Golden Rose Care Center

F-F607

Findings:

During a review of Resident 1's Admission Record indicated Resident 1 was originally admitted 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 non-dominant side, muscle weakness, and hypertension (high blood pressure).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 8 055862 Department of Health & Human Services Printed: 09/13/2025 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 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

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 0609 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 Level of Harm - Minimal harm or reading this documentation, she was not made aware about the Resident 1's allegation of abuse on potential for actual harm 7/28/2024. The DON verified, alleged abuse by CNA to Resident 1 was not reported on 7/28/2024, and investigation was not initiated by the facility. The DON also stated Resident 1's abuse allegation on Residents Affected - Few 7/28/2024 should have been reported to local agencies, which included California Department of Public Health, ombudsman, and local enforcement agency. The DON 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 is 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, 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 8 055862 Department of Health & Human Services Printed: 09/13/2025 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 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

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087

Residents Affected - Some Based on interview, and record review, the facility failed to provide treatments and services to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for two (2) of two (2) sampled residents (Residents 1, and 2) as ordered by the physician when:

1. Resident 1 was not provided restorative nursing services (a program available in nursing homes that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician.

2. Resident 2 was not provided restorative nursing services as ordered by the physician.

This deficient practice placed Residents 1 and 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in other extremities (a limb of the body, such as the arm or leg) for not receiving the needed exercises.

Findings:

1. During a review of Resident 1's Admission Record indicated Resident 1 was originally admitted 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 non-dominant side, muscle weakness, and hypertension (high blood pressure).

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. The MDS also indicated Resident 1 was on the restorative nursing program requiring five (5) days a week for passive range of motion (the range that can be achieved by external means such as another person or a device) and 5 days on training and skill practice on walking.

During a review of Resident 1's order summary report dated 8/7/2024, it indicated the following orders:

a. Restorative Nursing Assistant (RNA, provides the restorative nursing services) order for ambulation using hallway siderails, 5 days a week as tolerated, ordered on 8/3/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 055862 Department of Health & Human Services Printed: 09/13/2025 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 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

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 0688 b. RNA program to do left upper extremity passive (the manipulation of the body without voluntary effort) ROM (when a joint is moved by an outside force, such as a therapist or machine, instead of the patient Level of Harm - Minimal harm or themselves) exercise 5 days a week, ordered on 8/3/2023. potential for actual harm c. RNA program to use passive assisted bike 5 days a week, ordered on 8/3/2023. Residents Affected - Some 2. During a review of Resident 2's Admission Record indicated Resident 1 was originally admitted on [DATE REDACTED], with diagnoses including but not limited to Systemic lupus erythematosus (a chronic [long-lasting] autoimmune disease [a condition in which the body's immune system mistakes its own healthy tissues as foreign and attacks them] that can affect many parts of the body), diabetes mellitus (diseases that result in too much sugar in the blood), and hypertension (high blood pressure).

During a review of Resident 2's MDS dated [DATE REDACTED], indicated Resident 2 had moderate impairment of cognitive skills for daily decision making. The MDS indicated Resident 2 required setup or clean-up assistance with eating. The MDS indicated Resident 2 required partial/moderate assistance with oral hygiene, toileting hygiene, shower, upper body dressing, and personal hygiene. The MDS indicated Resident 2 was dependent to staff with lower body dressing and putting on/taking off footwear. The MDS did not indicate that Resident 2 is on restorative nursing program.

During a review of Resident 2's order summary report dated 8/7/2024, it indicated the following orders:

d. RNA for active ROM (person can achieve by using their muscles to move a body part without assistance) for both upper extremities, 5 times a week, as tolerated, ordered on 10/19/2023.

e. RNA for passive ROM to both lower extremities, 5 times a week, ordered on 10/19/2023.

f. RNA program for lower body ergometer bike (a stationary exercise bike that measures how much work a person does by pedaling), 5 times a week, ordered on 5/23/2024.

g. RNA program for sit to stand in parallel bars with 2 RNA's, 3 times a week, every Monday, Wednesday, and Friday, ordered on 5/23/2024.

