Health inspection·September 2, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm room floors had numerous black stains; and the window bed wheelchair noted to have cracked and torn arms. room [ROOM NUMBER] - Room floor covered with black stains; wheelchair (A-bed) arms were ripped and torn; room walls had areas of peeling paint; and dresser drawers were broken. Residents Affected - Some room [ROOM NUMBER] - Room floor covered with black areas and stains. room [ROOM NUMBER] - Room floor covered with black areas and stains; and room walls had areas of peeling paint and required re-painting. room [ROOM NUMBER] - Room floor was heavily black stained; and the floor area near the bathroom entrance was lifting. room [ROOM NUMBER] - Room floor was heavily black stained; and the toilet required re-caulking to the bathroom floor. room [ROOM NUMBER] - Exterior to room dresser was scratched and damaged. room [ROOM NUMBER] - Room floor was heavily black stained. room [ROOM NUMBER] - Room floor was heavily black stained; and the toilet required re-caulking to the bathroom floor. room [ROOM NUMBER] - Bathroom noted to have foul and pervasive urine odor. Hallway (between room [ROOM NUMBER] to #350) the wall handrails located on both sides of the hallway were noted to be heavily worn and stained. Following the tour, the issues were again confirmed with the Directors. The Maintenance Director stated that there is a Maintenance/Housekeeping log book located at the each nurses station (2). Staff are are required to document any issues. 2) During an observational tour conducted of the East hallway bathroom, located directly off the East side nursing station, on 08/30/22 at 2:23 PM, it was noted that there were two (2) live roaches/insects observed/video-recorded for a total of forty-seven (47) seconds, one (1) of which was a large dying roach/insect was noted lying on its belly, legs folded in, with its antennae still actively moving was observed on the floor of the East unit bathroom near the side wall on the floor. And, a second (2nd) live roach/insect actively running/mobile inside in the East bathroom. This East bathroom is near resident rooms and approximately thirty-eight (38) feet away from the resident facility kitchen doorway entrance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 2 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy and procedure, the facility failed to provide nail care for 1 of 5 sampled residents (Resident #11) reviewed for Activities of Daily Living (ADLs). Residents Affected - Few The findings included: Review of the facility policy and procedure titled Nail Grooming with a last review date of 07/24/18, provided by the facility's Director of Nursing (DON) documented, regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as necessary . Review of Resident #11's clinical record documented an initial admission to the facility on [DATE] under hospice care. The resident's diagnoses included Dementia, Anemia, Hypertension, Pain, Depressive episodes and Unsteadiness on feet. Review of Resident #11's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 7 of 15, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive to total assistance from the facility staff with her ADL's. Review of Resident #11's care plan titled Self-care Deficit as evidenced by: weakness and cognitive impairment initiated on 09/01/21 and revised on 07/11/22 documented provide ADL care to ensure daily needs are met . On 08/30/22 at 10:01 AM, during an initial observational tour, Resident #11 was observed lying in bed with her eyes open. Observation revealed the residents both hands fingernails were long, sharp, jagged, unkempt. Further observation revealed the resident's right hand fingernails with dark debris underneath. An attempt was made to interview the resident but the resident kept looking at the surveyor and did not answer any questions asked. On 08/31/22 at 1:46 PM, an interview was conducted with Staff G, Certified Nursing Assistant (CNA), at Resident #11's bedside. Staff G stated that she fed Resident #11 today, because the resident was having trouble with her hand and added that both of her hands were stiff. Staff G, stated the resident could not hold a piece of burger during lunch time. Staff G stated the resident used to eat by herself. Staff G, was asked who will provide the residents with fingernail care and she stated that any CNA can do it. Staff G added she asks the nurse before nail care to see if the resident was diabetic. Consequently, a side by side review of Resident #11's fingernails was conducted with Staff G, and Staff H, CNA. Staff G stated the resident's nails were long and confirmed one fingernail was jagged and dark color material was noted under the nail bed. Subsequently, Staff C, a Registered Nurse (RN), Resident #11's nurse, was called to the resident's bedside. A side by side observation of resident's fingernails was conducted with Staff C, Staff G and Staff H. Staff C stated the resident's fingernails needed to be filed or provided nail care. Staff C stated that it is the CNAs responsibility to provide the resident's fingernail care. Staff H stated Resident #11's fingernails needed a cut. During the observation, a brief interview was conducted with Resident #11, and she was asked if she would like her fingernails done and she stated Yes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 3 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff G and Staff H both stated the facility has a CNA that comes in later who provides the residents with hair and nail care. On 09/01/22 at 9:54 AM, observation revealed Resident #11 in bed, attempting to eat her breakfast. Further observation revealed the resident continued to have both hands with her fingernails unkempt, jagged and long. The facility staff had not provided the resident with fingernail care, even after it was brought to their