The Dorothy & Joseph Goldberg Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to document and inventory medications brought in by the family, following a hospital discharge. The facility did not identify if the medication label matched the current physician's orders, resulting in a medication error for one of three residents (Resident 1), when reviewed for Pharmacy Services. This failure resulted in Resident 1 receiving a three milligram (mg) dose instead of 1.5 mg dose, as ordered by the physician.

Inspectors wroteBased on interview and record review, the facility failed to verify if one of 15 sampled residents (Resident 39) had an advance directive. In addition, the facility did not provide written information to Resident 39 related to formulating an advance directive. As a result, this had the potential to affect Resident 39's care and treatment in the event the resident could not make decisions for himself.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer and written notice of bed-hold policy to one of four residents (Resident 7) reviewed for transfer and discharge. As a result, there was the potential for residents to be uninformed about their transfer and bed-hold rights when sent to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set assessment (MDS, a comprehensive assessment) for two of 18 residents (Resident 39, and Resident 51). This deficient practice had the potential to affect the residents by delaying resident care needs and provided inaccurate information to the Federal database.1. A review of Resident 39's Resident Face Sheet indicated the resident was admitted to the facility on [DATE]. On 7/21/25 at 3:45 P.M., an observation and interview was conducted with Resident 39. Resident 39 stated he was continent of urine but that nursing staff put a urinary catheter on him at night. Resident 39 stated he did not know why and that it was the nursing staff who decided to put a urinary catheter on him. On 7/22/25 at 8:12 A.M., an observation of Resident 39 was conducted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan for one of 15 sampled residents (Resident 49) that addressed the resident's communication needs. This failure had the potential to impact the resident's quality of care and treatment. Cross reference F676.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 15 sampled residents (Resident 15 and 39) had resident-specific written care plans developed for:1. The use of an external urinary catheter (condom catheter) for Resident 39.2. Resident 15's medication administration preferences. As a result, there was the potential residents' needs would not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary language services for one of 15 sampled residents (Resident 49). As a result, there was the potential for miscommunication to impact the resident's care and quality of life. Cross reference F655.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide restorative nursing assistant (RNA , a staff who focuses on maintaining and improving resident's functional abilities) services for one of one sampled resident (Resident 32) reviewed for decreased range of motion (ROM, refers to how far one can move a joint or a body part, like an arm or leg, in different directions). This failure had the potential to cause contractures (stiffening of muscles), decreased ROM, and decreased mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 15 residents (Resident 39) reviewed for urinary incontinence, was:1. Evaluated and reassessed to determine if bladder continence or incontinence was present through an incontinence/bladder management program.2. Provided scheduled two-hour toileting based on the initial bladder assessment.3. Had a clear indication for the use of an external catheter (condom catheter) at night. These failures had the potential for Resident 39 to miss the opportunity to regain urinary continence through bladder retraining. In addition, this had the potential for the resident to develop urinary tract infections (UTI).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided for two residents (Resident 7 and 34) according to acceptable standards of practice when:1. Licensed nurse (LN) 11 did not follow the prescription label and gave Resident 34's levofloxacin (antibiotic) with calcium which was contraindicated.2. Resident 7's controlled drug record (CDR) for oxycodone (controlled pain medication) did not reconcile with the medication administration record (MAR). As a result there was the potential for Resident 34 to experience the adverse effect of not receiving the intended antibiotic dosage. In addition, there was the potential for Resident 7's controlled drug to be diverted (when a medication is taken for use by someone other than whom it is prescribed).

Inspectors wroteBased on interview and record review, the facility failed to ensure its pharmacist consultant (PC) identified medication irregularities during the monthly medication regimen review (MRR) for two sampled residents (Resident 33 and 39). As a result, there was the potential for residents to receive medications with inappropriate duration and in excessive dosages. Cross reference F757. 1. A review of Resident 39's Resident Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses to include urinary tract infection (UTI). A review of Resident 39's History and Physical dated 6/6/25, indicated the resident was in the hospital from [DATE] through 6/3/25, and .For presumed urinary tract infection, the patient was treated with Rocephin [antibiotic]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 15 sampled residents (Resident 33 and 39) were free from unnecessary medications when both residents were given antibiotics without verification of a stop date. As a result, there was the potential for Resident 33 and 39 to experience antibiotic resistance (when bacteria or other microorganisms evolve to become resistant to the drugs designed to kill them).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and nutrition services staff was able to safely and effectively carry out the functions of the department, when one Dietary Aide (DA 22) incorrectly demonstrated how to calibrate a food thermometer. This failure in staff competence could led to incorrect food temperature, which could increase the risk of foodborne illness in the resident population of 47.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Food item had brown spots and was not able to be served to the residents. 2. Cool down process (hot food must be cooled within 2 hours to 70 degree Fahrenheit, additional 4 hours to less than 41 degree Fahrenheit, total of 6 hours to cool down hot foods) was not properly followed per the facility's policy on handling potentially hazardous food (PHF, means any food which consists in whole or in part of milk or milk products, eggs, meat, poultry, rice ,fish, shellfish, edible crustacean, raw-seed sprouts, heat-treated vegetables and vegetable products and other ingredients in a form capable of supporting rapid and progressive growth of microorganism) item. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to implement their infection control policies and procedures when:1. Hand hygiene (washing hands or using hand sanitizer) was not offered to residents prior to eating in the dining room.2. Hand hygiene was not consistently performed during wound treatment. As a result there was a potential for cross contamination and transmission of infections to residents, staff, and visitors. 1a. On 7/21/25 at 11:20 A.M., an observation was conducted in the dining room. Two female residents in wheel chairs were being assisted by staff to table 10. Staff did not offer hand wipes or sanitizer to both residents. On 7/21/25 at 11:40 A.M., an observation of the female residents at table 10 was conducted. One of the two female residents was wheeled out of the dining room; Resident 42 remained seated and ate her lunch. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program when two sampled residents' (Resident 33 and 39) infections and antibiotic use was not monitored and reviewed June and July 2025. As a result, Resident 33 and 39 were both on antibiotics without verification of a stop date. This potentially excessive use of antibiotics had the potential to contribute to antibiotic resistance (when bacteria or other microorganisms evolve to become resistant to the drugs designed to kill them) in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 13 residents (Resident 151) had a physician ordered medication available to be administered. As a result, Resident 151 was not administered one of his medications for six days.

