Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Dorothy & Joseph Goldberg Healthcare Center during CMS and state inspections, most recent first.
A resident with a history of kidney transplant received an incorrect dose of tacrolimus after staff failed to document, inventory, and verify medications brought in by the family following hospital discharge. The lack of proper medication reconciliation and label verification resulted in the resident being given a double dose, as staff administered three 1 mg capsules instead of the prescribed three 0.5 mg capsules. Facility staff interviews confirmed that required procedures for handling and verifying family-supplied medications were not followed.
Failure to Verify and Provide Advance Directive Information: A resident admitted to the facility had no documentation of an advance directive in the clinical record, and the SSD did not verify whether one existed. The SSD later confirmed the resident did not have an advance directive on file at the prior ILF and stated the resident should have been offered written information about advance directives and informed of the facility's policies and procedures. The DON stated this was the expected admission process, and the facility policy required written advance directive information to be provided upon admission.
Failure to Provide Written Transfer and Bed-Hold Notices: A resident was transferred to the hospital twice for evaluation of fever and suspected UTI, and the facility did not provide written notice of transfer or written notice of the bed-hold policy for either transfer. The DSD stated the facility did not notify in writing when the resident was alert and it was a transfer, and the DON acknowledged the notices were not provided. The facility policy stated residents or resident representatives would be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves.
A facility failed to accurately code MDS assessments for two residents. One resident’s MDS did not capture external urinary catheter use despite observation, resident interview, and record review showing the appliance was in use, and the MDSC stated it was missed. Another resident’s MDS did not reflect the correct discharge information, which the MDSC described as a data entry error. The DON stated MDS coding was expected to accurately reflect resident care and information sent to CMS.
Baseline Care Plan Missing for Resident Communication Needs: A resident who spoke only a foreign language did not have a baseline care plan addressing communication preferences after admission. Staff reported relying on bilingual employees or the resident’s family member to translate, and confirmed there was no communication board or language line available. The DON stated language preference should have been care planned within 24 hours and included the resident’s preferred communication tools.
A facility failed to develop resident-specific care plans for two residents’ identified needs. One resident was using an external urinary catheter at night despite being continent, and staff were unsure why it was being used or how it should be monitored. Another resident preferred to take morning BP meds separately from other meds and delayed one medication, but no person-centered care plan addressed those medication administration preferences. Staff and the DON acknowledged the missing care plans.
Failure to provide language interpretation services: A resident who preferred a foreign language and needed an interpreter was observed communicating only in that language, while staff relied on ad hoc translators such as a CNA, housekeeper, charge nurse, or family member. An LPN stated no communication board or language line was available, and the resident’s family member reported the resident did not understand staff and was frustrated by not receiving requested breakfast choices. The DON acknowledged staff should have used communication tools and that a language translation line service was available.
A resident with stroke and quadriplegia, who was dependent on staff and had limited ROM, had physician orders for PROM to the knees and right upper extremity three times weekly. Observation found the resident with the right hand in a closed fist, and the RNA record showed multiple missed treatments over several weeks. Staff interviews confirmed missing documentation for the RNA services, and the LN and DON stated the ordered ROM care was not consistently documented as provided or refused.
A resident admitted with a UTI diagnosis was identified inconsistently as continent or incontinent, but the facility did not document a completed bladder assessment or the results of the required toileting trial. The resident stated he was continent but was placed in an external catheter at night without knowing why, and staff could not explain the indication. Record review showed no documented 2-hour toileting program, no clear plan of care for the external catheter, and no physician order until after the catheter had already been noted in use.
Pharmaceutical services were not provided according to acceptable standards when an LPN gave a resident levofloxacin together with calcium despite the antibiotic label warning to separate it from calcium-containing products. In a separate issue, a resident’s oxycodone CDR did not match the MAR, with missing documentation and a late entry added later that the DON said should not have been made.
The consultant pharmacist failed to identify medication irregularities during the monthly MRR for two residents. One resident received penicillin for UTI with no stop date, and another resident received nitrofurantoin for UTI prophylaxis with no stop date. The PC later stated both orders should have been flagged as irregularities, and the DON and IP acknowledged the antibiotics should have had stop dates.
