The failure at Golden Rose Care Center meant law enforcement and state health officials didn't learn about the July 28 abuse claim until federal inspectors arrived 10 days later for an unrelated complaint investigation.
Licensed Vocational Nurse 1 wrote in his progress notes at 1:20 PM on July 28, 2024, that Resident 1 "stated of being abused by a Certified Nurse Assistant." But he never told his supervisors or contacted outside agencies.
During an August 7 interview with federal inspectors, the nurse explained his reasoning. He "did not think of reporting it as an abuse because Resident 1 was just not happy with the CNA."
The Director of Nursing told inspectors it was "her first time reading this documentation" when they showed her the progress notes during their visit. She had never been informed about the resident's abuse allegation.
"The DON verified the alleged abuse was not reported on 7/28/2024, and investigation was not initiated by the facility," inspectors wrote.
Resident 1 had been admitted to the facility following a stroke that left him with paralysis and muscle weakness on his left side. His April assessment showed he had no cognitive impairment and could make daily decisions independently. He required setup assistance with eating and partial help with personal care tasks like bathing and dressing.
The facility's own policy requires staff to report abuse allegations "immediately, but no later than 2 hours after forming the suspicion." The policy states the facility has "zero-tolerance for abuse, neglect, mistreatment" and that "supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk of occurring."
California law requires nursing homes to report suspected abuse to the California Department of Public Health, local law enforcement, and the ombudsman within two hours of learning about it.
The Director of Nursing acknowledged to inspectors that the abuse allegation "should have been reported to local agencies, which included California Department of Public Health, ombudsman, and local enforcement agency within two hours from the allegation was made."
She explained why such reporting matters: "reporting to other local agencies is important so other agencies can conduct their investigation, for resident/s safety, so residents can be protected, to check if there's a pattern, and to stop it from happening again."
The inspection report noted that the facility's failure to report the allegation "resulted in delay of an onsite investigation by the law enforcement."
No details were provided about what type of abuse the resident alleged or which nursing assistant was involved. The inspection report does not indicate whether the facility eventually reported the allegation after inspectors discovered it, or what happened to the accused staff member.
The facility's abuse prevention policy emphasizes that "staff, residents, and families can report concerns, incidents, and grievances without fear of retribution or retaliation." It requires the facility to "conduct an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse."
But in this case, the resident's allegation never made it past the nurse who first documented it.
The licensed vocational nurse who wrote the progress notes told inspectors he understood the reporting requirements. When asked during his interview, he stated that "the alleged abuse should be reported to local agencies, which included California Department of Public Health, ombudsman, and local enforcement agency within two (2) hours form when the allegation was made."
Yet he had made a judgment call that what the resident described didn't rise to the level of abuse requiring outside intervention.
The inspection occurred as part of a complaint investigation on August 7, 2024. Federal inspectors cited the facility for failing to timely report suspected abuse and noted the violation affected few residents but created minimal harm or potential for actual harm.
The facility's policy states it "promptly and thoroughly investigates reports of resident abuse" and has procedures for immediate reporting. Staff are instructed that they "must not permit anyone to engage in any type of abuse, neglect, mistreatment, or misappropriation of resident property."
The case highlights how nursing home residents depend on staff to advocate for their safety when they report concerns. When a nurse dismissed Resident 1's abuse allegation as mere dissatisfaction with a caregiver, it left the resident without the protection that state and federal oversight systems are designed to provide.
The 10-day delay meant outside investigators lost the opportunity to immediately interview witnesses, preserve evidence, and potentially prevent further incidents while memories and physical evidence were fresh.
Golden Rose Care Center operates on North Raymond Avenue in Pasadena. The facility's response to the citation was not included in the inspection documents provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Rose Care Center from 2024-08-07 including all violations, facility responses, and corrective action plans.