Inspectors wroteBased on interview and record review, the facility failed to follow the prn (as needed) guidelines for psychotropic medications (medications which alters the mind) for one of five residents (Resident 33) selected for Medication Review, when: 1. A specific behavior was not documented, indicating the necessity of a prn psychotropic medication; and 2. The physician did not document a rationale for the continued use of a prn psychotropic medication beyond the 14-day limit. This failure had the potential for Resident 33 to have increased risk of side effects and a prolonged duration of use.

Inspectors wroteBased on interview and record review, the facility failed to ensure information in one of 13 resident's (Resident 3) medical/clinical record was readily accessible. As a result, it could not be determined if Resident 3 had been administered a controlled medication (medication with high potential for abuse).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meal assistance provided to one sampled resident (Resident 3) was conducted in a sanitary manner when certified nursing assistant (CNA) 1 did not perform hand hygiene (washing hands or using an alcohol-based hand rub) after assisting another resident and did not wear gloves while feeding Resident 3 a sandwich using her bare hands. This deficient practice had the potential to spread microorganisms and to cause foodborne illness among residents.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to ensure overall operational systems were established for oversight of the Food and Nutrition Services department. This failure to ensure an effective system for day-to-day dietary operations oversight may have placed 49 residents at risk for foodborne illness or further compromised their nutrition and health status due to unsafe, unsanitary, and improper dietetic service practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the kitchen staff obtained sufficient training to perform and competently when: 1. A Dishwasher (DSW) did not follow the proper procedure to clean dishes in the dish machine and was unable to demonstrate the correct process to test the dish machine sanitizer solution. 2. A DSW did not follow the manufacturer's guidelines for cleaning the Ice Machine. 3. Kitchen staff and non-kitchen staff did not follow food safety and sanitation practices by not wearing hair nets or performing hand hygiene when entering the satellite kitchen. 4. A DSW did not follow did not perform proper hand hygiene or change gloves after disposing the kitchen garbage and re-entering the kitchen. 5. Two Cooks and a Diet Aide were not trained on pureed diet preparation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. Expired ground meat was in the main kitchen PARVE (Jewish term that refers to neutral foods that may be eaten with milk and dairy or meats) walk-in refrigerator. 2. A dirty filter with gray lint, dust and black scum was inside the PARVE walk-in refrigerator's that contained uncovered pans of vegetables and meat. 3. The dish machine sanitizer solution was outside of the correct chemical range and tested at 200 ppm (parts per million); and the Dishwasher (DSW) could not correctly test the sanitizer. 4. The Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 5. [NAME] and flour were in large bulk unlabeled and dated in plastic bin containers. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to consistently document a POLST (Physician Orders for Life-Sustaining Treatment) form signed by the family, physician's order, and the computer indicator for code status (Full resuscitation vs Do Not Resuscitate-DNR), for one of three residents (Resident 33), reviewed for Advanced Directives. As a result, there was the potential for Resident 33's wishes to not be honored based on staff confusion of what the resident's wishes were.

Inspectors wroteBased on interview and record review the facility failed to ensure a physician's order for a pain medication was followed for 1 of 13 sampled residents (247) when the order for tramadol PRN at bedtime for pain was given at random times. The facility also failed to ensure pain medications ware ordered for all levels of pain for 1 of 13 sampled residents (247). As a result, there was the potential to not properly medicate the residents for pain

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing was changed according to facility policy for two of two sampled Residents (2, 29) reviewed for oxygen use. In addition, an oxygen humidifier was not changed and replaced for Resident 29. These failures had the potential for residents to be exposed for infection and not receive adequate oxygen humidification.

Inspectors wroteBased on interview and record review the facility failed to ensure nurses' clinical skills and competencies were maintained on an annual basis. This failure had the potential to affect Resident's quality of care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure (lock) one of three treatment carts (South unit cart), reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the pureed diet was prepared and served in a manner that conserved nutritive value, flavor, and appearance. This deficient practice affected the nutrient content and increased the risk of choking for eight residents on a pureed diet, and one sampled resident (R2) on a liquefied (drinkable) pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices were followed when: 1. A kitchen aide did not disinfect hands between delivery of meals to residents in one of two resident dining rooms (main dining room), reviewed for dining observation task; and 2. A urinary catheter drainage bag was in contact with the floor for one of three residents (Resident 33), reviewed for urinary catheter care. As a result, there was the potential for cross contamination of microorganisms (bacteria, virus, fungus).