The Dorothy & Joseph Goldberg Healthcare Center

In the surveyor’s words

From the most serious findings on record at The Dorothy & Joseph Goldberg Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF800Jan 27, 2023

  Based 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. Cross reference F802, F804, and F812 Findings: During the facility's recertification survey from [DATE]-[DATE], multiple deficient practices were identified in the Food and Nutrition Services Department's main and satellite kitchens, which included storage of expired, unlabeled, or undated foods; unsanitary kitchen food storage… […]

• No harm, potential for more than minimal, widespreadF802Jan 27, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jan 27, 2023

  Based 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. […]

• No harm, potential for more than minimal, isolatedF755Sep 3, 2025

  Based 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. […]

• No harm, potential for more than minimal, isolatedF578Jul 24, 2025

  Based 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.Findings:A review of Resident 39's Resident Face Sheet indicated the resident was admitted to the facility on [DATE].On 7/24/25 at 11:40 A.M., an interview and record review was conducted with the social services designee (SSD). The SSD stated it was her job to check if residents had an advance directive upon admission. This would then be discussed during the resident's first care conference. […]