Two residents received antibiotics without verified stop dates. One resident was given nitrofurantoin for UTI prophylaxis with no end date, and another resident received penicillin ordered for UTI despite no documented signs or symptoms of UTI in the facility and no clear indication for indefinite therapy. Staff interviews and record review showed the orders were not clarified, and the IP, pharmacist, and DON stated the regimens lacked appropriate stop dates.
Dietary staff were found unable to correctly demonstrate food thermometer calibration when a DA placed the probe against the bottom and side of a glass during an observed competency check. The DA had previously been signed off as competent on this task, and the RD stated dietary staff competency had been a facility project for the past six months with annual competency expected. The facility policy required the probe to be placed in the ice water mixture without touching the container.
Unsafe Food Storage and Improper Cooling of PHF A kitchen observation found produce with visible mold and brown spots, including green bell peppers with white porous material and a jalapeno pepper with brown dots. The RD stated kitchen staff were supposed to inspect produce and that the cook would not serve it. Review of the cool down log also showed cooked chicken was placed in the chiller at 175 degrees Fahrenheit, but no temp check was documented after 2 hours as required by the facility’s PHF cooling policy.
The facility failed to consistently follow infection control practices during mealtimes and wound care. Residents were observed being seated and served meals in the dining room without being offered hand hygiene, and staff confirmed hand wipes or sanitizer were not provided before eating. During wound treatment, a wound nurse used the same gloves throughout multiple tasks, including removing a soiled dressing and applying treatment to a resident with a left buttock pressure injury, without changing gloves or performing hand hygiene between steps.
Antibiotic stewardship was not implemented for two residents receiving antibiotics without verified stop dates. One resident had nitrofurantoin ordered for UTI prophylaxis with no stop date, and another had penicillin ordered with no end date despite no documented signs or symptoms of UTI in the facility. The IP, DON, and pharmacist stated the orders should have been reviewed and clarified, and facility policy required monitoring of antibiotic regimens, stop dates, and days of therapy.
A resident did not receive a physician-ordered medication for six days due to unavailability. The medication, calcium carbonate with vitamin D, was prescribed for vitamin D deficiency. Staff interviews revealed a lack of protocol for notifying physicians about unavailable medications, and the Director of Nursing confirmed the medication should have been available from central supply.
A facility failed to follow guidelines for PRN psychotropic medications for a resident with a non-traumatic intracerebral hemorrhage. Lorazepam was administered without specific behaviors documented, and the physician did not justify its use beyond 14 days, despite recommendations from the consulting pharmacist. Interviews revealed that the behavior listed as anxiety was subjective, and the facility's policy required specific behaviors to be documented before administration.
A facility failed to ensure a resident's medical records were accessible, leading to an inability to verify the administration of lorazepam, a controlled medication. The CDR showed the medication was removed from supply, but the MAR did not confirm administration. Interviews revealed the MAR was incomplete, and the facility's policy lacked guidance on record accessibility.
A CNA failed to perform hand hygiene and used bare hands to feed a resident a sandwich, despite the resident's dependency on staff for feeding due to medical conditions. Interviews with staff, including the RD and DON, highlighted the lack of specific training on hand hygiene during feeding assistance, which led to this unsanitary practice.
Failure to Document and Verify Family-Supplied Medications Leads to Medication Error
Penalty
Summary
The facility failed to properly document and inventory medications brought in by a resident's family following a hospital discharge. Upon admission, the resident, who had a history of kidney transplant, was to receive tacrolimus 0.5 mg capsules, three capsules twice daily, as ordered by the physician. However, there was no documentation regarding the medications provided by the family, including the number of bottles, dosages, or verification that the medication labels matched the physician's orders. Staff did not inventory or record the details of the medications upon receipt, and there was no evidence that the facility's pharmacist was asked to review or oversee the medications supplied by the family. A medication error occurred when the resident was moved to a different hall within the facility. During this transition, the wrong bottle of tacrolimus was placed on the new medication cart. As a result, the resident received three capsules of 1 mg each, totaling 3 mg, instead of the prescribed three capsules of 0.5 mg each, totaling 1.5 mg. Nursing staff involved in the administration of the medication did not verify the label against the physician's order, and there was confusion among the nurses regarding the correct dosage and bottle. The error was discovered after the resident questioned the medication and brought it to the attention of the staff. Interviews with facility staff, including nurses and the DON, revealed that there was no clear process for verifying, documenting, or storing medications brought in by families. The facility's own policies required that medications admitted with residents be checked for proper packaging and labeling, and that the administering nurse verify the medication label three times before administration. These procedures were not followed, leading to the administration of an incorrect dose of tacrolimus to the resident.
