Golden Rose Care Center

F-F550.

Findings:

1. A review of Resident 167's Admission Record indicated Resident 167 was initially admitted to the facility

on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included other seizures (abnormal electrical activity

in the brain that happens quickly), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and encounter for attention to gastrostomy tube(G-Tube- a flexible tube surgically inserted through

the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration).

A review of Resident 167's History and Physical Examination (H&P), dated 6/16/2024, indicated Resident 167 did not have the capacity to understand and make decisions.

A review of Resident 167's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/4/2024, indicated Resident 167 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and tub/shower transfer.

A review of Resident 167's Order Summary report, dated 7/10/2024, indicated a physician order, with a start date of 6/5/2024, for indwelling catheter attached to urinary drainage bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 67 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 0690 During an observation of Resident 167, on 7/8/2024, at 11:34 AM, Resident 167 was observed asleep in bed. Resident 167's bed was on the lowest level and the foley catheter collection bag was placed on the left Level of Harm - Minimal harm or side of the bed. Resident 167's indwelling catheter collection bag did not have a dignity bag to cover the potential for actual harm urine collected in the bag and it. was touching the floor.

Residents Affected - Some During a concurrent observation of Resident 167's collection bag and interview with Certified Nursing Assistant 1 (CNA 1), on 7/8/2024, at 1:21 PM, CNA 1 stated Resident 167's collection bag should not touch

the floor. CNA 1 stated Resident 167's collection bag should be covered with a dignity bag and placed inside

a bucket to prevent it from touching the floor.

During an interview with Treatment Nurse 2 (TN 2), on 7/10/2024, at 2:59 PM, TN 2 stated the floor was dirty and Resident 167's indwelling catheter collection bag should not touch the floor for infection control purposes. TN 2 stated Resident 167 can get sick and end up in the hospital if she gets an infection. TN 2 stated facility staff are responsible for making sure Resident 167's indwelling catheter collection bag does not touch the floor. TN 2 also stated a dignity bag should have been used to cover the indwelling catheter collection bag for the resident's privacy. TN 2 stated residents would not want anyone to see their urine in

the collection bag.

During an interview with the Director of Nursing (DON), on 7/11/2024, at 7:19 PM, the DON stated the collection bag should not touch the floor. The DON stated facility staff should leave a space between the floor and the collection bag when hanging the collection bag on the bed. The DON stated an infection or bacteria can ascend up the foley catheter tubing and cause a urinary tract infection (UTI) when the indwelling catheter collection bag touches the floor. The DON stated residents with UTI can get sick and end up in the hospital.

During the same interview with the DON on 7/11/2024, at 7:19 PM, the DON stated indwelling catheter collection bags should always be covered with a dignity bag. The DON stated a dignity bag is used to protect

the resident's privacy. The DON stated it is important for facility staff to respect the resident's right to privacy.

A review of the facility's policy and procedure (P&P), titled, Catheter-Care of, revised on 6/1/2017, indicated

a purpose, to prevent catheter-associated urinary tract infections while ensuring that residents are not given in-dwelling catheters unless medically necessary. The P&P indicated to, take care to ensure the collection bag does not touch the floor at any time. The P&P also indicated, The resident's privacy and dignity will be protected by placing cover over drainage bag when the resident is out of bed.

46087

2. A review of Resident 108's Admission Record indicated Resident 108 was admitted to the facility on [DATE REDACTED], readmitted on [DATE REDACTED], with diagnoses that included tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), sepsis (a serious condition in which the body responds improperly to an infection) and pressure ulcer (an injury that breaks down the skin and underlying tissue) of sacral region.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 67 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 0690 A review of Resident 108's MDS, a standardized assessment and care planning tool), dated 4/26/2024, indicated Resident 108 had severely impaired cognition (thought process and ability to reason or make Level of Harm - Minimal harm or decisions) for daily decision making. The MDS indicated Resident 108 was dependent with eating, oral potential for actual harm hygiene, toileting hygiene, shower, upper and lower body dressing, and personal hygiene. The MDS indicated Resident 108 is always incontinent (lacking in restraint or control) of bowel. Residents Affected - Some

During an observation on 7/8/2024 at 9:07 AM in resident's room, Resident 108 was observed in bed, asleep, with rectal tube drainage bag, draining by gravity, on Resident 108's left side of the bed.

During a concurrent record review of Resident 108's order summary report dated 7/11/2024 at 4:59 PM, and

interview with Treatment Nurse 2 (TN2), the order summary report indicated on 6/22/2024 to measure the output TN2 stated, Resident 108 was admitted on [DATE REDACTED] with a rectal tube from hospital. TN 2 verified that according to the order summary report Resident 108 only have an order to measure rectal tube output every shift on 6/22/2024 and did not have an order that Resident 108 may have rectal tube for wound management until 6/26/2024. TN 2 stated having an order that Resident 108 may have a rectal tube should have been ordered upon admission.

During a concurrent record review of Resident 108's care plan for rectal tube for wound management initiated on 7/8/2024 and interview with Registered Nurse Supervisor 3 (RNS 3) on 7/11/2024 at 5:05 PM, RNS 3 stated the care plan was just made, and it should have been initiated when Resident 108 was admitted on [DATE REDACTED]. RNS 3 stated that care plan should have been done so everyone taking care of Resident 108 would know and provide the necessary care for Resident 108's rectal tube.

A review of facility's Policy and Procedure (P&P), titled Rectal tube, revised on 6/1/2017, policy indicated the Attending Physician must order the use of a rectal tube.

A review of the facility's P&P titled, Care Planning, revised on 10/24/2022, policy indicated care plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 67 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48152

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) feeding was labeled with a date and time for one of two residents (Resident 52) as indicated

in the facility's policy.

This failure had the potential for Resident 52 to be administered an expired GT feeding, causing preventable gastric complications like nausea, vomiting and/or diarrhea.

Findings:

A review of Resident 's Admission Record indicated Resident 52 was readmitted [DATE REDACTED] with diagnoses that included dysphagia (difficulty swallowing), protein-calorie malnutrition (PCM- a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), and hypertensive heart disease (heart complications caused by high blood pressure that is present over a long time).

