Golden Rose Care Center

F-F759

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 208 and 3) as indicated on the facility policy by:

1. During a Medication Pass observation on 7/10/2024, Licensed Vocational Nurse 3 (LVN 3) failed to administer Resident 208's 12 medications within 60 minutes of scheduled time of 7:30 AM and 9 AM. LVN 3 did not indicate the actual time of medication administration in the medication administration record (MAR).

This deficient practice had the potential for Resident 208's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications.

2. Facility failed to administer Resident 3's levothyroxine sodium (a medicine used to treat an underactive thyroid gland [produces hormones in the body and plays a major role in chemical reactions in the body such as metabolism]) as ordered by the physician.

This deficient practice had the potential to result in Resident 3's not obtaining the therapeutic level of the medication.

Findings:

1. A review of Resident 208's Admission Record indicated Resident 208 was originally admitted on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses including but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke, a loss of blood flow to part of the brain) affecting left dominant side, angina pectoris (chest pain or discomfort that keeps coming back), and hypertension (high blood pressure).

A review of Resident 208's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/13/2023, indicated Resident 208 had moderately impaired (decisions poor; cues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making. The MDS indicated Resident 208 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), dressing, toilet use and personal hygiene. The MDS also indicated that Resident 208 was total dependent from staff during transfer, locomotion on and off unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 055862 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055862 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 A review of Resident 208's Physician's order, dated 7/11/2024, indicated the following orders:

Level of Harm - Minimal harm or 1. Benazepril (used to treat high blood pressure) oral tablet. Give 5 milligram (mg, unit of measurement) by potential for actual harm mouth, once a day for hypertension. With order date of 2/17/2024.

Residents Affected - Some 2. Cranberry tablet 450 mg. Give 1 tablet by mouth once a day, supplement. With order date of 12/22/2022.

3. Docusate Sodium (stool softener) tablet 100 mg. Give 1 tablet by mouth two times a day for bowel management. With order date of 6/21/2024.

4. Digoxin (used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat) tablet. Give 0.125 mg by mouth once a day for Congestive heart failure (CHF, a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). With order date of 12/22/2022.

5. Eliquis (used to treat and prevent certain types of dangerous blood clots that can block blood vessels in your body) oral tablet 5 mg. Give 1 tablet by mouth two times a day for Deep vein thrombosis (DVT, a condition that occurs when a blood clot forms in a vein deep inside a part of the body) prophylaxis. With order date of 2/17/2024.

6. Finasteride (used to shrink an enlarged prostate) tablet 5 mg. Give 1 tablet by mouth one time a day for benign prostatic hyperplasia (BPH, a noncancerous enlargement of the prostate gland). With order date of 12/22/2022.

7. Lasix (used to treat fluid retention and swelling) oral tablet 20 mg. Give 20 mg by mouth once a day for CHF. With order date of 12/22/2022.

8. Lacosamide (used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) oral tablet 200 mg. Give 200 mg by mouth two times a day for seizures. With order date of 12/22/2022.

9. Levetiracetam solution (used to treat seizures). Give 15 milliliters (ml, unit of measurement) by mouth every 12 hours related for seizures. With order date of 12/22/2022.

10. Metoprolol Tartrate (used to treat high blood pressure) tablet 25 mg. Give 1 tablet by mouth once a day for HTN. Give with food at 7:30 AM. With order date of 2/17/2024.

11. Multivitamin Minerals tablet. Give 1 tablet by mouth once a day for supplement. With order date of 12/22/2022.

12. Ranolazine (used to treat chronic angina) extended-release tablet 500 mg. Every 12 hours, give 1 tablet by mouth two times a day for Angina Pectoris. With Meals at 7:30 AM. With order date of 12/22/2022.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 055862 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055862 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a concurrent interview with LVN 3 and observation of the medication administration for Resident 208

on 7/10/2024, at 10:20 AM, LVN 3 were preparing Resident 208's medications. LVN 3 stated that the Level of Harm - Minimal harm or following 10 medications were Resident 208's scheduled medications to be given at 9 AM and should be not potential for actual harm later than 10 AM:

Residents Affected - Some Benazepril 5 mg oral tablet.

Cranberry tablet 450 mg.

