Goldberg Healthcare Center: Medication Mix-Up - CA
The inspection at The Dorothy & Joseph Goldberg Healthcare Center, triggered by a complaint, found that staff had failed to properly manage a critical medication belonging to Resident 1, a patient whose medical records show a hospitalization that began July 31, 2025.
The drug was tacrolimus, an immunosuppressant used to prevent the body from rejecting a transplanted organ. It requires precise, consistent dosing. The hospital had Resident 1 on tacrolimus 1.5 mg capsules twice a day through August 2. On August 3, the day of discharge back to the facility, the physician wrote a new order: tacrolimus 0.5 mg capsules, three capsules twice a day, achieving the same total dose through a different formulation.
That medication, sent with Resident 1 from the hospital, ended up on the wrong cart entirely.
The facility has two medication storage areas. Resident 1's drugs belonged on the South hall cart. Instead, they were found on a different hall's cart. The Director of Nursing conducted an investigation and came up empty. She told inspectors she was unable to determine who had removed the medication from the South hall cart and placed it in the other.
Nobody had.
The facility's own policy on handling medications admitted with residents, dated November 2017, requires the medication nurse to examine and check for proper packaging and labeling. A separate policy on administering medication, dated April 2019, spells out that whoever gives a drug must check the label three times before administration, confirming the right resident, right medication, right dose, right time, and right route. The label check is not a formality. It is the mechanism by which a nurse is supposed to catch exactly this kind of error before a patient is harmed.
Whether those checks happened, and whether they happened correctly, the investigation could not establish. The Director of Nursing's inability to identify the responsible staff member left the question of what actually occurred unanswered.
Inspectors obtained Resident 1's hospital records on September 10, 2025, more than a month after the hospitalization began. Those records confirmed the physician's orders and the discharge prescription. They did not resolve what happened to the medication once it arrived at the facility.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory finding. It does not capture what tacrolimus actually does, or what happens when a transplant patient misses it. The drug suppresses the immune system's response to a transplanted organ. Gaps in dosing can trigger rejection. The margin for error is narrow, and the consequences of getting it wrong are not.
The facility's response to the complaint did not produce an answer. The internal investigation closed without identifying who moved the medication or why. The nurses who may have administered drugs from the wrong cart, or who may have checked labels and missed the mismatch, were not identified in the inspection record.
Resident 1 was hospitalized. The medication was on the wrong cart. And the person responsible, according to the Director of Nursing's own account to inspectors, remains unknown.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Dorothy & Joseph Goldberg Healthcare Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 28, 2026 · Our methodology
THE DOROTHY & JOSEPH GOLDBERG HEALTHCARE CENTER in ENCINITAS, CA was cited for violations during a health inspection on September 3, 2025.
The drug was tacrolimus, an immunosuppressant used to prevent the body from rejecting a transplanted organ.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.