Golden Rose Care Center: Medication Safety Failure - CA
That's what inspectors found at Golden Rose Care Center during a complaint inspection completed August 19, 2025.
The facility's director of nursing told inspectors that the resident, identified in the report as Resident 2, had the potential to suffer respiratory distress if he went without his Advair. She also told them, plainly, that two licensed vocational nurses, LVN 1 and LVN 2, had not followed the facility's own medication administration policy when the resident refused his medication.
The policy itself was not new or ambiguous. Written in 2017 and revised on June 1 of that year, it laid out a clear sequence of steps for exactly this situation. If a resident refuses a medication, the licensed nurse is supposed to return after one hour and try again. If the resident refuses a second time, the medication is destroyed and the nurse documents the refusal in the medical record. If refusals happen repeatedly, the nurse contacts the attending physician to discuss alternatives.
None of that happened the way it was supposed to.
The inspection report does not specify which step was skipped or whether the physician was ever notified. What it does say is that the director of nursing acknowledged the policy was not followed, and that the resident who needed that medication for his lungs did not receive it.
Advair is a combination inhaler used to manage chronic obstructive pulmonary disease and asthma. Missing a dose is not automatically a crisis, but for a resident whose own facility acknowledged he had the potential for respiratory distress without it, the failure to follow through, to try again, to call the doctor, carries weight.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, and noted that few residents were affected. In the language of federal nursing home oversight, that places it toward the lower end of the severity scale. But the scale measures what was documented, and what was documented here is a gap between what two nurses were supposed to do and what they did, in a situation where the stakes were clear enough that the director of nursing named them out loud.
Nursing homes operate on policies in part because individual judgment, under the pressure of a busy shift, is not always enough. A nurse who is managing a hall full of residents and encounters a refusal has to remember: come back in an hour, document it, call the doctor if it keeps happening. The policy exists so that a resident like Resident 2 doesn't fall through the cracks between one refusal and the end of a shift.
At Golden Rose Care Center, on at least this occasion, the policy did not hold.
The director of nursing's acknowledgment is notable. She did not dispute what happened. She confirmed the medication was important, confirmed her nurses did not follow procedure, and left inspectors with a picture of a resident who needed a drug for his respiratory health and did not get it because the system that was supposed to catch that failure did not catch it.
Resident 2's condition after the missed medication is not described in the inspection report. Whether he experienced any respiratory symptoms, whether a physician was eventually contacted, whether the situation was corrected before inspectors arrived, none of that is recorded in the four pages filed with CMS. What remains is the director of nursing's own words: the potential for respiratory distress was real, and the policy meant to prevent it was not followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Rose Care Center from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 30, 2026 · Our methodology
GOLDEN ROSE CARE CENTER in PASADENA, CA was cited for violations during a health inspection on August 19, 2025.
That's what inspectors found at Golden Rose Care Center during a complaint inspection completed August 19, 2025.
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.