A review of Resident 52's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated [DATE REDACTED], indicated Resident 52 has unclear speech and was severely impaired with cognitive skills (ability to think, remember and reason) for daily decision making. Resident 52 was dependent (staff does all effort to complete activity) with bathing, toileting, oral and personal hygiene.

A review of Resident 52's Physician's order, dated [DATE REDACTED], indicated enteral feed order of Fibersource (a nutritionally complete tube feeding formula with fiber) 1.2 at 60 milliliters (ml- a unit of measurement) for 12 hours, turn on at 6 PM and turn off at 6 AM.

During an observation on [DATE REDACTED] at 9:25 AM at Resident 52's bedside, Resident 52's GT feeding bag did not have a label to indicate a date and time.

During a concurrent review and interview on [DATE REDACTED] at 2:39 PM with the Director of Nursing (DON), the DON verified that Resident 52's GT feeding was not labeled with date and time. The DON stated the facility policy is for the GT feeding formula to be labeled with the date and time the feeding was opened and administered to the resident. The DON stated, If the feeding is not labeled with the date and time, staff will not know when

the feeding was first opened and will not be able to ensure residents are receiving unexpired feedings. The DON stated residents can experience diarrhea, vomiting, abdominal pain and other negative side effects if given expired GT feedings.

A review of facility's Policy and Procedure (P&P) titled, Gastronomy Placement, revised [DATE REDACTED], indicated all equipment and products are labeled with the date and time they were first used or opened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 67 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48152 potential for actual harm Based on observation, interview, and record review, the facility failed to provide necessary respiratory Residents Affected - Some services for three (5) of five (5) sampled residents (Residents 260, 161, and 54) as indicated in the facility's policy by failing to:

1. Obtain a doctor's order before administering oxygen therapy to Resident 260.

2. Ensure Resident 161 received the amount of oxygen as ordered by the physician.

3. Obtain a physician's order before administering oxygen therapy to Resident 54

This deficient practice had the potential to cause complications or adverse effects (an undesired harmful effect resulting from a medication or other intervention) to Residents 260, 161, and 54 associated with oxygen therapy.

Findings:

1. A review of Resident 260's Admission Record indicated Resident 260 was readmitted to the facility on [DATE REDACTED] with diagnoses that included acute respiratory failure (a sudden condition in which not enough oxygen passes from the lungs into the blood), end stage renal disease (ESRD - a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance), hemiplegia (paralysis of one side of the body), and dysphagia (difficulty swallowing).

A review of Resident 260's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/18/2024, indicated Resident 260 with severely impaired cognitive skills (ability to think, remember and reason) for daily decision making. Resident 260 required supervision/touching assistance (staff provide verbal cues and/or touching steadying while completing the activity) while eating and was dependent (staff does all effort needed to complete activity) for bathing, dressing, oral, personal and toileting hygiene.

A review of Resident 260's History & Physical (H&P), dated 10/5/2023, indicated Resident 260 could make needs known but could not make medical decisions.

During an observation on 7/8/2024 at 9:34 AM, Resident 260 was observed in bed receiving oxygen via nasal cannula (NC - nasal cannula is a device that delivers extra oxygen through a tube and into your nose) at three (3) liters per minute.

A review of Resident 260's Order Summary Report, dated 7/10/2024, did not indicate a physician's order for oxygen administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 67 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 0695 During a concurrent record review of Resident 260's electronic chart from 8/1/2023 through 7/8/2024 and

interview on 7/10/2024 at 2:16 PM with the Director of Nursing (DON), the DON stated Resident 260's Level of Harm - Minimal harm or electronic chart did not indicate a doctor's order for oxygen administration. The DON stated oxygen is potential for actual harm considered a treatment and needs to have a doctor's order before it can be given. The DON stated giving oxygen without a doctor's order means treatment was not validated by the doctor and the resident can be Residents Affected - Some given unnecessary or unmonitored treatments.

A review of facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 6/1/2017, indicated a physician's order (including the rate, method of administration and usage) is required to initiate oxygen therapy and staff are to administer at the prescribed rate.

46919

2. A review of Resident 161's Admission Record indicated Resident 161 was admitted on [DATE REDACTED] with diagnoses that included chronic obstructive pulmonary disease unspecified (COPD- a lung disease characterized by long term poor airflow), pneumonia (an infection that affects one or both lungs), and heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should).

A review of Resident 161's H&P, dated 6/8/2024, indicated Resident 161 had the capacity to understand and make decisions.

A review of Resident 161's MDS, dated [DATE REDACTED], indicated Resident 161 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, lower body dressing, and putting on/taking off footwear. The MDS also indicated Resident 161 required partial/moderate assistance (helper does less than half the effort) with shower/bathe self, upper body dressing, sit to stand, chair/bed-to-chair transfer, toilet transfer, and walking 10 feet (ft- unit of measurement).

A review of Resident 161's Order Summary Report, dated 7/10/2024, indicated a physician order, with a start date of 6/12/2024, for oxygen at 5 liters of oxygen per minute (LPM, unit of measurement usually used to determine amount of oxygen given) via nasal cannula (oxygen tubing used to deliver supplemental oxygen that is placed directly on the nostrils) humidification (moistened oxygen) continuously for COPD.

A review of Resident 161's Care Plan, revised on 6/12/2024, indicated Resident 161 had oxygen therapy related to COPD. The Care Plan interventions indicated an oxygen setting via nasal (nose) of 5 LPM continuous humidified.

During a concurrent observation in Resident 161's room and interview on 7/8/2024, at 11:52 AM, Resident 161 was on 4.5 LPM of oxygen via nasal cannula. Resident 161 stated he was supposed to receive between 5 LPM and 6 LPM of oxygen.