Docusate Sodium tablet 100 mg.

Digoxin 0.125 mg tablet.

Eliquis oral tablet 5 mg

Finasteride tablet 5 mg.

Lasix oral tablet 20 mg.

Lacosamide oral tablet 200 mg.

Levetiracetam Solution 15 ml.

Multivitamin Minerals tablet.

LVN 3 also stated, Ranolazine extended-release tablet 500 mg and Metoprolol Tartrate tablet 25 mg was scheduled to be given at 7:30 AM with meals and should be given no later than 8:30 AM

During a concurrent record review of Resident 208's medication administration record and interview with Registered Nurse Supervisor 1 (RNS 1) at 7/11/2024 at 8:53 AM, RNS 1 verified that LVN 3 administered Resident 208's 7:30 AM and 9 AM medication late on 7/10/2024 because LVN 3 gave them after 10 AM which was outside the 1-hour window. RNS 1 stated that medications can be administered one hour before or after the scheduled time. RNS 1 stated that medications that were given late might be close to next scheduled dose and might lead to overdosing. RNS 1 stated medications that were ordered to be given with meals should be followed because these medications might cause stomach upset if not given with food or medication might not be effective. RNS 1 stated Resident 208 did not receive Metoprolol Tartrate tablet 25 mg and Ranolazine extended-release tablet 500 mg with meals on 7/10/2024, since they were administered at 10:27 AM. RNS 1 stated they should have been given with meals during breakfast at 7:30 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 055862 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055862 B. Wing 07/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During an interview with the Director of Nursing (DON) on 7/11/2024 at 8:25 PM, the DON stated that it was important to administer medication as ordered to get the full benefit of the medication and to prevent Level of Harm - Minimal harm or complications of inconsistent timing of medication administration. The DON stated, If medications were not potential for actual harm administered on time, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition. The DON stated, Resident 208's Metoprolol Residents Affected - Some Tartrate order was to control the resident's blood pressure and Resident 208's Ranolazine extended-release tablet 500 mg order was to prevent and treat chest pain. The DON stated if these medications were not given timely, Resident 208 can develop uncontrolled high blood pressure and chest pain that can cause complications such as death.

A review of facility's Policy and Procedure titled, Medication-Administration, revised in 6/1/2017, indicated medication will be administered by a Licensed Nurse per the order of an Attending Physician (Doctor). It also indicated medications may be administered one hour before or after the scheduled medication administration time.

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2. A review of Resident 3's Admission Record indicated Resident 3 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses that included quadriplegia (paralysis that affects all four limbs plus the torso), epilepsy (brain activity that causes sudden, uncontrolled electrical disturbance in

the brain and sometimes loss of awareness), chronic obstructive pulmonary disease (COPD- a lung disease characterized by long term poor airflow) and hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone)

A review of Resident 3's History and Physical Examination (H&P), dated 12/23/2023, indicated Resident 3 can make needs known but cannot make medical decisions.

A review of Resident 3's MDS, dated [DATE REDACTED], indicated Resident 3 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and was dependent with toileting hygiene, shower/bathe self, upper and lower body dressing, personally hygiene, roll left and right, and toilet transfer.

During concurrent interview and record review of Resident 3's Order Summary Report for July 2024 and Medication Administration Record (MAR) for January 2024 , on 7/11/2024 at 8:00 PM with the Director of Nursing (DON). The DON stated levothyroxine sodium oral solution 175 microgram per milliliter (mcg/ml- weight-based measurement commonly used for vitamins and minerals) date ordered indicated start on 12/24/2023 at 6 AM. The DON stated according to the Resident 3's MAR, the levothyroxine 175mcg/ml was not given on 1/12/2024 and 1/16/2024 at 6 AM and the resident missed two dosed of levothyroxine 175mcg/ml. The DON further stated it is important to give medication in accordance with the physician's order to obtain the therapeutic thyroid level.

A review of the facility's Policy and Procedure (P&P) titled, Physician Order, revised 5/1/2019, the P&P indicated Purpose, this will ensure that all physician orders are complete and accurate. The medical records will verify that physician order is complete accurate and clarified as necessary. Whenever possible, the license nurse receiving the order will be responsible for documentation and implementing the order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 055862