During an interview on 8/7/2024 at 2:05 PM with Resident 1, Resident 1 stated, sometimes she was not getting the RNA service because there is no RNA staff to conduct the exercise with her.

During an interview on 8/7/2024 at 3:40 PM with Resident 2, Resident 2 stated exercises was not given to him daily and RNA staff explained to him that RNA had to take Certified Nurse Assistant (CNA) assignment.

During an interview on 8/7/2024 at 4:20 PM with RNA 1, RNA 1 stated, at times he would work as a CNA when the facility did not have enough CNAs to take care of the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 055862 Department of Health & Human Services Printed: 09/13/2025 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 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

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 0688 During a concurrent record review of Resident 1 and 2's Restorative Nursing Record for the month of July 2024, and interview with RNA 1 on 8/7/2024 at 4:30 PM, RNA 1 verified, there were a lot of days with no Level of Harm - Minimal harm or signature. RNA 1 stated, if there were no signature, it meant RNA service was not provided to Resident 1 potential for actual harm and2. RNA 1 stated for Resident 1's July 2024's Restorative Nursing Record, from 7/21/2024 to 7/31/2024, which is a 10-day period, Resident 1 only had 4 days of RNA service on the following dates: Residents Affected - Some a. 7/24/2024

b. 7/25/2024

c. 7/26/2024

d. 7/29/2024

RNA 1 verified for Resident 2's July 2024's Restorative Nursing Record, from 7/21/2024 to 7/31/2024, which is a 10-day period, Resident 2 only had 2 days of RNA service on the following dates:

a. 7/25/2024

b. 7/26/2024

RNA 1 stated the dates were left blank or not sign because the RNAs (general) were working as CNAs and did not provide the restorative nursing services for the resident. RNA 1 stated Resident 1 needed to receive

the RNA services in accordance with the physician's order to prevent getting contractions. RNA 1 stated the need to prevent more contractions by performing exercises and ROM to prevent further decline. RNA 1 stated residents would decline when they were not provided with the RNA services.

During a concurrent record review of Resident 1 and 2's Restorative Nursing Record for the month of July 2024, and interview with the Director of Nursing (DON) on 8/7/2024 at 4:45 PM, the DON verified there were days with no RNA signature. The DON stated, missed signature meant that RNA service was not provided to Resident 1 and 2. The DON stated the RNA services should be done per the physician's order because it was important for residents to receive RNA services to prevent or minimize a decline of ROM, ambulation, promote the highest level of functioning, and prevent contractures. The DON is unable to provide Joint Mobility Screening (composite flexibility test measures multiple joint movements in a non-functional pattern) for Resident 1 and 2, DON stated that Resident 1 and Resident 2 should have Joint Mobility Screening and assessment to determine if Residents 1 and 2 have decline in function and to identify the areas to improve.

The DON stated, she is still adapting the facility's process since she is a new staff. The DON added the only time nursing department would communicate to rehabilitation department was when nursing noticed and assessed resident with decline, and that is the only time when rehabilitation department would do rehabilitation screening and assessment, but we need to have a better process.

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 055862 Department of Health & Human Services Printed: 09/13/2025 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 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

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 0688 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 Level of Harm - Minimal harm or resident's ability to adapt and adjust to living as independently and safely as possible. This program actively potential for actual harm focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 055862

F-F609

Findings:

During a review of Resident 1's Admission Record indicated Resident 1 was originally admitted 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 non-dominant side, muscle weakness, and hypertension (high blood pressure).

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 8 055862 Department of Health & Human Services Printed: 09/13/2025 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 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

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 0607 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. Level of Harm - Minimal harm or potential for actual harm 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, Residents Affected - Few 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.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 8 055862 Department of Health & Human Services Printed: 09/13/2025 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 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

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46087

Residents Affected - Few Based on interview and record review, the facility failed to report an alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to California Department of Public Health (CDPH), Law enforcement and Ombudsman (advocates for residents of nursing homes) within 2 hours from when the allegation was made for one of two sampled resident (Resident 1).

This deficient practice resulted in delay of an onsite investigation by the law enforcement.

Cross reference