During a concurrent observation of Resident 161's oxygen and interview with Infection Prevention Nurse (IPN 1) on 7/9/2024, at 12:29 PM, IPN 1 stated Resident 161 was currently receiving 4.5 LPM of oxygen via nasal cannula.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 67 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 0695 During the same concurrent observation of Resident 161's oxygen concentrator (a machine that uses the air

in the atmosphere, filters it, and gives the resident air that is 90% to 95% oxygen) and interview with Level of Harm - Minimal harm or Resident 161 on 7/9/2024, at 12:29 PM, Resident 161 stated he cannot receive less than 5 LPM of oxygen at potential for actual harm any time. Resident 161 stated oxygen was very important for him because he has periods of anxiety which causes him to have shortness of breath. Residents Affected - Some

During a concurrent observation of Resident 161's room and interview with Registered Nurse 1 (RN 1) on 7/10/2024, at 9:55 PM, RN 1 stated Resident 161 was currently receiving 4 LPM via nasal cannula. RN 1 stated Resident 161 was ordered to receive oxygen at 5 LPM.

During an interview with RN 1 on, 7/10/2024, at 4:53 PM, RN 1 stated Resident 161 was diagnosed with COPD and received oxygen continuously for difficulty breathing. RN 1 stated Resident 161 can get sick, have difficulty breathing, desaturate (condition of low blood oxygen concentration in the body), and end up in

the hospital for respiratory distress if he does not get enough oxygen. RN 1 stated licensed nurses are responsible in checking that Resident 161 gets the prescribed amount of oxygen.

During an interview with the Director of Nursing (DON), on 7/11/2024, at 12:20 PM, the DON stated it was important for facility staff to follow Resident 161's oxygen order to receive 5 LPM of oxygen continuously because Resident 161 was diagnosed with COPD. The DON stated Resident 161 can have shortness of breath, oxygen desaturation, COPD exacerbation (sudden worsening of symptoms), and end up in the hospital if he does not get enough oxygen. The DON stated it is the responsibility of the licensed nurses to check Resident 161's oxygen rate every shift and during medication administration.

A review of the facility's P&P titled, Oxygen Administration, revised on 6/1/2017, indicated the facility will prevent or reverse hypoxemia and provide oxygen to the tissues.

48143

3. A review of Resident 54's Admission Record indicated Resident 54 was admitted to the facility on [DATE REDACTED] with diagnoses that included malignant neoplasm of anterior mediastinum (masses of cells that appear in the space between the lungs) with dysphagia (difficulty swallowing), neuralgia (refers to severe, sharp, often shock-like pain that follows the path of a nerve), and neuritis (an inflammation of the nerves).

A review of Resident 54's MDS, dated [DATE REDACTED], indicated Resident 54 was moderately impaired with cognitive skills (ability to think, remember and reason) for daily decision making. Resident 54 required partial, moderate assistance (helper does less than half the effort) with the toilet, personal hygiene, change of position, and transfer.

A review of Resident 54's H&P, dated 7/5/2024, indicated Resident 54 has the capacity to understand and make decisions.

During an observation on 7/10/2024 at 12:52 PM, in Resident 54's room, Resident 54 was observed being administered with oxygen at 3L (metric unit of capacity)/minute via a nasal cannula.

During a concurrent observation and interview on 7/10/2024 at 2:02 PM with Licensed Vocational Nurse 3 (LVN 3), in Resident 54's room, LVN 3 checked the resident and stated Resident 54 is getting oxygen at 3 liters per minute.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 67 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 0695 During a concurrent record review of Resident 54's electronic health record (EHR) and hospice (end of life care) binder and interview on 7/10/2024 at 2:20 PM with LVN 3, LVN 3 confirmed that she cannot find any Level of Harm - Minimal harm or physician's order for Resident 54's oxygen therapy. LVN 3 stated a physician's order should have been potential for actual harm obtained before administering oxygen to Resident 54. LVN 3 stated this may cause harm to Resident 54 if oxygen was administered to resident 54 without a physician's order. Residents Affected - Some

During an interview on 7/10/2024 at 2:25 PM with Registered Nurse Supervisor 1(RNS 1), RNS 1 stated all oxygen administration were supposed to be administered to the resident with a physician's order. RNS 1 stated if oxygen was administered without physician's order, it had the potential to cause complications associated with oxygen therapy.

A review of the facility's P&P titled, Oxygen Administration, revised dated 6/1/2017, indicated a physician's order is required to initiate oxygen therapy, except in an emergency situation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 67 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 0699 Provide care or services that was trauma informed and/or culturally competent.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48152 potential for actual harm Based on interview and record review, the facility failed to provide trauma-informed care (an approach to Residents Affected - Few delivering care that involves understanding, recognizing, and responding to the effects of all types of traumas) to one of 24 sampled resident (Resident 9) who was diagnosed with post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event).

This deficient practice had the potential for Resident 9 to experience re-traumatization, (unintentionally causing harm through practices, policies, and/or activities that are insensitive to the needs of the residents) that could lead to severe psychosocial harm and negatively affecting his quality of life.

Findings:

A review of Resident 9's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses that included post traumatic PTSD, depression (mood disorder that causes a persistent feeling of sadness and loss of interest in life), bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration), hemiplegia(paralysis of one side of the body), and hemiparesis (inability to move one side of the body).

A review of Resident 9's History and Physical (H&P), dated 4/13/2023, indicated Resident 9 had the capacity to understand and make decisions.

A review of Resident 9's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool), dated 5/1/2024, indicated Resident 9 had:

a. Intact cognitive skills (ability to think, remember and reason) for daily decision making.

b. Several days (2-6 days) out of 2 weeks with little interest and please in doing things.

c. Maximal assistance (staff does more than half effort needed to complete activity) with eating and toileting.

d. Dependent (staff does all effort needed to complete activity) with bathing, dressing, oral and personal hygiene.

e. Active diagnoses of PTSD

During an interview on 7/11/24 at 2:12 PM with the Director of Nursing (DON), DON stated PTSD was what a resident experienced due to something that has occurred in their past that presently causes stress to them. DON stated staff must ensure residents who have PTSD were safe, and to do that, staff must be aware of

the triggers for that specific resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 67 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 0699 During an interview on 7/11/2024 at 3:42 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated caring for Resident 9 on more than one occasion. LVN 1 stated Resident 9 has a diagnosis of PTSD but did not Level of Harm - Minimal harm or know any triggers (anything including sound, sight, smell or thought that is a reminder of a traumatic event) potential for actual harm for Resident 9's PTSD, the history related to Resident 9's PTSD or trauma informed care interventions for Resident 9's PTSD. LVN 1 stated it was important to know a resident's triggers to avoid them, so that the Residents Affected - Few resident would not be triggered by staff while assisting and providing care. LVN 1 also stated not knowing a PTSD resident's triggers could be detrimental to their health.

