F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to follow its own policy for investigating an abuse
allegation, when a certified nurse assistant (CNA), was not suspended, pending an investigation of an
alleged verbal abuse allegation for one of two resident (Resident 1), reviewed for resident abuse.
Residents Affected - Few
As a result, other residents were potentially at risk to be abused by the same CNA.
Findings:
Resident 1 was admitted to the facility on [DATE], with diagnoses which included Parkinson ' s disease, (a
progressive disease that affects the nervous system), per the facility ' s Resident Face Sheet.
On 4/3/23, Resident 1 ' s clinical record was reviewed:
According to the Minimum Data Set, (a clinical assessment tool), dated 3/20/23, listed a cognitive score of
12, indicated moderately impaired cognition. The functional status of activities of daily living, indicated one
person staff-assist with bed mobility, transfers, and toiletry.
According to the plan of care, titled Behavioral symptoms, dated 3/18/23, interventions listed included:
Emphasize rights, security and safety of all, approach calmly and unhurried, attempt to identify underlying
cause, attempt to listen to resident vent anger, if they become abusive, explain to resident why you are
leaving (ensuring their safety), reassure resident that needs will be met.
On 4/3/23 at 10:05 A.M., an interview was conducted with the Administrator (ADM) and the Director of
Nursing (DON, regarding the facility ' s self-reported incident of an alleged staff to resident verbal abuse
that occurred on 3/26/23 P.M. shift (3 P.M. to 11:30 P.M.) The DON stated she received a call from the
evening Resource Nurse (RN), of an allegation of CNA 1 telling Resident 1 to F--K yourself. The DON
stated the decision was made to move CNA 1 to a different hallway, to finish out her shift.
The DON continued, stated the RN for that shift, started to conduct an investigation and the decision was
made to keep CNA 1 working. The DON stated they determined the verbal abuse had occurred and was a
temporary lapse of CNA 1 ' s judgment and frustration.
On 4/3/23 at 11:12 A.M., an interview was conducted with the RN. The RN stated she was informed by a
licensed nurse 1 (LN 1) of something being overheard between Resident 1 and CNA 1. The RC stated she
assessed Resident 1, who could not recall anything. The RN notified the DON, and the DON made the
(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:
555424
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
555424
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Dorothy & Joseph Goldberg Healthcare Center
211 Saxony Road
Encinitas, CA 92024
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 0610
decision to move CNA 1 to a different area.
Level of Harm - Minimal harm
or potential for actual harm
On 4/3/23 at 11:41 A.M., an interview was conducted with CNA 1. CNA 1 stated she works all different
shifts at the facility and had cared for Resident 1 many times, who is confused and difficult at times. CNA 1
stated Resident 1 told her to F--K off, and as she was walking out of the room, she said F--k yourself. CNA
1 stated she realized she should have just left the room sooner and told the charge nurse she was having
difficulty dealing with the resident. CNA 1 stated she was able to finish her shift and she worked the next
two days.
Residents Affected - Few
On 4/3/23 at 11:46 A.M., an interview was conducted with CNA 2. CNA 2 stated if he overheard something
inappropriate between staff and a resident, he would immediately intervene and ask the staff member to
leave. CNA 2 stated he would inform the charge nurse and document what he saw or heard. CNA 2 stated
the facility was responsible for investigating the alleged incident and the staff should be removed from
resident care, until it was determined what happened and what should be done.
On 4/3/23 at 11:54 P.M., an interview was conducted with LN 2. LN 2 stated if an allegation of abuse
occurred between staff and a resident, the staff member should be sent home immediately and removed
from resident care. LN 2 stated the facility was required to investigate including the ADM, DON, Human
Resource Officer, along with informing the physician and family.
On 4/3/23 at 12:12 P.M., an observation and interview was conducted of Resident 1 as he sat in the dining
room with another male resident, waiting for lunch. Resident 1 was dressed and well groomed.
Resident 1 did not answer the questions asked but smiled instead.
According to the facility ' s policy, titled Abuse Investigation and Reporting, dated July 2017, .4. The
Administrator will suspend immediately any employee who had been accused of resident abuse, pending
the outcome of the investigation .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555424
If continuation sheet
Page 2 of 2