Failure to Verify and Provide Advance Directive Information
Penalty
Summary
The facility failed to verify whether Resident 39 had an advance directive and did not provide written information about formulating an advance directive upon admission. A review of the resident's face sheet showed Resident 39 was admitted to the facility on [DATE]. During an interview and record review on 7/24/25, the social services designee (SSD) stated it was her responsibility to check for an advance directive on admission and discuss it during the resident's first care conference, but she found no documentation in the clinical record showing that Resident 39 had an advance directive and stated she had not verified whether one existed. The SSD stated Resident 39 had previously lived in an independent living facility and may have had an advance directive there, but later confirmed that Resident 39 did not have an advance directive on file at the ILF. The SSD stated she should have discussed advance directives with Resident 39 and should have provided written information about formulating one and the facility's policies and procedures. The DON stated it was her expectation that the SSD check for an advance directive upon admission and provide written information related to advance directives. The facility policy stated residents are to be provided written information concerning the right to formulate an advance directive upon admission and that the Social Services Director or designee will inquire about the existence of any written advance directives.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notice of transfer and written notice of the bed-hold policy to Resident 7 when the resident was transferred to the hospital on 4/27/25 for evaluation of a fever and again on 7/1/25 for evaluation of a suspected urinary tract infection. Resident 7 was not sent via 911 services on either occasion. During an interview and record review on 7/23/25, the DSD reviewed the resident's clinical record and stated that no written notice of bed-hold policy was provided when the resident was transferred to the hospital, and that the facility did not provide written notices of bed-hold upon transfer to long-term residents. The DSD also stated there was no documentation of written notices of transfer provided to Resident 7 and said, "We don't notify in writing when they're alert and it's a transfer." On 7/24/25, the DSD stated the facility did not have a policy related to written notice of transfer. The DON later acknowledged that written notices of bed-hold policy and written notices of transfer were not provided to Resident 7 for either hospital transfer. The facility policy titled Bed-Holds and Return, revised March 2017, stated that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.
Inaccurate MDS Coding for Urinary Appliance Use and Discharge Information
Penalty
Summary
The facility failed to accurately code the MDS assessment for two residents. For Resident 39, the admission MDS dated 6/9/25 was coded in Section H- Bladder and Bowel as “Z. None of the above” for urinary or bowel appliances. During observation and interview, Resident 39 stated he was continent of urine but that nursing staff put a urinary catheter on him at night, and an observation showed him using a urinary catheter draining clear, yellow urine into a drainage bag. The MDS coordinator reviewed the record and stated the look-back period was 6/3/25 through 6/9/25, that the resident did not use a urinary catheter during that time, and that the external catheter use documented in progress notes on 6/5/25 was missed because there was no order until 7/11/25. The MDS coordinator stated the assessment was inaccurately coded, and the DON stated the external catheter should have been captured and coded correctly. For Resident 51, the MDS was not coded to reflect the resident’s discharge information. Record review showed the resident was discharged to a general acute care hospital on 4/22/25, while a licensed nurse progress note dated 4/22/25 indicated discharge to another SNF. During interview, LN 22 stated the MDS coordinator was responsible for encoding the discharge on the MDS. The MDS coordinator stated she was responsible for coding residents when admitted and discharged and said Resident 51’s MDS should have been coded correctly to reflect the information provided to CMS, describing the issue as a data entry error. The DON stated the expectation was for the MDS coordinator to provide correct coding so accurate information was relayed to CMS.