During an interview on 7/11/2024 at 3:51 PM with Treatment Nurse 1 (TN 1), TN 1 stated providing treatment care (wound, skin) for Resident 9. TN 1 stated she was unaware that Resident 9 had a diagnosis of PTSD. TN 1 was unable to state any of Resident 9's PTSD triggers or interventions to provide trauma informed care to Resident 9.

During an interview on 7/11/2024 at 4:08 PM with Certified Nursing Assistant 9 (CNA 9), CNA9 stated she was not aware of Resident 9's PTSD diagnosis. CNA 9 stated she does not know any of Resident 9's PTSD triggers or specific PTSD trauma informed care interventions.

A review of the facility's policy and procedure (P&P) titled Social Service Assessment and Documentation, revised 10/22/2024, indicated:

a. The Facility will use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences. This includes asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event.

b. The Facility will identify triggers which may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening.

The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 67 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087

Residents Affected - Some Cross reference:

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 46 of 67 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 47 of 67 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 48 of 67 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.

47362

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 49 of 67 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48143

Residents Affected - Few Based on interview and record review, the facility failed to relay the recommendations of pharmacist in Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to the doctor and to take action to address the recommendation/ irregularities for the month of June 2024's MRR for two of five sampled residents (Resident 11and 19) for unnecessary medications review.

This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to the resident.

Findings:

1. A review of Resident 19's Admission Record indicated Resident 19 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses that included major depressive disorder (mental disorder characterized by a pervasive and persistent low mood that is accompanied by a loss of interest or pleasure

in normally enjoyable activities), and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and metabolic encephalopathy (this comprise a series of neurological disorders not caused by primary structural abnormalities; rather, they result from systemic illness, such as diabetes, liver disease, renal failure and heart failure).

A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 6/21/2024, indicated Resident 19 had some difficulty in new situations only for modified independence of cognitive skills for daily decision making. Resident 19 required substantial and maximum assistance, (helper does more than half the effort) with the toilet, personal hygiene, change of position, and transfer. The MDS also indicated Resident 19 was receiving antipsychotic (drug used to treat symptoms of psychosis. These include hallucinations (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real), delusions (false beliefs), and dementia (loss of the ability to think, remember, learn, make decisions, and solve problems). and antidepression medications.

A review of Resident 19's Physician Orders, dated 12/27/23, indicated Resident 19 to have remeron (increase the levels of the chemicals serotonin and norepinephrine in the brain, which helps improve mood) 15 milligrams (mg, a unit of measure) for depression for verbalization of sadness leading to poor oral intake, abilify (can treat schizophrenia, bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs, mania episodes, to lows, depression episode) and/ or depression) 5 mg for psychosis believing that staffs are out to get her.

2. A review of Resident 11's Admission Record indicated Resident 11 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED], with diagnoses that included other seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), bipolar disorder, and dysphagia (difficulty swallowing).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 67 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 0756 A review of Resident 11's MDS, dated [DATE REDACTED], indicated Resident 11 has the capacity to understand and make decisions. Resident 11 required partial assistance from another person with the toilet, personal Level of Harm - Minimal harm or hygiene, change of position, and transfer. potential for actual harm

A review of Resident 11's Physician Orders, dated 4/8/24, indicated Resident 11 to have Keppra (medication Residents Affected - Few for seizure) 750 mg for seizure.

During a review of Consultant Pharmacist's Medication Regimen Review, dated 6/30/2024, the MRR indicated:

a. For Resident 19 to decrease Remeron (mirtazapine) to 7.5 mg and to decrease Abilify (aripiprazole) to 2.5 mg daily (QD).

b. For Resident 11, the resident is currently receiving: Keppra (levetiracetam) for seizure disorder. Please get

an order from MD for a Keppra level on the next available lab day, so we can better assess the appropriateness of the current dose.

During a concurrent interview and record review on 7/11/24 at 6:41 PM, with the Director of Nurses (DON),

the DON confirmed that she has the copy of Medication Regiment Review (MRR) for the month of June 2024, but she has not started working and did not review the MRR that pharmacy sent to her for any irregularities/ pharmacist's recommendations. The DON stated if MRR result was not reviewed and if there's any irregularities or recommendation in the MRR were not relayed to the doctor and no action has been taken by the facility, it can cause medications overdose or medication misuse which can lead to resident harm serious illness and/ or worsening of condition.

During an interview on 7/11/2024 at 7:29 PM, with the Administrator (ADM), ADM stated she still has the MRR of June 2024 in her computer, the MRR results were not reviewed for irregularities and/ or recommendations by the pharmacist therefore was not carried out.

A review of the facility Policy and Procedure titled, Drug Regimen Review, revised 11/1/2017, indicated the

I. The pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications.

II. The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.

III. The Medical Director and DON will also review the pharmacist's report if any irregularities are identified.

A. The DON is responsible for following up with the Attending Physician, as indicated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 67 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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate Residents Affected - Some was less than five (5) percent (%). 12 medication errors out of 27 total opportunities for error, to yield an overall medication error rate of 44.44 % for on (1) of six (6) residents observed for medication administration (Resident 208). The medication errors were as follows:

A. During a Medication Pass observation, Licensed Vocational Nurse 3 (LVN 3) failed to administer Resident 208's medications within 60 minutes of scheduled time of 7:30 AM on 7/10/2024.

B. During a Medication Pass observation, LVN 3 failed to administer Resident 208's medications within 60 minutes of scheduled time of 9 AM on 7/10/2024.

These deficient practices had the potential to result in Resident 208 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents health and well-being to be negatively impacted.

Findings:

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).

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

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 67 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 0759 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. Level of Harm - Minimal harm or potential for actual harm 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 Residents Affected - Some 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 [chest pain]) 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.

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 was observed preparing Resident 208's medications. LVN 3 stated that

the following medications were Resident 208's scheduled medications for 9 AM:

Benazepril 5 mg oral tablet.

