stated she had cared for Resident 9 "on more than one occasion," told inspectors she was aware the resident had PTSD but "did not know any triggers for Resident 9's PTSD, the history related to Resident 9's PTSD or trauma informed care interventions." LVN 1 acknowledged that not knowing a resident's triggers "could be detrimental to their health."
Treatment Nurse 1, who provided wound and skin care for the resident, told inspectors she "was unaware that Resident 9 had a diagnosis of PTSD." A Certified Nursing Assistant similarly stated she did not know about the diagnosis, triggers, or any specific care interventions.
Without knowledge of a resident's PTSD triggers, routine care activities — repositioning, bathing, wound treatment — could inadvertently cause re-traumatization. Trauma-informed care requires that all staff interacting with a resident understand their specific triggers and have clear interventions to follow. The facility's own social services policy requires identifying trauma history, documenting triggers, and developing individualized interventions in collaboration with residents and mental health professionals.
Additional Care Lapses Documented
Inspectors found further deficiencies involving a feeding tube that lacked required date and time labels, making it impossible for staff to determine whether the formula had expired. The DON confirmed the tube feeding for Resident 52 was unlabeled and stated that expired formula could cause "diarrhea, vomiting, abdominal pain and other negative side effects."
Separately, a resident admitted with a rectal tube from the hospital did not receive a physician order for the device until four days after admission, and a corresponding care plan was not created until the inspection itself prompted it — weeks after the resident arrived.
Pattern of Documentation and Monitoring Failures
The July 2024 inspection at Golden Rose Care Center reveals a pattern of care that fell short not in dramatic, acute incidents, but in the routine monitoring and documentation that forms the backbone of safe nursing home operations. Oxygen rates went unchecked across shifts. Medical devices were used without physician authorization. Basic infection control measures were not maintained. Staff lacked awareness of residents' critical psychiatric diagnoses.
These are the types of systemic lapses that, individually, may not result in immediate visible harm — but cumulatively create an environment where serious adverse events become far more likely. Each deficiency documented represents a point where the standard safety net failed for a vulnerable resident.
The full inspection report is available through the Centers for Medicare & Medicaid Services and contains additional findings beyond those detailed here. Families of current and prospective residents are encouraged to review the complete survey results.
Golden Rose Care Center is located at 1899 N. Raymond Ave., Pasadena, CA 91103. The deficiencies cited here were identified during a health inspection completed on July 11, 2024.
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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