Baseline Care Plan Missing for Resident Communication Needs
Penalty
Summary
The facility failed to develop a baseline care plan for Resident 49 that addressed the resident’s communication needs within the first 48 hours of admission. Resident 49 was admitted to the facility and the MDS assessment dated 7/13/25 identified the resident’s preferred language as a foreign language and indicated that an interpreter was needed or wanted to communicate with a doctor or health care staff. A review of the resident’s written care plans showed there was no baseline care plan for language or communication preferences. During observation and interviews on 7/21/25, Resident 49 spoke only a foreign language, and staff described using a foreign-language-speaking CNA, housekeeper, charge nurse, unit clerk, or the resident’s family member to translate when needed. The IP stated there were no communication tools available, such as a communication board or language translation line. LN 36, LN 2, and LN 3 each confirmed there was no language line, no communication board, and no baseline care plan related to language preference. The resident’s family member stated she translated for the resident and reported that the resident sometimes did not understand what staff were telling her, that translators were not always provided, and that the resident was often alone and could not get her needs met. The DON stated the care plan was expected to be developed within 24 hours of admission and that language preference should have been care planned for a resident who did not speak English.
Missing Care Plans for External Catheter Use and Medication Preferences
Penalty
Summary
The facility failed to ensure that two sampled residents had resident-specific written care plans developed for identified needs. For one resident, staff used an external urinary catheter at night even though the resident stated he was continent of urine and did not know why the catheter was being used. A CNA stated the resident was continent of bowel and bladder and could tell staff when he needed to use the bathroom, while nursing staff were unsure why the external catheter was in use and acknowledged that a written care plan should have addressed its use, duration, and monitoring. The DSD also stated there was no order for the external catheter until 7/11/25, that it had been documented in use earlier without an order, and that there was no plan of care related to its use. For the second resident, physician orders included morning medications such as Labetalol, Valsartan, Metamucil, a multivitamin, Vitamin B-12, and Vitamin D3 scheduled for 8:00 A.M. During medication administration, an LPN gave the blood pressure medications separately from the other morning medications because the resident preferred that routine, and later returned to give the remaining medications. The resident also requested that Metamucil be delayed and asked the nurse to return in 15 minutes. The LPN stated the resident’s morning medications were scheduled for 8 A.M., medications were considered late if given after 9 A.M., and there should have been a written care plan for the resident’s medication administration preferences. Record review confirmed that neither resident had a care plan addressing the identified issue. Nursing staff and the DON stated that the resident using the external catheter should have had a care plan for that intervention, and that the resident with medication preferences should have had a person-centered care plan for later medication administration if she did not want medications by 9 A.M. The facility policy required medications to be administered within one hour of the prescribed time unless otherwise specified, and the care plan policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident’s needs.
Failure to Provide Language Interpretation Services
Penalty
Summary
The facility failed to provide necessary language services for one sampled resident who preferred a foreign language and indicated a need for an interpreter to communicate with staff. The resident’s MDS documented the preferred language and that an interpreter was needed, but during observation the resident only spoke the foreign language and staff relied on a foreign-language-speaking CNA, housekeeper, or charge nurse to translate. A white board in the room contained goals and a menu written in English, and a licensed nurse stated there were no communication tools available, such as a communication board or language translation line, to help staff communicate with the resident. Interviews showed that staff commonly depended on finding someone who spoke the resident’s language or calling the family member to translate. The resident’s family member stated she translated for the resident and reported that the resident did not understand what staff were telling her, had not been getting the breakfast choices she wanted, and said there were times when the facility did not provide a translator. The DON stated staff should have used communication tools preferred by the resident and acknowledged that a language translation line service was available, while the facility policy stated competent oral translation of vital information should be provided in a timely manner and that family members and friends shall not be relied upon for interpretation services.
Missed and Undocumented RNA ROM Services
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason, was not consistently done for one resident with stroke and quadriplegia. The resident was admitted with diagnoses including stroke and quadriplegia, was documented as lacking decision-making capacity, and was dependent on staff for activities of daily living. The resident’s MDS indicated functional limitations in ROM in both upper and lower extremities and dependence on staff. Physician orders directed restorative nursing assistant (RNA) services for passive ROM to the bilateral knees three times a week and passive ROM to the right upper extremity three times a week as tolerated. Observation showed the resident’s upper extremities exposed, with the resident not responding when her name was called and the right hand observed in a closed fist with the right thumb extended. Review of the RNA treatment record showed multiple missed treatments in June and July, and staff interviews confirmed missing documentation for those services. A CNA stated he did not see RNA treatment in the afternoon shifts, while the RNA stated the resident was scheduled for PROM on Tuesdays, Thursdays, and Saturdays and that missed services should have been documented as refused. The LN and DON stated there was missing documentation of RNA services and that the orders should have been carried out as prescribed to prevent contractures and maintain ROM.