Cranberry tablet 450 mg.

Docusate Sodium tablet 100 mg.

Digoxin 0.125 mg tablet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 67 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 0759 Eliquis oral tablet 5 mg

Level of Harm - Minimal harm or Finasteride tablet 5 mg. potential for actual harm Lasix oral tablet 20 mg. Residents Affected - Some Lacosamide oral tablet 200 mg.

Levetiracetam Solution 15 ml.

Metoprolol Tartrate tablet 25 mg.

Multivitamin Minerals tablet.

Ranolazine extended-release tablet 500 mg.

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.

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 complications of inconsistent timing of medication administration. The DON stated, If medications were not 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 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 (P&P) titled, Medication-Administration, revised 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.

A review of the facility's P&P titled, Charge Nurse, dated 2003, indicated duties and responsibilities to prepare and administer medications as ordered by the physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 67 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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure for one of six (6) sampled Residents Affected - Few residents (Residents 208) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professionals providing services) by failing to administer two (2) medications due to be given at 7:30 AM with meals in accordance with the physician's order and four (4) medications due to be given at 9 AM in accordance with

the physician's order. The following medications for Resident 208 were administered more than one (1) hour from the scheduled administration time:

1. Metoprolol Tartrate (used to treat high blood pressure) tablet 25 milligram (mg, unit of measurement).

2. Ranolazine (used to treat chronic angina [chest pain]) extended-release tablet 500 mg.

3. Benazepril (used to treat high blood pressure) 5 mg oral tablet.

4. Digoxin (used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat) 0.125 mg tablet.

5. Lacosamide (used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) oral tablet 200 mg.

6. Levetiracetam solution (used to treat seizures) 15 milliliters (ml, unit of measurement).

This deficient practice had the potential to affect the efficacy and side effects of the medications, which could cause harm to Resident 208.

Findings:

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 67 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 0760 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 Level of Harm - Minimal harm or required) cognitive skills (mental action or process of acquiring knowledge and understanding through potential for actual harm 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 Residents Affected - Few 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).

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

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

2. Ranolazine extended-release tablet 500 mg. Every 12 hours, give 1 tablet by mouth two times a day for Angina Pectoris (chest pain or discomfort that keeps coming back). With Meals at 7:30 AM. With order date of 12/22/2022.

3. Benazepril oral tablet. Give 5 mg by mouth, once a day for hypertension. With order date of 2/17/2024.

4. Digoxin 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. Lacosamide oral tablet 200 mg. Give 200 mg by mouth two times a day for seizures. With order date of 12/22/2022.

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

During a concurrent observation of the medication administration for Resident 208 and interview with Licensed Vocational Nurse 3 (LVN 3) on 7/10/2024, at 10:20 AM, LVN 3 administered the following medications to Resident 208 with a cup of water:

1. Metoprolol Tartrate tablet 25 mg

2. Ranolazine extended-release tablet 500 mg.

3. Benazepril 5 mg oral tablet.

4. Digoxin 0.125 mg tablet.

5. Lacosamide oral tablet 200 mg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 67 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 0760 6. Levetiracetam Solution 15 ml.

Level of Harm - Minimal harm or During a concurrent record review of Resident 208's medication administration record (MAR) and interview potential for actual harm with Registered Nurse Supervisor 1 (RNS 1) at 7/11/2024 at 8:54 AM, RNS 1 verified that LVN 3 administered Resident 208's 7:30 AM medication late on 7/10/2024 that the medication was given after 10 Residents Affected - Few AM, which was outside the 1 hour window of medication administration. 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 the medications should have been given with meals during breakfast at 7:30 AM. RNs 1 stated there was no documentation that Resident 208's physician was called on 7/10/2024 since the medications were administered not in accordance with the physician's order.

During an interview with RNS 2 on 7/11/2024 at 7:05 PM, RNS 2 stated medications may be administered one-hour before or after the scheduled time, but should not go beyond, as it can alter the medication's efficacy and resident could develop adverse reactions or side effects from the medication.

During an interview with the Director of Nursing (DON) on 7/11/2024 at 8:26 PM, the DON stated that it was important to administer medication as ordered to get the full benefit of the medication and to prevent complications of inconsistent timing of medication administration. The DON stated, If medications were not 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 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, and if it was 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 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 67 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087 Residents Affected - Some Based on observation, interview, and record review the facility failed to follow its policy by failing to:

1. Remove six (6) vials of Epogen (drug used to treat anemia [lack of blood]) of a resident who has been discharged from Medication Refrigerator 3.

This deficient practice had the potential for this medication to be mistakenly given to other residents that can lead to a medication error.

2. Defrost (become free of accumulated ice) Medication Refrigerator 1 and 2.

This deficient practice had the potential to affect the temperature quality of Medication Refrigerator 1 and 2, which might affect the efficacy of the refrigerated medications for the residents.

3. Secure medications at all times to prevent unauthorized access of the medications in the facility and failed to not leave the narcotic (drug or other substance used to treat moderate to severe pain that affects mood or behavior) key attached to the narcotic drawer of the medication cart while attending to Resident 3.

This deficient practice had the potential to result in unauthorized access to medications and narcotics by residents, visitors, and staff and predisposing them to possible medication overdose (taking a toxic or poisonous amount of a drug or medication, unauthorized use of medications, adverse reactions (any unexpected or dangerous reaction to a drug), and drug-to-drug interactions (a reaction between two or more drugs or between a drug, and a good, beverage, or supplement).

Findings:

1. During a concurrent observation of Medication Refrigerator 3 and interview with the Infection Preventionist Nurse (IPN) on 7/11/2024 at 12:08 PM, a container with 6 vials of Epogen were observed inside Medication Refrigerator 3. IPN stated the the 6 vials of Epogen belonging to a resident who was no longer in the facility were still in the Medication Refrigerator 3. IPN stated the medications for the Residents who have already been discharged , should have been disposed.

