Golden Rose Care Center: Missing POLST During Emergency - CA
The resident, identified in inspection records only as Resident 1, had been at the facility since being admitted with chronic obstructive pulmonary disease, difficulty swallowing, and dependence on a ventilator, a machine that breathes for patients who cannot breathe adequately on their own. A formal assessment completed in April rated her cognitive ability for daily decision-making as impaired. She needed full assistance with bathing, dressing, and toileting hygiene. She was, by any measure, seriously ill.
Five days before the emergency, on April 9, a Physician Orders for Life-Sustaining Treatment form had been completed for her. A POLST is not a preference form or a suggestion. It is a medical order that tells emergency responders exactly what interventions a patient wants — whether to attempt resuscitation, whether to hospitalize, how aggressively to treat. For a ventilator-dependent patient with impaired decision-making being rushed out by EMS, it is the document that speaks when the patient cannot.
It was not in her chart.
Licensed Vocational Nurse 2, interviewed by inspectors on April 28, confirmed the POLST was not available in Resident 1's medical record when EMS arrived at 5 p.m. on April 14. The nurse said it was important to have the POLST in the chart to know what the resident's wishes were.
The facility's administrator, interviewed later the same day, confirmed that a POLST dated April 9 existed but was not in the resident's medical records. The administrator said it was important to have the document in the chart to provide actionable medical orders and to ensure the resident's care preferences were honored during an emergency.
The nurse practitioner who had signed the original POLST described what happened next. On April 14, she said, she called the resident's daughter because the POLST was not available in the medical chart. A new POLST was created and signed by the nurse practitioner that day. The nurse practitioner told inspectors it was important to have the POLST readily available in the medical chart so that all appropriate and desired care could be provided to the resident.
That phone call to the daughter, made while a chest-pain emergency was unfolding, was the workaround. It should not have been necessary.
The facility's own policy, dated June 2017, is specific: the original POLST is to be placed in the front section of the medical record, and a copy marked as such is to be kept in the advance directive legal section. If the facility uses electronic health records, the form is to be scanned and placed in the appropriate section. The POLST signed April 9 cleared none of those thresholds before EMS walked through the door five days later.
Federal inspectors, completing their complaint survey on April 29, cited the lapse as a deficiency. They classified the level of harm as minimal harm or potential for actual harm, and noted the deficient practice had the potential to create conflict in carrying out the resident's treatment preferences and health care decisions.
What the inspection record does not say is what was in the original POLST, or whether the document created by the nurse practitioner on April 14 matched it. It does not say what happened to Resident 1 at the hospital, or whether she has since returned. It does not say who was responsible for filing the April 9 form, or why it never made it into the chart.
A ventilator-dependent woman with impaired decision-making was loaded into an ambulance in chest pain. The document she had signed five days earlier, the one meant to ensure her wishes followed her out the door, stayed behind.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Rose Care Center from 2026-04-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
GOLDEN ROSE CARE CENTER in PASADENA, CA was cited for violations during a health inspection on April 29, 2026.
A formal assessment completed in April rated her cognitive ability for daily decision-making as impaired.
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.