Failure to Document Bladder Assessment, Toileting Trial, and External Catheter Use
Penalty
Summary
The facility failed to ensure Resident 39, who was admitted with a diagnosis that included UTI, was properly evaluated and reassessed for bladder continence or incontinence through an incontinence/bladder management program. The resident told staff he was continent of urine but that nursing staff applied an external catheter at night, and he did not know why it was used. On observation, the resident was lying in bed with the external catheter in place and draining clear yellow urine into a drainage bag. Record review and staff interviews showed the resident’s admission assessment identified him as incontinent based on hospital documentation, while the MDS coded him as occasionally incontinent and indicated a toileting trial had been attempted, with the response listed as unable to determine or trial in progress. However, the MDS Coordinator, DSD, and DON all stated there was no documentation that the toileting program was actually implemented or that its results were reviewed. The DSD stated residents were supposed to receive a 14-day bowel and bladder assessment with toileting every two hours, but no documentation of that program was found in the electronic record or in the paper Intake and Output form that was supposed to be kept in the resident’s bathroom. The record also showed there was no physician order for the external catheter until 7/11/25, even though a progress note documented its use on 6/5/25. The DSD stated there was no plan of care related to the resident’s use of the external catheter. Facility staff, including a CNA and an LN, stated the resident was continent during the day and used the external catheter at night, but neither could explain why it was being used. The facility policy required scheduled toileting or other interventions based on assessment and documentation of the resident’s response to attempted interventions, but that documentation was not present for Resident 39.
Medication Administration and Controlled Substance Record Discrepancies
Penalty
Summary
Pharmaceutical services were not provided according to acceptable standards of practice for two residents. One resident had orders for levofloxacin 500 mg daily at 8 A.M. and oyster shell calcium 500 mg, 2 tablets daily at 8 A.M. During medication administration, an LN prepared the resident’s morning medications and the levofloxacin label included a warning to give it 2 hours before antacids, multivitamins, minerals, and iron. The LN administered the levofloxacin and the calcium together. When interviewed later, the LN stated the calcium should not have been given with the levofloxacin because it could interfere with the medication’s effectiveness. The facility pharmacist consultant stated the warning label should have been followed and that giving levofloxacin at the same time as calcium was a medication error. A second resident had an order for oxycodone 15 mg one tablet every 8 hours as needed for severe pain. The resident’s controlled drug record showed oxycodone was received on two occasions, but the MAR did not match the controlled drug record. The MAR documented one administration at 7:37 A.M. on one date, showed no documentation for another date listed on the controlled drug record, and later contained a late entry stating the medication had been given at 12 A.M. The DON reviewed the records and stated the MAR and controlled drug record did not match, documentation was missing, and the late documentation should not have been entered because the nurse would not have known what was done two months earlier.
Pharmacist Failed to Identify Antibiotic Orders Without Stop Dates
Penalty
Summary
The facility failed to ensure the consultant pharmacist identified medication irregularities during the monthly medication regimen review for two residents. One resident was admitted with diagnoses including urinary tract infection and had a physician order for penicillin 500 mg twice daily with no end date. The resident received the penicillin as ordered on the MAR, and the consultant pharmacist later stated the antibiotic should have had a stop date and that the issue was missed during the June 2025 review. A second resident was re-admitted with severe unspecified dementia with agitation and had a physician order for nitrofurantoin macrocrystal 100 mg once daily for UTI prophylaxis with no stop date. The resident received nitrofurantoin daily from 6/14/25 through 7/23/25. The consultant pharmacist stated this order should have had a stop date and should have been identified as a medication irregularity during the June 2025 medication regimen review. The facility’s medication regimen review listing showed both residents were reviewed by the consultant pharmacist and no recommendations were made. The Infection Preventionist and DON both stated the antibiotics should have had stop dates and acknowledged that prolonged antibiotic use without stop dates should have been identified as irregularities during the June 2025 review. The facility policies stated the consultant pharmacist reviews medication regimens monthly, including antibiotic orders, and is to identify antibiotics not consistent with stewardship practices.
