Health inspection·May 27, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately document records for one (1) of two (2) sampled residents (Resident 2) in accordance with professional standards and practices by failing to document Resident 2's wound treatment in Resident 2's medical record from 5/14/2025 to 5/27/2025. These deficient practices had the potential to affect the accuracy of clinical assessments and medical management for Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to stage 4 (pressure injury/ ulcer is very deep, reaching into muscle and bone and causing extensive damage) pressure ulcer of right buttock, paraplegia (partial or complete paralysis [loss of voluntary muscle function] of the lower half of the body with involvement of both legs), and neuromuscular dysfunction of bladder (lack bladder control due to a brain, spinal cord or nerve problem). During a record review of Resident 2's Physician Order Summary Report, dated 2/13/2025, the report indicated treatment: right buttock pressure injury (pressure ulcer). Cleanse with normal saline (NS, mixture of salt and water used to replenish fluid and electrolyte), apply collagen powder (used in wound treatment to stimulate new tissue growth), alginate (highly absorbent wound care product from natural seaweed extracts), and cover with foam dressing every day shift for 90 days with end date 5/14/2025. During a record review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 3/3/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS indicated Resident 2 was dependent (helper does all the effort, resident does none of the effort to complete the activity) for toileting hygiene, showering/bathing self, lower body dressing, and chair/bed-to-chair transferring. The MDS also indicated Resident 2 had a stage 4 pressure ulcer (location not indicated). During a record review of Resident 2's Physician Order Summary Report for the month of May 2025, there was no order for Resident 2's stage 4 pressure ulcer. During a record review of Resident 2's TAR for the month of May 2025, the TAR indicated Resident 2's right buttock pressure injury treatment was last done on 5/13/2025. Page 1 of 2 055862 055862 05/27/2025 Golden Rose Care Center 1899 N Raymond Ave Pasadena, CA 91103

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a record review of Resident 2's Wound Assessment by the Wound Consultant, dated 5/11/2025, the assessment indicated Resident 2 had a re-evaluation of the right buttock Stage 4 pressure injury. The wound measurements were length 4.0 centimeters (cm, unit of measurement), width 0.2 cm, and depth 0.1 cm. During a record review of Resident 2's Skin Wound Note, dated 5/15/2025, the note indicated treatment to be continued as cleanse with NS, pat dry, apply collagen powder, alginate, cover with foam dressing. During a concurrent interview and record review on 5/27/2025 at 2:50 PM Resident 2's medical records dated from 5/14/2025 to 5/27/2025 were reviewed. Resident 2's medical records dated from 5/14/2025 to 5/27/2025 did not indicate the wound care treatment done from 5/14/2025 to 5/27/2025 on Resident 2's stage 4 pressure ulcer. Treatment Nurse (TXN) stated, TXN provided the wound care to Resident 2 from 5/14/2025 to 5/27/2025 and once Resident 2's treatment was completed, TXN should have documented in Resident 2's medical records to confirm the treatment was provided. TXN stated there was no documentation to indicate treatment was provided for Resident 2's stage 4 pressure ulcer from 5/14/2025 to 5/27/2025 (14 days). During an interview on 5/27/2025 at 3:55 PM with the Director of Nursing (DON), the DON stated licensed nurse who provided the wound care treatment to Resident 2's stage 4 pressure ulcer did not and should have documented in Resident 2's medical records once the treatment was completed as a proof the treatment was done. During a record review of the facility's policy and procedure titled, Documentation - Nursing, revised 6/1/2017, the policy indicated treatment records are completed with each treatment completed. The P7P indicated treatments completed and documented as per physician's order. 055862 Page 2 of 2