Golden Rose Care Center Medication Failures - CA
PASADENA, CA - State inspectors at Golden Rose Care Center documented significant medication administration failures affecting multiple residents, including critical timing violations and missed doses of life-sustaining medications during a July 11, 2024 complaint investigation.
Critical Timing Violations Impact Cardiovascular Patients
The inspection revealed that Licensed Vocational Nurse 3 failed to administer 12 scheduled medications to Resident 208 within the facility's required one-hour window on July 10, 2024. The resident, who has a complex medical history including stroke with left-side paralysis, high blood pressure, and heart conditions, was prescribed multiple time-sensitive medications to manage these serious conditions.
Resident 208's morning medications, scheduled for 7:30 AM and 9:00 AM, were not administered until after 10:20 AM. This delay exceeded the facility's policy allowing medications to be given one hour before or after the scheduled time. Two critical heart medications - Metoprolol Tartrate for blood pressure control and Ranolazine for chest pain prevention - were specifically ordered to be taken with breakfast at 7:30 AM but were not given until 10:27 AM, well after the morning meal.
The resident's medication regimen included 12 different drugs managing conditions ranging from seizure control to heart failure. These included Digoxin for heart efficiency, Eliquis to prevent dangerous blood clots, Lasix for fluid retention, and two anti-seizure medications - Lacosamide and Levetiracetam.
Medical Consequences of Delayed Administration
Medication timing violations create serious health risks for residents with complex medical conditions. When cardiovascular medications are not taken as prescribed, the therapeutic blood levels necessary for optimal treatment cannot be maintained. This is particularly critical for residents like Resident 208, who relies on multiple medications working in coordination to manage stroke recovery, heart failure, and high blood pressure.
Blood pressure medications like Metoprolol work by maintaining steady levels in the bloodstream. Delays in administration can cause fluctuations that may lead to dangerous spikes in blood pressure or inadequate cardiovascular protection. Similarly, anti-seizure medications require consistent timing to prevent breakthrough seizures, which can be life-threatening for residents with epilepsy.
The facility's Registered Nurse Supervisor acknowledged during the inspection that "medications that were given late might be close to next scheduled dose and might lead to overdosing." This creates additional risk when the next dose is due, potentially causing dangerous medication interactions or toxicity.
Thyroid Medication Completely Missed
The inspection also revealed that Resident 3, who has quadriplegia, epilepsy, and hypothyroidism, missed two complete doses of levothyroxine sodium on January 12 and January 16, 2024. Levothyroxine is the primary treatment for hypothyroidism, a condition where the thyroid gland cannot produce adequate hormones essential for metabolism and overall bodily functions.
This resident requires levothyroxine 175 micrograms daily at 6:00 AM to maintain proper thyroid hormone levels. The medication was prescribed to start December 24, 2023, but facility records showed the doses were simply not administered on the documented dates.
Thyroid hormone replacement therapy requires consistent daily dosing to maintain therapeutic levels. Missing doses can lead to symptoms of hypothyroidism returning, including fatigue, depression, weight gain, and cognitive impairment. For a resident with existing severe disabilities, these additional complications can significantly impact quality of life and overall health status.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
GOLDEN ROSE CARE CENTER in PASADENA, CA was cited for violations during a health inspection on July 11, 2024.
Resident 208's morning medications, scheduled for 7:30 AM and 9:00 AM, were not administered until after 10:20 AM.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.