Unnecessary Antibiotic Use Without Stop Dates
Penalty
Summary
The facility failed to ensure that two sampled residents were free from unnecessary drugs when both were given antibiotics without verification of a stop date. Resident 33 was readmitted with a diagnosis of severe unspecified dementia with agitation. A physician order dated 6/13/25 directed nitrofurantoin macrocrystal 100 mg once daily for UTI prophylaxis with no stop date, and the MAR showed the resident received the medication daily from 6/14/25 through 7/23/25. Resident 39 was admitted with diagnoses including UTI. The history and physical stated the resident had been hospitalized and treated for a presumed UTI with Rocephin, which was completed after a 5-day course, and the resident was restarted on penicillin because osteomyelitis of the left second toe was suspected. The resident’s urine culture from May 27, 2025 showed Klebsiella pneumoniae resistant to several antibiotics but susceptible to Rocephin, ceftazidime, Augmentin, ciprofloxacin, and Bactrim, and the resident was described as currently asymptomatic. A physician order dated 6/3/25 directed penicillin 500 mg twice daily with no end date and listed UTI as the diagnosis, and the MAR showed the medication was administered as ordered in June and July 2025. The clinical record and staff interviews showed no documentation that Resident 39 had signs or symptoms of a UTI while in the facility, and no labs were done to determine whether a UTI was present. A nurse stated the resident was taking penicillin for a UTI, toe infection, and pneumonia, but the order was reviewed as being for UTI treatment and should have been clarified because there was no clear reason for no stop date. The infection preventionist, pharmacist consultant, and DON all stated the antibiotic orders for Residents 33 and 39 should have had stop dates or documented valid reasons to continue indefinitely, and that antibiotics without stop dates could be unnecessary and contribute to antibiotic resistance.
Dietary Staff Incorrectly Demonstrated Food Thermometer Calibration
Penalty
Summary
The facility failed to ensure food and nutrition services staff could safely and effectively carry out department functions when Dietary Aide 22 incorrectly demonstrated how to calibrate a food thermometer. During observation, Dietary Aide 22 placed ice and water in a glass, immersed the thermometer with the probe touching the bottom and side of the glass, and stated he was unable to get the right temperature to calibrate it, asking whether more ice was needed. A review of the dietary competency assessment showed Dietary Aide 22 had been signed off as competent on calibrating a food thermometer. The Registered Dietitian stated dietary staff competency had been a facility project for the last six months and that staff were expected to receive competency checks annually. The facility policy for taking accurate temperature stated the thermometer probe should be placed into the ice water mixture without touching the sides or bottom of the container.
Unsafe Food Storage and Improper Cooling of Potentially Hazardous Food
Penalty
Summary
Safe and sanitary food handling was not maintained in the kitchen during dietary operations when produce was observed with visible spoilage. On 7/21/25 at 8:07 A.M., during an observation of the produce walk-in refrigerator, three green bell peppers were seen with white porous material and a jalapeno pepper had three brown dots. A Dietary Aide stated the items would be discarded. On 7/23/25 at 11:15 A.M., the Registered Dietitian stated she had been informed of the green peppers with mold. She stated kitchen staff were supposed to inspect food items and produce, and that the cook would see it and not serve it. The facility policy titled General Food Preparation and Handling, dated 7/22, stated food items would be prepared to conserve maximum nutritive value, develop and enhance flavor, and keep free of harmful organisms and substances, and that food would be received, checked, and stored properly. The facility also failed to follow its cool down process for potentially hazardous food. On 7/23/25 at 3:20 P.M., review of the kitchen cool down process log with the Registered Dietitian and Director of Culinary showed cooked chicken was placed in the chiller at 10 A.M. at 175 degrees Fahrenheit, but there was no temperature check documented after 2 hours. The Registered Dietitian stated there should be a temperature check after 2 hours and that kitchen staff needed to ensure the cool down process was followed to prevent food borne illness, noting the food might be in the danger zone. The Dietary Aide who prepared the cool down process was gone for the day. The facility policy titled Use of Leftover, dated 7/22, stated leftovers must be cooled to 70 degrees Fahrenheit within 2 hours and then to 41 degrees Fahrenheit within another 4 hours.
