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Golden Rose Care Center Medication Failures - CA
Resident 208's morning medications, scheduled for 7:30 AM and 9:00 AM, were not administered until after 10:20 AM....
Latest reports, citations, and penalties from CMS data
Resident 208's morning medications, scheduled for 7:30 AM and 9:00 AM, were not administered until after 10:20 AM....
On July 13, 2024, at 5:24 a.m., the resident complained of pain extending from his groin down to his thigh....
Inspectors documented soiled surfaces, contaminated equipment, and improper food storage that violated fundamental food safety protocols....
This cross-contamination scenario represents a fundamental breach of infection control protocols....
However, inspectors found no physician's order authorizing the transfer in the medical record....
The dietitian recommended **Arginaid, an amino acid supplement essential for wound healing**, twice daily for 30 days in December 2024....
According to inspection records, the resident first reported abdominal discomfort on July 22 at 9:45 PM and received antacid medication twice without relief....
Scores typically range from 0-28, with scores above 10 indicating significant fall risk requiring immediate interventions....
Hospital records confirmed the resident sustained a left eyebrow laceration from the unwitnessed fall and required sutures....
The dietitian specifically recommended continuous feeding at 45 ml per hour of Diabetisource AC nutritional formula....
The resident died at an area hospital after experiencing dangerously low blood sugar levels of 27 mg/dL (normal range is 70-100 mg/dL)....
Documentation review revealed alarming patterns of missing bowel movement records....
This recurring citation indicates a persistent compliance issue that the facility has failed to adequately address over more than a year....
This violation received an F-level citation, indicating widespread systemic issues with potential for more than minimal harm to residents....
Yellow dried material consistent with urine was visible on the broken toilet seat, which hung sideways from the fixture....
This practice affected multiple vulnerable residents, including those with severe cognitive impairment, mobility limitations, and histories of falls....
The resident, who had a below-knee amputation and used a wheelchair, left the facility during a day when temperatures reached 95 degrees Fahrenheit....
This delay in medical notification prevented timely interventions that could prevent minor issues from escalating into serious medical emergencies....
The resident, identified as R8, was discovered on December 22, 2024, in a compromised position after attempting to get out of bed....
The facility's response to this incident initially created additional compliance issues....