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Complaint Investigation

Golden Rose Care Center

July 11, 2024 · Pasadena, CA · 1899 N Raymond Ave
Citations 1
CMS Rating 1/5
Beds 99
Provider ID 055862
Healthcare Facility
Golden Rose Care Center
Pasadena, CA  ·  View full profile →
Inspection Summary

GOLDEN ROSE CARE CENTER in PASADENA, CA — inspection on July 11, 2024.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF759
Minimal harm or 1. Benazepril (used to treat high blood pressure) oral tablet. Give 5 milligram (mg, unit of measurement) by Some 2. Cranberry tablet 450 mg. Give 1 tablet by mouth once a day, supplement. With order date of 12/22/2022. affected

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] and readmitted on [DATE], 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).

055862

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PASADENA, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GOLDEN ROSE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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