Golden Rose Care Center
GOLDEN ROSE CARE CENTER in PASADENA, CA — inspection on August 7, 2024.
Found 5 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 a concurrent record review of Resident 1's progress notes dated 7/28/2024, timed 1:20 PM, and interview with LVN 1 on 8/7/2024 at 3:55 PM, LVN 1 stated, he documented the progress notes on 7/28/2024 at 1:20 PM, and he indicated in progress notes that Resident 1 stated of being abused by a Certified Nurse Assistant (CNA). LVN 1 stated he did not think of reporting it as an abuse because Resident 1 was just not happy with the CNA.
During a concurrent record review of Resident 1's progress notes dated 7/28/2024, timed 1:20 PM, and interview with the Director of Nursing (DON) on 8/7/2024 at 3:58 PM, the DON stated it is her first time reading this (progress notes) documentation, she was not made aware about the Resident 1's allegation of abuse on 7/28/2024 by CNA.
The DON verified the alleged abuse was not reported on 7/28/2024, and investigation was not initiated by the facility.
The DON stated Resident 1's abuse allegation on 7/28/2024 should have been reported to local agencies, which included California Department of Public Health, ombudsman, and local enforcement agency within two hours from the allegation was made.
The DON also added reporting to other local agencies is important so other agencies can conduct their investigation, for resident/s safety, so residents can be protected, to check if there's a pattern, and to stop it from happening again.
During a review of the facility's policy and procedure titled, Abuse Prevention and Prohibition Program, revised on 8/1/2023, it indicated each resident has the right to be free from abuse, neglect (fail to care for properly), mistreatment, and/or misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or. permanent use of a resident's belongings or money without the resident's consent).
The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property.
Staff must not permit anyone to engage in any type of abuse, neglect, mistreatment, or misappropriation of resident property.
The policy also indicated, staff, residents, and families can report concerns, incidents, and grievances without fear of retribution or retaliation.
Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk of occurring.
The Facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. It also indicated the Facility promptly and thoroughly investigates reports of resident abuse and will report allegations of abuse immediately, but no later than 2 hours after forming the suspicion.
055862 08/07/2024
Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103
During a review of the facility's policy and procedure titled, Abuse Prevention and Prohibition Program, revised on 8/1/2023, it indicated, facility staff are mandatory reporters. It also indicated that the facility would report allegations of abuse, neglect (fail to care for properly), mistreatment, injuries of unknown source, misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or. permanent use of a resident's belongings or money without the resident's consent), or other incidents that qualify as a crime.
Immediately, but no later than 2 hours after forming the suspicion.
055862 08/07/2024
Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103
During a review of the facility's Policy and Procedure titled, Performing Range of Motion Exercises, revised on 6/1/2017, it indicated the facility will provide Range of Motion exercises per an order from the Attending Physician (Doctor).
During a review of the facility's Policy and Procedure titled, Restorative Nursing Program Guidelines, revised on 6/1/2017, indicated the Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible.
This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/26/2024, indicated Resident 1 had no impairment of cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making.
The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity.
Helper assists only prior to or following the activity) with eating.
The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort.
Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene.
During a review of Resident 1's progress note dated 7/28/2024, time indicated 1:20 PM, it indicated Resident 1 has an allegation of abuse.
During an interview on 8/7/2024 at 3:50 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, the alleged abuse should be reported to local agencies, which included California Department of Public Health, ombudsman, and local enforcement agency within two (2) hours form when the allegation was made.
During a concurrent record review of Resident 1's progress notes dated 7/28/2024, timed 1:20 PM, and interview with LVN 1 on 8/7/2024 at 3:55 PM, LVN 1 stated, he documented the progress notes on 7/28/2024 at 1:20 PM, and he indicated in progress notes that Resident 1 stated of being abused by a Certified Nurse Assistant (CNA). LVN 1 stated he did not think of reporting it as an abuse because Resident 1 was just not happy with the CNA.
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 08/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/26/2024, indicated Resident 1 had no impairment of cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making.
The MDS indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity.
Helper assists only prior to or following the activity) with eating.
The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort.
Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on/taking off footwear and personal hygiene.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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 08/07/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.