Health inspection·September 11, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Bed Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy for one of two sampled residents (Resident 1) by failing to hold Resident 1's bed for up to seven (7) days while the resident was transferred to the General Acute Care Hospital (GACH) on 9/2/2025. This deficient practice resulted in Resident 1 not being readmitted back when the resident was ready to return to the facility from GACH on 9/7/2025. This had the potential to cause psychosocial harm from displacement and incurred unnecessary hospital days (12 days) at the GACH (from 9/6/2025 to 9/18/2025). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis which included respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body) , dependence on respirator /ventilator (patient cannot breathe sufficiently on their own and requires mechanical assistance for daily respiration ), and persistent vegetative state (individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). During a review of Resident 1's Bed Hold Consent, dated 8/14/2025, the Bed Hold Consent indicated Resident 1 has the option of requesting a 7- day bed hold to keep a bed vacant and available for return to the facility. The Bed Hold Consent was signed by Resident 1's Responsible Party on 8/14/2025. The Bed Hold Consent also indicated confirmation of Resident 1's bed hold provision and GACH transfer on 9/2/2025 at 10:30PM. During a review of Resident 1's Order Summary Report, dated 9/3/2025, the Order Summary Report indicated to transfer Resident 1 to GACH via 911 (the number to call to contact the emergency services) due to tachycardia (a rapid heart rate), and hypertension (high blood pressure) for further evaluation and treatment. The Order Summary Report also indicated Bed hold x (for) 7days. During a review of Resident 1's Progress Notes, initiated 9/2/2025, and timed at 10:55 PM, the Progress Notes indicated Resident 1's heart rate increased to 180 beats per minute (BPM) to 190 BPM and Resident 1's blood pressure was 150/80 millimeters of mercury (mmHg, a unit of pressure). The paramedics (medical professional who specializes in emergency treatment) arrived at the facility on 9/2/2025 at 10:25 PM and transferred Resident 1 to GACH. During a concurrent record review of the facility's census from 9/1/2025 to 9/10/2025 and interview with Licensed Vocational Nurse 1 (LVN 1) on 9/11/2025 at 9:55 AM, LVN 1 stated that according to the census, Resident 1 was occupying a bed on 9/1/2025. LVN 1 added that from 9/2/2025 to 9/4/2025, the census indicated Resident 1 was on bed hold. LVN 1 stated Resident 1's bed was occupied by a new resident on 9/5/2025. LVN 1 stated there was no available bed for Resident 1 on 9/6/2025. During an interview on 9/11/2025 at 10:29 AM with the facility's Marketing admission Staff (MA), MA stated she received a call from the GACH Case Manager on 9/6/2025 stating that Resident 1 was ready to return to the facility. MA stated there was no available bed for Resident 1 on 9/6/2025 since another resident was now occupying Resident 1's (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055862 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 09/11/2025 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)