Health inspection·August 19, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The DOR stated Resident 1 was young and having ungroomed nails can cause Resident 1 to feel bad and lower the resident's self- esteem. 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. Event ID: Facility ID: 055862 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received treatment and care in accordance with professional standards of practice by failing to notify the physician after Resident 2 refused the resident's Advair (an inhaled medication used daily to prevent and control shortness of breath, chest tightness, and wheezing [a high-pitched, whistling, or raspy sound produced during breathing, usually when air moves through narrowed or blocked airways in the lungs]) on three separate occasions as indicated in the facility's policy and procedure (P&P). This deficient practice placed Resident 2 at risk for experiencing respiratory distress (a condition where a person experienced difficulty breathing, often accompanied by other signs like shortness of breath, rapid breathing, and a pale or bluish tinge to the skin) which could lead to hospitalization. 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 was readmitted on [DATE] with diagnoses that included respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic obstructive pulmonary disease with acute exacerbation (COPD- a long term lung disease causing difficulty breathing), and acute combined systolic and diastolic heart failure (CHF- a serious condition in which the heart does not pump blood as efficiently as it should). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 6/27/2025, the MDS indicated Resident 2 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 2 was dependent (helper does all of the effort) with shower/bathe self, lower body dressing, putting on/taking off footwear, and chair/bed-to-chair transfer. Resident 2 required partial/moderate assistance (helper does less than half the effort) with oral/personal hygiene, toileting hygiene, upper body dressing, sitting to lying, and lying to sitting on side of bed. During a review of Resident 2's Order Summary Report, dated 8/15/2025, the Order Summary Report indicated a physician's order, with a start date or 6/13/2025 for Advair Diskus Inhalation Aerosol Powder Breath Activated 500-50 micrograms (mcg- unit of measurement) 1 puff inhale orally two times a day for COPD, rinse mouth with water (H2O) after use. During a review of Resident 2's Medication Administration Record (MAR) dated 7/1/2025 to 7/31/2025 and 8/1/2025 to 8/31/2025, the MAR indicated Resident 1 refused his Advair on 7/31/2025 at 6 PM, 8/1/2025 at 9 AM, and 8/6/2025 at 6 PM. During a review or Resident 2's Progress Note, dated 7/31/2025, at 7:51 PM, the Progress Note indicated Advair Diskus Inhalation Aerosol Powder Breath Activated 500-50 mcg 1 puff inhale orally two times a day for COPD, rinse mouth with H2O after use, refused three times, risks and benefits explained. The progress note did not indicate Resident 2's primary physician was notified. During an interview on 8/15/2025, at 2:39 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 2 refused to take his Advair on 8/1/2025 at 9 AM and 8/6/2025 at 6 PM. LVN 1 stated she did not notify Resident 2's physician when the resident refused his Advair on 8/1/2025 at 9 AM and 8/6/2025 at 6 PM. LVN 1 stated Resident 2's physician should have been notified when he refused his Advair on 8/1/2025 and 8/6/2025. LVN 1 stated it was important to notify the physician about the refusal to see if the physician wanted to change the medication or monitor Resident 2 closely. During an interview on 8/15/2025, at 3:08 PM, with LVN 2, LVN 2 stated Resident 2 refused to take his Advair on 7/31/2025 at 6 PM. LVN 2 stated she forgot to notify Resident 2's physician after Resident 2 refused to take his Advair on 7/31/2025. LVN 2 stated she did not know what the facility's policy was regarding residents who refuse to take their medications. During an interview on 8/15/2025, at 3:30 PM, with the Director of Nursing (DON), the DON stated she was not notified and aware that Resident 2 Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055862 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055862 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete refused to take his Advair on 7/31/2025, 8/1/2025, at 8/6/2025. 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. Event ID: Facility ID: 055862 If continuation sheet Page 4 of 4