Infection Control Failures During Meals and Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control program when residents were not offered hand hygiene before meals in the dining room. During observations, two residents being brought to a table were not offered hand wipes or sanitizer, and one resident later ate a bread roll with bare hands. In another dining room observation, residents seated at tables were served lunch and breakfast without being offered hand hygiene beforehand. One resident stated staff did not offer hand wipes or sanitizer before meals, and another resident said she was not offered hand hygiene before breakfast because she had showered earlier that morning. Interviews confirmed that staff did not consistently provide hand hygiene before meals. A CNA stated she did not offer hand hygiene to one resident and acknowledged that hand hygiene before eating is important to clean hands and prevent infection. The Infection Preventionist stated residents should have clean hands before eating, that staff should provide soap and water or hand hygiene wipes prior to meals, and that hand hygiene was important because a resident could get sick and get other residents sick. The facility policy titled Handwashing/Hand Hygiene stated hand hygiene is the primary means to prevent the spread of infections and that residents, family members, and visitors will be encouraged to practice hand hygiene. The facility also failed to follow infection control practices during wound treatment for a resident with a left buttock pressure injury and a history that included infection of the left knee prosthesis. During the wound treatment observation, the wound nurse wore gloves and used the same gloves while closing the door, pulling the privacy curtain, adjusting the bed remote, repositioning the resident, folding the incontinence brief, removing the old dressing, applying saline, patting the wound, applying cream, cleaning the wound edges, and applying dressings. The wound nurse did not change gloves or perform hand hygiene between these tasks. The wound nurse later stated he should have changed his gloves because the old dressing was not clean and could contaminate the wound. The DON stated the expectation was for the wound nurse to remove gloves and perform hand hygiene after removing the soiled dressing. The facility policy for dry, clean dressings instructed staff to put on clean gloves, remove the soiled dressing, and wash and dry hands thoroughly.
Antibiotic Stewardship Program Not Implemented
Penalty
Summary
The facility failed to implement its antibiotic stewardship program when two sampled residents were receiving antibiotics without verified stop dates and their infections and antibiotic use were not monitored and reviewed in June and July 2025. Resident 33, who was re-admitted with severe dementia and agitation, had a physician order dated 6/13/25 for nitrofurantoin macrocrystal 100 mg once daily for UTI prophylaxis with no stop date. Resident 39, admitted with a diagnosis including UTI, had a physician order dated 6/3/25 for penicillin 500 mg twice daily with no end date and a diagnosis of UTI, site not specified. Resident 39’s history and physical stated he had been hospitalized and treated for a presumed UTI with Rocephin, then restarted on penicillin, with suspected osteomyelitis of the left second toe also noted. The record stated the patient was currently asymptomatic. His care plan listed prophylactic antibiotics related to chronic UTI and osteomyelitis of the left second toe, and a long-term goal that the UTI would resolve. However, staff interviews found no documentation of signs or symptoms of UTI while the resident was in the facility and no labs or urinalysis were done to determine whether an active UTI was present. During interviews, the LN, IP, PC, and DON stated the antibiotic orders should have been reviewed for stop dates and clarified with the physician when no valid reason was documented for indefinite use. The IP stated he was unable to perform oversight of the antibiotic stewardship program during the period because he was dealing with an outbreak in another area of the building, but also stated the stewardship process should have identified the antibiotics without stop dates. Facility policies required the DON and IP to monitor antibiotic regimens, review start/stop dates and days of therapy, and document all resident antibiotic regimens on the antibiotic surveillance tracking form.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 151, received a physician-ordered medication, calcium carbonate with vitamin D, for six consecutive days. The medication was prescribed to address a vitamin D deficiency, but it was not available for administration from 7/6/24 to 7/11/24. During a medication administration observation, a licensed nurse (LN 3) confirmed the unavailability of the medication and expressed uncertainty about when to notify the physician regarding the issue. Interviews with staff, including LN 4 and the Director of Nursing (DON), revealed that the facility lacked a clear protocol for addressing unavailable medications. LN 4 indicated that the physician should have been informed by the third day of unavailability, while the DON acknowledged that the medication should have been available from the facility's central supply. The DON also noted that the central supply delayed ordering the medication until 7/12/24, which was not acceptable. There was no documentation indicating that the physician was notified about the medication's unavailability, and the issue was not resolved in a timely manner.
