PASADENA, CA - A federal complaint investigation at Golden Rose Care Center found that a licensed nurse documented a resident's allegation of abuse by a certified nurse assistant but failed to report it to state authorities, law enforcement, or the facility's own leadership, leaving the claim uninvestigated for at least 10 days before inspectors discovered it.
The August 7, 2024 inspection also revealed that the Pasadena facility failed to deliver physician-ordered restorative nursing services to two residents with serious physical conditions, placing them at risk of further physical decline and permanent joint deformity.
Abuse Allegation Documented but Never Reported
On July 28, 2024, a resident at Golden Rose Care Center — identified in federal records as Resident 1, a stroke survivor with partial paralysis on one side of the body — told a Licensed Vocational Nurse (LVN 1) that a Certified Nurse Assistant had abused them. The nurse recorded the allegation in a progress note at 1:20 PM that day.
What happened next was, according to federal investigators, nothing.
During the August 7 inspection, LVN 1 acknowledged that abuse allegations must be reported to the California Department of Public Health, the long-term care ombudsman, and local law enforcement within two hours of the report being made. Yet when asked why the allegation was never forwarded, the nurse told investigators he "did not think of reporting it as an abuse because Resident 1 was just not happy with the CNA."
Under federal regulations governing nursing homes that receive Medicare and Medicaid funding, staff members are mandatory reporters. The determination of whether an allegation constitutes abuse is not left to the discretion of an individual nurse — it must be reported and formally investigated regardless of the staff member's personal assessment of the complaint's validity.
The facility's own policy, titled "Abuse Prevention and Prohibition Program" and revised in August 2023, explicitly requires that allegations of abuse, neglect, mistreatment, or injuries of unknown source be reported immediately, but no later than two hours after the suspicion is formed.
Director of Nursing Unaware Until Inspection
Perhaps most concerning, the facility's Director of Nursing (DON) told investigators on August 7 that it was "her first time reading this documentation" and that she had not been made aware of Resident 1's abuse allegation at any point in the 10 days since it was recorded.
The DON confirmed that the allegation was never reported to external agencies and that no investigation was ever initiated by the facility. She acknowledged that reporting to outside agencies is critical "so other agencies can conduct their investigation, for resident safety, so residents can be protected, to check if there is a pattern, and to stop it from happening again."
The failure to report represents a breakdown at multiple levels. The documenting nurse made an independent judgment that the allegation did not warrant escalation. No supervisory review of the progress note caught the allegation. And no system within the facility flagged the documentation for follow-up — meaning the abuse claim sat in the medical record for more than a week with no action taken.
Federal and state mandatory reporting laws exist precisely because abuse victims in nursing homes are among the most vulnerable populations. Many residents have cognitive impairments, physical limitations, or communication difficulties that make it challenging to advocate for themselves. When a cognitively intact resident — as Resident 1 was documented to be — makes a direct allegation, the regulatory framework requires an immediate institutional response.
Restorative Nursing Services Denied to Vulnerable Residents
The inspection uncovered a second significant deficiency: the facility's failure to provide physician-ordered restorative nursing services to two residents with conditions that made regular exercise and range-of-motion therapy medically essential.
Resident 1: Stroke Survivor Missing Prescribed Therapy
Resident 1, the same individual who reported the abuse allegation, had been living with hemiplegia and hemiparesis — paralysis and muscle weakness on one side of the body — following a stroke. A physician had ordered three restorative nursing programs for this resident, all dated August 3, 2023:
- Ambulation training using hallway side rails, five days per week - Passive range-of-motion exercises for the left upper extremity, five days per week - Assisted bike program, five days per week
A review of the restorative nursing records for July 2024 showed that during the 10-day period from July 21 through July 31, Resident 1 received restorative services on only four days — July 24, 25, 26, and 29. The physician's orders called for services on approximately seven of those ten days (five days per week).
