Health inspection·November 25, 2025

F 0790 Provide routine and 24-hour emergency dental care for each resident. 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 notify one (1) out of three (3) sampled residents (Resident 1) of an upcoming scheduled routine dental cleaning appointment. This deficient practice resulted in Resident 1 missing his dental appointment by not receiving routine dental cleaning/mouth care as scheduled. This deficient practice can potentially lead to oral diseases. During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to paraplegia (paralysis of the legs and lower body), type 2 Diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), morbid obesity (when a person's weight is more than 80 to 100 pounds above their ideal body weight) and chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a review of Resident 1's Minimum Data Set (MDS; a care assessment and screening tool) dated 9/23/2025, indicated the resident was assessed to have intact cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and was dependent (helper does all effort) when showering, lower body dressing, putting on footwear. The MDS also indicated Resident 1 was assessed to require partial assistance (helper does half the effort) for oral hygiene, toileting, upper body dressing and personal hygiene. During a review of Resident 1's Visit Notification Email dated 11/3/25 at 11:00 AM, the Visit Notification Email indicated that Resident 1 was scheduled for a Dental Hygienist (a dental worker that specializes in cleaning teeth) visit on 11/4/25 for oral hygiene (teeth cleaning). The Visit Notification Email indicated that the facility's Social Worker (SW) was one of the recipients of the email. During a review of Resident 1's Dental Visit Report dated 11/4/2025 at 1:21 PM, the Dental Visit Report indicated Resident 1's dental appointment will be rescheduled due to Resident 1 being out on pass (outside of facility) during scheduled dental visit. During an interview on 11/25/2025 at 9:33 AM with Resident 1, Resident 1 stated that the SW did not tell him he had a dental cleaning appointment scheduled for 11/4/2025 so he went to Target on that day. Resident 1 stated that he missed his appointment that day because he didn't know he had an appointment scheduled. During an interview on 11/25/2025 at 9:52 AM with the Dental Office Manager (DOM), DOM stated that Resident 1 missed his dental cleaning appointment on 11/4/2025 because he was out on pass when the Dental Hygienist visited the facility. Findings, During a concurrent interview and record review on 11/25/2025 at 10:45 AM with the facility's SW, Resident 1's Visit Notification Email dated 11/3/25 at 11:00 AM was reviewed. SW stated that she received an email reminder of Resident 1's dental cleaning appointment scheduled for 11/4/2025 on 11/3/2025 at 11:00 AM but did not check her email until late in that day. SW stated that she did not notify Resident 1 of the appointment because she did not know that Resident 1 would be out on pass on 11/4/2025. SW stated that she is responsible for notifying residents of upcoming dental appointments. During a concurrent interview and record review on 11/25/2025 at 11:40 AM with the Administrator (ADM), the Residents Affected - Few (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 11/25/2025 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)