During an interview with Registered Nurse Supervisor 3 (RNS 3) on 7/11/2024 at 7:08 PM, RNS 3 stated ice build up inside the medication refrigerator might affect the medications that are stored inside the refrigerator and might not be beneficial to Residents when used. RNS 3 stated licensed nurses should discard the medications of discharged residents to avoid confusion.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 67 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 0761 During an interview with the DON on 7/11/2024 at 8:15 PM, the DON stated storing medications of a resident who has already been discharged increases the risk to be mistakenly used and can cause possible harm and Level of Harm - Minimal harm or hospitalization to the residents. The DON stated that medication refrigerators should be defrosted and potential for actual harm cleaned weekly. The DON stated, I don't know when the refrigerator was cleaned and defrosted by licensed nurses since there was no log. The DON stated having ice build up in the medication refrigerators was not a Residents Affected - Some good practice, The DON stated If refrigerated medications were not stored properly, medications could be ineffective which could cause medical complication to the residents leading to harm and hospitalization .

2. During a concurrent observation of Medication Refrigerator 1 and interview with IPN on 7/11/2024 at 11:53 AM, IPN verified Refrigerator 1 has ice buildup. IPN stated that this was not a common practice because it may affect the temperature of the entire fridge affect the efficacy of the residents' refrigerated medications.

During a concurrent observation of Medication Refrigerator 2 and interview with IPN on 7/11/2024 at 12:03 PM, IPN stated that half of the freezer space was accumulated with built up ice. IPN stated the refrigerator should have been defrosted because it can impact the temperature quality of refrigerator. IPN stated, It might damage and cause problem with preservation of efficacy of the stored refrigerated medication for the residents. IPN was unable to state and provide documented evidence when the last time Medication Refrigerator 1 was and 2 was defrosted.

A review of facility's undated Policy and Procedure (P&P) titled, Medication Storage in the Facility, indicated medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures.

A review of Facility's P&P titled, Maintenance Services, revised on 6/1/2017, indicated Maintenance Department maintains all areas of the building, grounds, and equipment. It also indicated that Maintenance Department maintains all mechanical, electrical, and patient care equipment in safe operating condition

46919

3. 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), and chronic obstructive pulmonary disease (COPD- a lung disease characterized by long term poor airflow).

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

A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/22/2024, 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 67 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 0761 During an observation of the facility hallway in front of Resident 3's room, on 7/10/2024, at 10:10 AM, Medication Cart 1 (MC 1) was observed unattended in the middle of the hallway with the key attached to the Level of Harm - Minimal harm or lock next to the narcotic drawer. Facility staff were observed walking by the unlocked medication cart. potential for actual harm

During an interview with Licensed Vocational Nurse 1 (LVN 1), on 7/10/2024, at 10:12 AM, LVN 1 stated the Residents Affected - Some medication cart was left unlocked and unattended with the key still in the lock because Resident 3 called and sounded distressed. LVN 1 stated the medication cart should be locked at all times and not left in the middle of the hallway. LVN 1 stated residents, staff, and visitors can open the medication cart and take the medications if the medication cart was left unlocked if they get access to the medication cart key. LVN 1 stated residents, staff, and visitors who would take medications that were not prescribed for them can get sick, have an allergic reaction, or have a drug overdose (an excessive and dangerous dose of a drug).

During an interview with the Director of Nursing (DON), on 7/11/2024, at 12:35 PM, the DON stated facility staff should not leave the medication carts unlocked. The DON stated facility staff should always lock and take the medication cart key with them before administering medications or providing care to residents. The DON stated it was important to lock the medication cart to keep the residents safe and prevent them from taking medications inside the medication cart. The DON stated it was also important to lock the medication cart to prevent staff or visitors from stealing medications from the medication cart. The DON stated narcotics can be stolen from the medication cart if the key was left attached to the lock. The DON stated licensed staff were responsible for the narcotics and they can get reported to the Board of Nursing ( a government body that oversees nursing licenses) if a narcotic was missing. The DON stated residents, staff, or visitors can have an adverse reaction to the medication, overdose, get sick, or die if they take medications that were not prescribed to them. The DON stated medication carts should be placed on one side of the hallway and not in

the middle of the hallway for the safety of the residents, staff, and visitors.

A review of the undated facility Policy and Procedure (P&P) titled, Medication Storage in the Facility, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The P&P indicated, Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 67 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48152

Residents Affected - Some Based on observation, interview, and record review, the facility failed to follow proper food handling practices

in accordance with the facility's policy and procedure by failing to:

1. Ensure a box of raw porkchops were stored and labeled per protocol once opened.

2. Ensure plastic containers of flour and dry pasta were tightly sealed while in storage.

3. Boxed juice concentrates were labeled.

4. Walk in refrigerator temperature was below 41 degrees Fahrenheit ( F: a scale of temperature).

These deficient practices had the potential to result in contaminated (the presence of unwanted substances, such as bacteria, viruses, parasites, and other microorganisms) food items being given or exposure to residents, with risk for residents to develop foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization .

Findings:

1. During a concurrent observation and interview on [DATE REDACTED] at 7:56 AM with DSS, in the kitchen walk in refrigerator, an unlabeled, undated opened cardboard box containing porkchops were observed. DSS stated

the cardboard box contain porkchops was unlabeled and did not indicate an open date (date product was opened). DSS stated per policy, the meat (porkchops) should be in a sealed bag, labeled with an open date, receiving date and a discard date.

2. During a concurrent observation and interview on [DATE REDACTED] at 8:02 AM with Dietary Service Supervisor (DSS), in the facility dry storage room, the lids of one (1) plastic storage container containing dry pasta and 1 plastic storage containing flour were opened. DSS stated the containers were opened and should be tightly closed to prevent rodents, dust or anything from going inside the storage containers and also to prevent residents from getting sick if eating the [contaminated] foods.

