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Complaint Investigation

Golden Rose Care Center

August 19, 2025 · Pasadena, CA · 1899 N Raymond Ave
Citations 2
CMS Rating 1/5
Beds 99
Provider ID 055862
Healthcare Facility
Golden Rose Care Center
Pasadena, CA  ·  View full profile →
Inspection Summary

GOLDEN ROSE CARE CENTER in PASADENA, CA — inspection on August 19, 2025.

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.

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Inspection Findings

FF0677
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

During a concurrent observation and interview of Resident 1's fingernails, on 8/15/2025, at 1:28 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated some of Resident 1's fingernails were long and dirty. CNA 1 stated the gray nail polish on Resident 1's fingernails were old and should be removed. CNA 1 stated CNAs were responsible for checking the residents' nails during their shower days and for providing nail care to residents in the facility. CNA 1 stated Resident 1's fingernails should have been cleaned, trimmed, and the resident's nail polish should have been removed as soon as it started looking outgrown. CNA 1 stated long fingernails can cut the skin and cause an infection. CNA 1 stated Resident 1 was alert and young and having long and dirty fingernails can make her feel bad and sad about her condition.

During an interview on 8/19/2025, at 11:36 AM, with the Director of Nursing (DON), the DON stated the CNAs were responsible for ensuring that the residents' fingernails are groomed and trimmed.

The DON stated the residents can accidentally scratch themselves and get a skin infection if their fingernails are long.

The DON stated CNAs should check the Residents' nails daily during ADLs.

The DON stated having long and ungroomed fingernails can affect the resident's dignity.

During a review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, revised on 6/1/2017, the P&P indicated, nail care is given to clean and keep the nails trimmed.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/19/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Golden Rose Care Center

1899 N Raymond Ave Pasadena, CA 91103

SUMMARY STATEMENT OF DEFICIENCIES

During a follow up interview on 8/19/2025, at 11:36 AM, with the DON, the DON stated Resident 2's physician should have been notified after Resident 2 refused to take his Advair on 7/31/2025 at 6 PM, 8/1/2025 at 9 AM and 8/6/2025 at 6 PM.

The DON stated it was important to notify Resident 2's physician to see if the physician wanted order a new medication for Resident 2.

The DON stated Resident 2 had the potential to have respiratory distress from not getting his Advair.

The DON stated the facility's P&P for medication administration was not followed by LVN 1 and LVN 2.

During a review of the facility's P&P, titled, Medication-Administration, revised on 6/1/2017, the P&P indicated the following: The Licensed Nurse will re-approach the resident and attempt to give the medications at a later time, but if resident continues to refuse after one hour, the refused medications will be destroyed.

Licensed Nurse will notify the attending Physician and document in the medical record. If the resident repeatedly refused medication, the Licensed Nurse will contact the physician to discuss alternative measures for medication administration.

Facility ID:

Frequently Asked Questions

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


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