Failure to Follow PRN Psychotropic Medication Guidelines
Penalty
Summary
The facility failed to adhere to the guidelines for administering PRN psychotropic medications for Resident 33, who was admitted with a diagnosis of non-traumatic intracerebral hemorrhage. The physician's order for Lorazepam, a medication used to treat anxiety, was open-ended and lacked a specific behavior that warranted its administration. The Medication Administration Record (MAR) showed that Lorazepam was administered multiple times for generalized behaviors such as anxiety and yelling out, which were not specific enough according to the facility's policy. Interviews with nursing staff and the Director of Nursing (DON) revealed that the behavior listed as anxiety was subjective and open to interpretation, and a specific behavior should have been documented before administering the medication. Additionally, the facility did not comply with the federal requirement that PRN psychotropic medications must be justified and documented by the physician if continued beyond 14 days. The physician failed to provide a rationale for the continued use of Lorazepam for Resident 33, despite recommendations from the consulting pharmacist to either discontinue the medication or document the reason for its necessity. The facility's policy required that the need to continue PRN orders beyond 14 days be documented, but this was not done for Resident 33. The consulting pharmacist noted the lack of written justification for the continued use of Lorazepam and made recommendations to the physician, which were not followed. The Minimum Data Set Nurse (MDSN) confirmed that the physician was required to document a justification for renewing the 14-day PRN psychotropic medication, but no such documentation was found in the Medication Regimen Review (MRR) for Resident 33. The failure to follow these guidelines and document the necessity of the medication could lead to increased risk of side effects and prolonged use for Resident 33.
Inaccessible Medical Records for Controlled Medication
Penalty
Summary
The facility failed to ensure that the medical records for a resident were readily accessible, which led to an inability to verify the administration of a controlled medication. The resident was readmitted to the facility, and a request was made for the resident's physician's orders, medication administration record (MAR), and controlled drug record (CDR) for lorazepam, a controlled medication. The CDR indicated that lorazepam had been removed from supply on several dates, but the MAR did not reflect that the medication had been administered on those dates. Additionally, the physician's orders showed that the medication had been discontinued prior to these dates. Interviews with the licensed nurse and the director of nursing revealed that the MAR was incomplete and not readily accessible, preventing confirmation of whether the resident received the medication. The director of nursing acknowledged the issue and stated that the complete MAR should have been accessible. The facility's policy on electronic medical records did not provide guidance on ensuring records were readily accessible, contributing to the deficiency.
Inadequate Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to ensure that meal assistance was provided in a sanitary manner to a resident, identified as Resident 3, who was dependent on staff for feeding due to right-sided weakness, paralysis following a stroke, difficulty swallowing, and was receiving palliative care. During a lunchtime observation, a certified nursing assistant (CNA 1) was seen feeding Resident 3 a sandwich using her bare hands without performing hand hygiene after assisting another resident. This action was observed after CNA 1 had touched another resident's wheelchair and clothing protector, and then proceeded to feed Resident 3 without washing hands or using gloves. Interviews conducted with other staff members, including CNA 2, the registered dietitian (RD), and the director of nursing (DON), revealed that it was against the facility's expectations and standards to touch a resident's food with bare hands. The RD and DON both emphasized the importance of performing hand hygiene and wearing gloves when assisting residents with eating. However, CNA 1 admitted to not knowing the requirement for hand hygiene and glove use, and the director of staff development (DSD) confirmed that specific training on hand hygiene related to feeding assistance was not provided to the staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 430 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Encinitas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviara Healthcare Center | 0.9 mi | ★★★★★ | 27 | 0 |
| Encinitas Post-acute | 1.5 mi | ★★★★★ | 0 | 0 |
| Glenbrook | 2.3 mi | ★★★★★ | 18 | 0 |
| Bayshire Torrey Pines Post-acute | 7.4 mi | ★★★★★ | 1 | 0 |
| Village Square Healthcare Center | 7.6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.