3. During a concurrent observation and interview on [DATE REDACTED] at 8:07 AM with DSS, in the kitchen dry storage,

a box of Nutri Juice (juice full of healthy vital substances such as Vitamins C, E and A as well as numerous micro-nutrients, minerals and enzymes) thickened water (a medical dietary adjustment that thickens the consistency of fluids in order to prevent choking) and a box of Nutri Juice pineapple blend were observed with no date indicating the receiving or 'best by 'date (when a product will be of best flavor or quality). DSS stated the items should be labeled with a receiving date and best by date. DSS also stated a label indicating dates, such as received date, best by date are required to ensure food items are not expired. The DSS stated if expired food items were served to residents, residents could become sick for consuming expired food items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 67 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 0812 4. During a concurrent observation and interview on [DATE REDACTED] at 7:43 AM with [NAME] 1, in the kitchen walk in refrigerator, the thermometer [located inside refrigerator] indicated a temperature of 48 F. [NAME] 1 stated Level of Harm - Minimal harm or the refrigerator temperature should be between 40 F to 50 F per policy. potential for actual harm

During a concurrent observation and interview on [DATE REDACTED] at 7:50 AM with Dietary Aide 1 (DA 1), in the Residents Affected - Some kitchen walk in refrigerator, the thermometer [located inside refrigerator] read a temperature of 48 F. DA 1 stated per policy, walk in fridge temp should be above 50 F.

A review of facility's Refrigerator/Freezer Temperature Log, dated [DATE REDACTED], indicated the following dates with

a refrigerator temperature less than 41 F:

1. [DATE REDACTED] PM shift at 42 F

2. [DATE REDACTED] PM shift at 42 F

3. [DATE REDACTED] PM shift at 42 F

4. ,d+[DATE REDACTED] /2024 PM shift at 49 F

5. [DATE REDACTED] AM shift at 42 F

6. [DATE REDACTED] PM shift at 52 F

7. [DATE REDACTED] AM shift at 43 F

8. [DATE REDACTED] PM shift at 55 F

During an interview on [DATE REDACTED] at 8:48 AM with DSS, DSS stated the walk-in refrigerator temperature must be less than 41 F per the facility's policy. DSS stated the importance of maintaining the appropriate temperature of the refrigerators was to maintain the quality of the food and prevent food items from spoiling. DSS stated serving spoiled food items to residents could result in the residents becoming sick, such as the stomach flu (a viral infection that affects your stomach and intestines), diarrhea and/or vomiting.

A review of the facility's policy & procedure (P&P) titled Food Storage, revised [DATE REDACTED], indicated:

1. Food items will be stored in accordance with good sanitary practices,

2. Raw meats, poultry, seafood, eggs, milk, cheese, and dairy products should be stored at a temperature below 41 degrees F,

3. Fresh fruits and fresh vegetables will be stored at a temperature of 41 degrees F or less

4. Any opened products should be placed in storage containers with tight fitting lids.

5. Label and date storage products and all food items

6. Date meats when taken out of freezer and with date of meal service

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 67 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48152 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food items placed in the Residents Affected - Some resident refrigerator (used to store residents' perishable foods brought from outside the facility) were stored and labeled with resident's name and date as indicated in the facility policy.

This failure had the potential for residents to consume expired and/or contaminated foods resulting in food-borne illnesses (food poisoning) with symptoms including stomach cramps, nausea, vomiting, diarrhea and fever.

Findings:

During a concurrent observation and interview on [DATE REDACTED] at 8:16 AM with Dietary Service Supervisor (DDS),

the residents' refrigerator was observed with the following food items unlabeled with a resident room number and/or date:

a. one bottle of creamer

b. one two-liter bottle of soda

c. one bottle of protein shake

d. two uncontained heads of lettuce

e. seven plastic containers of food

f. one bag of bean sprouts

g. two whole watermelons

h. one bag of corn ears

i. one bag of raw apples

j. one carton of eggs

DDS stated food and drinks in the residents' refrigerator were not and should have been labeled. DDS stated per facility policy, all food stored in the refrigerator must be labeled with the resident's room number, received date and should be discarded in 48 hours. DDS also stated it was important for food to be labeled and dated to make sure residents do not eat expired food which can cause the residents to get sick.

A review of the facility's Policy and Procedure (P&P) titled, Food Brought in by Visitors, revised [DATE REDACTED], indicated food from outside should be stored in a sealable container with the resident's name and date when brought to the facility. Perishable [brought in by visitors] items requiring refrigeration will be labeled, dated, and discarded after 48 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 67 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46919 potential for actual harm Based on interview and record review, the facility staff failed to administer the influenza (flu- a common but Residents Affected - Few sometimes deadly viral infection of the nose, throat, and lungs) vaccine (a preparation that used to stimulate

the body's immune response against diseases) for one (1) of five (5) sampled residents (Resident 34) after

the responsible party signed the consent form on 2/2/2024.

This deficient practice placed Resident 34 at a higher risk of acquiring and transmitting the flu virus to other residents in the facility.

Findings:

A review of Resident 34's Admission Record indicated Resident 34 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses that included nontraumatic intracerebral hemorrhage (bleeding in the substance in the brain in the absence of trauma or injury), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and immunodeficiency (decrease ability of the body to fight infections and other diseases).

A review of Resident 34's History and Physical Examination (H&P), dated 1/30/2024, indicated Resident 34 did not have the capacity to understand and make decisions.

A review of Resident 34's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/8/2024, indicated Resident 34 was assessed having severely impaired (never/rarely makes decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 34 was dependent (helper does all of the effort) with eating, oral and toileting hygiene, upper/lower body dressing, personal hygiene, roll left to right, and chair/bed-to-chair transfer.

A review of Resident 34's Pneumococcal (PNA- and infection of the lungs) and Influenza Vaccination Screening and Informed Consent Form (a form used to screen residents for contraindications and precautions before a vaccine is administered and is signed by the resident or the authorized representative agreeing to the vaccination) indicated Resident 34's authorized representative gave consent to receive the influenza vaccine now and annually. Vaccine will be given now and annually thereafter. The Pneumococcal and Influenza Vaccination Screening and Informed Consent Form was signed and dated by Resident 34's authorized representative on 2/2/2024. The Pneumococcal and Influenza Vaccination Screening and Informed Consent Form was signed by the facility's screening nurse on 2/7/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 67 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 0883 During an interview with Infection Prevention Nurse 1 (IPN 1), on 7/11/2024, at 4:47 PM, IPN 1 stated the flu vaccine was never given to Resident 34 because IPN 1 stated she did not find Resident 34's signed Level of Harm - Minimal harm or Pneumococcal and Influenza Vaccination Screening and Informed Consent Form not until this afternoon. IPN potential for actual harm 1 stated Resident 34's consent form was signed by his authorized representative on 2/2/24 and by the screening nurse on 2/7/2024. IPN 1 stated she cannot distinguish the signature of the licensed nurse who Residents Affected - Few screened and signed Resident 34's Pneumococcal and Influenza Vaccination Screening and Informed Consent Form. IPN 1 stated the facility informs the residents or their authorized representatives about the flu vaccine on admission. IPN 1 stated it was important to inform and give residents the flu vaccine to protect

the residents from getting the flu virus. IPN 1 stated Resident 34 was at high risk for getting infections and should have received the flu vaccine on 2/2/24 when it was signed by his authorized representative.

