Golden Rose Care Center

In the surveyor’s words

From the most serious findings on record at Golden Rose Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 8, 2024

  Based on observation, interview, and record review the facility failed to practice infection control measures to prevent scabies (a contagious, intensely itchy skin condition marked by itching and small raised red spots caused by a tiny, burrowing [to make a hole or tunnel] mite) for two (2) of 2 residents (Residents 1 and 2) by failing to: 1. Detect symptoms of scabies (severe itching, pimple-like itchy rash) and provide treatment for Resident 1. 2. Respond to a scabies outbreak (2 or more confirmed cases or one (1) confirmed case and at least 2 suspected cases occurring among residents, healthcare workers (HCW), visitors, or volunteers during a 2 week period) by notifying California Department of Public Health (CDPH) and local health department on 1/27/2024 when four (4) Certified Nurses… […]

• Immediate jeopardy, isolatedF695Oct 20, 2024

  Based on interview and record review, the facility failed to provide continuity of respiratory care and treatment to three (3) of 38 sampled residents (Residents 1, 2 and 3). 1. Resident 1, who was diagnosed with chronic respiratory failure (a long term condition that makes it difficult to breathe because the lungs cannot exchange air properly), chronic obstructive pulmonary disease (COPD; a common lung disease that makes it hard to breathe) and asthma (a chronic lung disease that causes the airways in the lungs to narrow and swell making it difficult to breathe), and on continuous oxygen (colorless, tasteless and odorless gas) therapy (treatment that provides oxygen to people who have breathing problems or lung disease) was transferred from the Long-Term Acute Care Hospital (LTACH, a… […]

• Immediate jeopardy, isolatedF755Oct 20, 2024

  Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided to one of 36 sampled residents (Resident 1) who had a diagnoses of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), asthma (a chronic inflammatory disease of the lungs), sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become very shallow during sleep), and shortness of breath (SOB) by failing to: 1. […]

• Immediate jeopardy, isolatedF600Sep 9, 2021

  Based on observation, interview, and record review the facility neglected to provide care, ensure freedom from physical and verbal abuse for one of four sampled residents (Resident 1). By failing to: 1. Notify Resident 1's physician after the resident fell on [DATE]. 2. Assess Resident 1 from head to toe, identify any injuries, and seek medical care after she fell on [DATE]. 3. Investigate and verify if the cause of Resident 1's right [CONDITION(S)] (broken bone) injury was from Resident 1's fall on 5/5/2021. 4 Ensure Resident 1 was free from verbally and physically aggressive behavior from Certified Nursing Assistant 1 (CNA 1) providing care to her on 5/10/2021. […]

• Immediate jeopardy, isolatedF689Sep 9, 2021

  Based on observation, interview, and record review, the facility failed to prevent avoidable fall accidents for two of four sampled residents who were at risk for falls (Resident 1 and Resident 4). The facility failed to: A. Ensure Resident 1's environment was free of accident hazards. Resident 1's bed side rail (a metal or plastic bar positioned along the side of a bed) was not inspected and maintained in good operating condition, and Resident 1's behavior of jiggling or pulling-on the siderail was not addressed in Resident 1's care interventions. On 5/5/2021, 6:43 p.m., Resident 1 was found lying on the floor. […]