During the inspection, Resident 1 told investigators that "sometimes she was not getting the RNA service because there is no RNA staff to conduct the exercise with her."
Resident 2: Lupus Patient Receiving Even Less Care
Resident 2, who was living with systemic lupus erythematosus, diabetes, and hypertension, had an even more extensive restorative nursing program ordered by a physician. The orders, dating from October 2023 and May 2024, included:
- Active range-of-motion exercises for both upper extremities, five times per week - Passive range-of-motion exercises for both lower extremities, five times per week - Lower body ergometer bike, five times per week - Sit-to-stand exercises in parallel bars with two restorative nursing assistants, three times per week
During the same July 21-31 period, Resident 2 received restorative services on just two days — July 25 and 26. This resident had physician orders for services nearly every day of the week across four separate programs.
Resident 2 told inspectors that "exercises was not given to him daily and RNA staff explained to him that RNA had to take Certified Nurse Assistant assignment."
Staffing Shortages at the Root
The investigation revealed a straightforward explanation for the missed therapy sessions: the facility was pulling its restorative nursing assistants off their specialized duties to fill gaps in the general certified nurse assistant workforce.
A Restorative Nursing Assistant (RNA 1) confirmed to inspectors that "at times he would work as a CNA when the facility did not have enough CNAs to take care of the residents." The RNA verified that blank dates on the restorative nursing records indicated that no services were provided because "the RNAs were working as CNAs."
RNA 1 articulated what this meant for residents in clinical terms: Resident 1 "needed to receive the RNA services in accordance with the physician's order to prevent getting contractions," adding that exercises and range-of-motion work are necessary "to prevent further decline." The RNA stated plainly that "residents would decline when they were not provided with the RNA services."
This practice — reassigning specialized rehabilitation staff to cover basic care shortages — creates a cascading problem. For individuals recovering from strokes or managing chronic autoimmune conditions, range-of-motion exercises and mobility training are not optional wellness activities. They are prescribed medical interventions designed to prevent contractures, a condition in which muscles, tendons, and other tissues shorten and harden, leading to permanent joint deformity and rigidity. Once contractures develop, they can be extremely difficult or impossible to reverse, potentially leaving a resident with permanently reduced mobility.
For a stroke survivor like Resident 1, who already had paralysis and weakness on one side of the body, the failure to maintain regular passive range-of-motion exercises places the affected limbs at heightened risk for contracture development. Immobile joints can begin to lose range within days of inactivity, and the cumulative effect of repeated missed sessions can accelerate physical decline.
No Joint Mobility Screening Conducted
The Director of Nursing acknowledged during the inspection that neither Resident 1 nor Resident 2 had received a Joint Mobility Screening — a composite assessment that measures flexibility and function across multiple joints. The DON stated that such screenings "should have" been performed to determine whether the residents had experienced functional decline and to identify areas requiring improvement.
The DON also acknowledged systemic communication gaps between the nursing and rehabilitation departments, stating that nursing staff would only contact rehabilitation "when nursing noticed and assessed resident with decline." She conceded the facility needed "a better process," noting that she was "still adapting the facility's process since she is a new staff."
The facility's own policy on restorative nursing, last revised in June 2017, states that the program "provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible" and "actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning."
Federal Regulatory Context
Golden Rose Care Center was cited under two federal deficiency tags. F607 addresses the requirement that facilities develop and implement policies prohibiting abuse and requiring timely reporting. F688 requires facilities to provide appropriate care to maintain or improve residents' range of motion and mobility.
Both citations were classified at the level of "minimal harm or potential for actual harm," meaning inspectors determined that while no severe injury had yet occurred, the conditions created risk for the affected residents.
The full inspection report, including the facility's plan of correction, is available through the Centers for Medicare & Medicaid Services and the California Department of Public Health. Families of residents at Golden Rose Care Center can contact the California Long-Term Care Ombudsman for assistance with concerns about care quality.
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.
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