Health inspection·November 17, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some blankets towards her. During a concurrent observation and interview on 11/17/2025, at 12:03 PM, with Certified Nursing Assistant 1 (CNA 1) in Resident 1's room, CNA 1 stated Resident 1 had a tendency to scream and pull her patient gown or linen during diaper change. During an interview on 11/17/2025, at 12:26 PM, with Treatment Nurse (TN), TN stated Resident 1 has pulled Resident 1's G-tube at least two times. TN stated Resident 1 had a strong grip and would grab Resident 1's stomach or G-tube as soon as the resident's abdominal binder was opened during dressing changes. TN stated getting Resident 1 to release her G-tube was like playing tug of war (a game in which two teams pull at opposite ends of a rope). TN stated she would sometimes ask staff to assist during G-tube dressing changes so they can hold Resident 1 and prevent the resident from grabbing the resident's G-tube. During an interview on 11/17/2025, at 12:52 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 had a history of pulling her G-tube. LVN 1 stated Resident 1 was confused and would hold on to or pull things. LVN 1 stated LVN 1 does not know if Resident 1 has care plan for G-tube dislodgment. LVN 1 stated care plans were endorsed, created, and updated by the RNS. LVN 1 stated care plans were important because it had goals and interventions on how to fix resident problems. LVN 1 stated care plans were important to prevent problems from recurring. During an interview on 11/17/2025, at 1:05 PM, with LVN 2, LVN 2 stated she has not seen Resident 1's care plan for G-tube dislodgment. During an interview with on 11/17/2025, at 1:26 PM, with Minimum Data Set Nurse (MDSN), MDSN stated Resident 1 has been hospitalized numerous times for pulling her G-tube and G-tube dislodgement. MDSN stated he reviews care plans but has not reviewed Resident 1's care plan for G-tube dislodgement if it was resident centered care plan. MDSN stated he attended interdisciplinary team (IDT- a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a resident) meetings but has not gone into an IDT for Resident 1 to discuss the resident's current problems such as the behavior of pulling the G-tube/ frequent G- tube dislodgement, and the plan of care with interventions specific to the needs of the resident. During a concurrent interview and record review on 11/17/2025, at 2:19 PM, with RNS 1, Resident 1's care plans dated from 3/19/2025 to 9/24/2025 were reviewed. RNS 1 stated Resident 1 did not have a care plan for G-tube pulling and dislodgement from 3/19/2025 to 9/24/2025. RNS 1 stated Resident 1 should have had a care plan for G-tube dislodgement since the resident had a history of dislodgement since admission to the facility. RNS 1 stated a care plan should be immediately created after a change in the resident's condition to find a solution to the problem and to prevent the problem from recurring. RNS 1 stated Resident 1's care plan for G-tube dislodgement was not created until 9/29/2025. During the same concurrent interview and record review on 11/17/2025, at 2:19 PM, with RNS 1, Resident 1's care plan for G-tube dislodgement, dated 9/29/2025 was reviewed. RNS 1 stated Resident 1's behavior of holding on to her G-tube which causes G-tube dislodgement was not and should be included in Resident 1's care plan. RNS 1 stated Resident 1's care plan for G-tube dislodgement should be resident-centered and specific to what Resident 1 needs such as intervention to address Resident 1's behavior of pulling the G- tube. During the same concurrent interview and record review on 11/17/2025, at 2:19 PM, with RNS 1, RNS 1 stated there was no record of an IDT meeting conducted for Resident 1 to discuss and address Resident 1's history of frequent G-tube dislodgement. RNS 1 stated IDT meetings should be done quarterly and as needed to discuss the residents plan of care. During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised 10/24/2022, the P&P indicated the following:1. The purpose of the policy was to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.2. The facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each Resident in accordance with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055862 If continuation sheet Page 2 of 3 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 11/17/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Omnibus Budget Reconciliation Act (OBRA - a series of federal laws) and Minimum Data Set (MDS- a resident assessment tool) guidelines.3. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.4. A licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis.5. Each resident's Comprehensive Care Plan will describe services that are to be furnished to attain or maintain the Resident's highest practicable physical, mental and psychosocial well-being.6. The Comprehensive Care Plan must be prepared by the IDT Team. Event ID: Facility ID: 055862 If continuation sheet Page 3 of 3