Golden Rose Care Center
GOLDEN ROSE CARE CENTER in PASADENA, CA — inspection on July 11, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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], readmitted on [DATE], 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.
055862
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055862 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103
During a Medication Pass observation on 7/10/2024, Licensed Vocational Nurse 3 (LVN 3) failed to administer Resident 208's 12 medications within 60 minutes of scheduled time of 7:30 AM and 9 AM. LVN 3 did not indicate the actual time of medication administration in the medication administration record (MAR).
This deficient practice had the potential for Resident 208's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications.
2.
Facility failed to administer Resident 3's levothyroxine sodium (a medicine used to treat an underactive thyroid gland [produces hormones in the body and plays a major role in chemical reactions in the body such as metabolism]) as ordered by the physician.
This deficient practice had the potential to result in Resident 3's not obtaining the therapeutic level of the medication.
Findings:
1. A review of Resident 208's Admission Record indicated Resident 208 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including but not limited to hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke, a loss of blood flow to part of the brain) affecting left dominant side, angina pectoris (chest pain or discomfort that keeps coming back), and hypertension (high blood pressure).
A review of Resident 208's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/13/2023, indicated Resident 208 had moderately impaired (decisions poor; cues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making.
The MDS indicated Resident 208 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with eating and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), dressing, toilet use and personal hygiene.
The MDS also indicated that Resident 208 was total dependent from staff during transfer, locomotion on and off unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair).
055862
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055862 B.
Wing 07/11/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103