During an interview with the Director of Nursing (DON), on 7/11/2024, at 5:14 PM, the DON stated the facility offers the flu vaccines during the flu season which is from the month of October to March. The DON stated Resident 34 was a high risk for infections and should have received the flu vaccine after the consent was signed. The DON stated Resident 34 can get really sick and die if Resident 34 gets the flu. The DON stated IPN 1 was responsible for following up with the residents' vaccinations to make sure they were given during flu season.

A review of the facility's Policy and Procedure (P&P) titled, Influenza Prevention & Control, revised on 3/6/2023, indicated, The facility will ensure that the Facility prevents and controls the spread of influenza in

the Facility. The P&P indicated, The Residents are offered an influenza vaccine during flu season annually, unless the vaccination is medically contraindicated, or the resident has already been vaccinated during this time period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 67 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46919 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control Residents Affected - Few program to ensure the facility remains free of pests (a general term for organisms [rats, insects, cockroaches, etc.] which may cause illnesses) for two (2) of 24 sampled residents (Resident 36 and Resident 165) in accordance with the facility's policy and procedure (P&P).

This deficient practice had the potential to affect residents when the flies that carry bacteria land on the food that the residents eat, which could result to illness.

Findings:

1. A review of Resident 36's Admission Record indicated Resident 36 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of the inability to move one side of the body) following cerebral infarction affecting left non-dominant side (when the blood supply to part of the brain is blocked or reduced causing muscle weakness or partial paralysis on one side of the body) , type 2 diabetes mellitus with unspecified complications (a disease that occurs when the blood sugar is too high), and heart failure (CHF- a serious condition in which the heart doesn't' pump blood as efficiently as it should).

A review of Resident 36's History and Physical Examination (H&P), dated 4/16/2024, indicated Resident 36 can make needs knows but cannot make medical decisions.

A review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/28/2024, indicated Resident 36 had intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 36 required setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating and required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, personal hygiene, roll left to right, and tub/shower transfer. Resident 36 was dependent (helper does all of the effort) with upper/lower body dressing and toilet transfer.

During a concurrent observation in Resident 36's room and interview with Resident 36, on 7/8/2024, at 9:16 AM, a black fly was observed flying in Resident 36's room. Resident 36 stated he saw the fly in the room and stated the flies have been in his room the last couple of days. Resident 36 stated he informed facility staff about the flies when he first saw them.

2. A review of Resident 165's Admission Record indicated Resident 165 was initially admitted to the facility

on [DATE REDACTED] and was readmitted on [DATE REDACTED] with diagnoses that included end stage renal disease (a condition

in which the kidneys lose the ability to remove waste and balance fluids), type 2 diabetes mellitus (a disease that occurs when the blood sugar is too high), and chronic obstructive pulmonary disease (COPD- a lung disease characterized by long term poor airflow)

A review of Resident 165's H&P, dated 1/26/2024, indicated Resident 165 had the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 67 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 0925 A review of Resident 165's MDS, dated [DATE REDACTED], indicated Resident 165 had intact memory and cognitive skills for daily decision making. Resident 165 required supervision or touching assistance with eating, oral Level of Harm - Minimal harm or hygiene, upper and lower body dressing, personal hygiene, and toilet transfer. Resident 165 required potential for actual harm partial/moderate assistance (helper does less than half the effort) with shower/bathe self and tub/shower transfer. Residents Affected - Few

During a concurrent observation in Resident 165's room and interview with the Director of Staff Development (DSD), on 7/8/2024, at 9:20 AM, a black fly was observed on Resident 165's uncovered corn on his bedside table. DSD confirmed the black fly on Resident 165's corn.

During an interview with DSD on 7/10/2024, at 1 PM, DSD stated flies can transmit bacteria and infection because they land on things that are not clean. DSD stated Resident 165 can get sick if he ate corn that was touched by a fly. The DSD stated facility staff should clean the room and remove the resident's food if they see a fly in the resident's room. DSD stated if facility staff should immediately report to the charge nurse of housekeeping if they see a fly inside the facility.

During an interview with the Laundry Supervisor (LS), on 7/10/2024, at 2:45 PM, the LS stated flies enter the facility when the doors are left open. LS stated Resident 36 and Resident 165's roommate uses the sliding door in the room and leaves the sliding door open when he goes to the patio. LS stated facility staff need to make sure the sliding doors are always closed. LS stated facility staff need to close the sliding door when facility staff sees it open.

During an interview with Maintenance Supervisor (MS), on 7/11/2024, at 9:05 AM, MS stated the facility had

a pest control company that came to the facility every month. MS stated flies should not be found inside the facility. MS stated flies enter the facility when residents leave the screen and sliding doors open when they go to the patio. MS stated it is not safe to eat food that was touched by a fly. MS stated facility staff should make sure sliding doors are always closed to prevent flies from entering the facility.

During an interview with the Director of Nursing (DON), on 7/11/2024, at 12:16 PM, the DON stated it is important for facility staff to keep flies from entering the facility. The DON stated residents who eat food touched by flies can get diarrhea, stomach problems, or end up in the hospital.

A review of the facility's Policy and Procedure (P&P) titled, Pest Control, revised on 11/1/2017, indicated the facility will ensure the Facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, Facility Staff, and visitors. The P&P indicated, The Facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. The P&P further indicated, Facility Staff will report to the Housekeeping Supervisor and sign of rodents or insects, including ants, in the Facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 67 055862