attention by the surveyor. On 09/01/22 at 11:54 AM, an interview was conducted with Staff I, CNA who stated the CNA also provides the residents with fingernail care, if they need it. On 09/01/22 at 11:56 AM, an interview was conducted with Staff J, CNA, assigned to Resident #11. Staff J stated she provided ADL care to the resident this morning and got her out of bed. Staff J was asked who does the residents fingernail care and she stated that sometimes she herself would do it and added that the facility had a CNA that does fingernail care for the residents. Staff J was asked if she trimmed Resident #11's fingernail today and she stated she saw the resident's fingernails were long, but did not trim them. Staff J was asked if she was planning to do Resident #11's fingernails today and replied that she will do it as soon as she finished with the surveyor's interview. On 09/01/22 at 3:45 PM, during an interview, the facility's DON was apprised of Resident 11's unkempt fingernails. The DON was informed that a side by side observation of the resident's fingernails was conducted on 08/31/22 with the staff and the resident fingernails continued to be untrimmed as of 09/01/22 at 11:56 AM. The DON stated that a facility wide of all residents fingernails was conducted on 08/31/22 and some residents were found to need fingernail care. The DON stated that the CNA documentation did not specify when fingernail care was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 4 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure that a resident who requires respiratory care is provided such care as ordered by the physician and failed to document O2 (oxygen) saturations for every shift, as ordered by the physician for 1 of 1 sampled residents (Resident #254). Residents Affected - Few The findings include: Review of the policy, titled Respiratory Oxygen Administration - Nasal Cannula Clinical Practice Guideline last reviewed on 07/25/22, included the purpose: oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Humidification of oxygen is used for a flow rate of four liters per minute or greater, or if requested by a patient. Record review for Resident #254 revealed that the resident was admitted to the facility on [DATE] and discharged to hospital on [DATE] at 11:00 PM. The residents diagnoses included Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Unspecified Acute Lower Respiratory Infection, Depression, Allergy Unspecified, Shortness of Breath, Anxiety Disorder, and Acute upper Respiratory Infection. Review of Section C of the Minimum Data Set (MDS) assessment documented that Resident #254 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive response. Review of Section G of the MDS documented that Resident #254 had bed mobility self-performance of extensive assistance with support of one person assist, transfers and toilet use both have a self-performance of limited assist with support of one person assist. Review of Section O of the MDS documented that Resident #254 was receiving oxygen therapy. Review of the Physician's Orders showed that Resident #254 had an order dated 08/26/22 for oxygen, which read: continuous O2 via nasal canula at 3 liters every shift, an order dated 08/18/22 for oxygen therapy: check humidification bottle every shift, change when empty every shift; days, nights, and an order dated 08/18/22 for oxygen therapy: O2 saturations (Sats) every shift day, nights. Review of the Care Plan dated 08/17/22 for Resident #254 with a focus on resident is at risk for shortness of breath, impaired breathing pattern secondary to diagnosis of respiratory failure, COPD with exacerbation, Congestive Heart Failure (CHF). Goal was resident will not have shortness of breath as evidenced by respirations within normal range. Interventions included monitor for episodes of shortness of breath and implement interventions as ordered, notify Medical Doctor (MD) if ineffective and follow up as indicated, oxygen per Medical Doctor (MD) order, prompt participation in activities that do not depend on physical stamina or exertion. provide reassurance and support to prevent anxiety during episode of shortness of breath. Record review for Resident #254 revealed the night shift (7:00 PM -7:00 PM), from 08/16/22 to 08/31/22 documentation revealed the OS saturation was not documented as ordered. Record review from 08/16/22 to 08/31/22 for Resident #254 revealed there were only 2 progress notes for the night shift (7:00 PM -7:00 PM). Progress note dated 08/29/22 at 7:38 PM included the resident was seen by the medical doctor (MD) this evening. Antibiotic (ABT) ordered for Bronchitis. Resident's emergency contact was notified of change in status and new order. Progress note dated 08/31/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 5 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0695 at 11:06 PM revealed the resident left facility via stretcher x2. Left in stab le condition. Level of Harm - Minimal harm or potential for actual harm Record review of progress note for Resident #254 dated 08/31/2022 revealed resident requesting facility to send her to the hospital. Resident is awake and alert, noted anxious, vital sign blood pressure (BP) 159/99, pulse (P) 100 respirations (R)18, temperature (T) 97.3, oxygen saturation (SO2) 93% with continuous O2 at 3L. Safety measure in place and comfort. Doctor aware, resident friend was called but no respond. Residents Affected - Few Record review of Resident #254's vitals report from 08/18/22 to 08/30/22 revealed O2 saturations were only documented on the day shift. Record review of Resident #254's treatment administration record (TAR) from 08/18/22 to 08/30/22 revealed O2 saturations were only documented on the day shift. During an observation conducted on 08/30/22 at 10:15 AM, Resident #254 was wearing oxygen 2.5 liters via nasal canula with the oxygen tubing dated 08/28/22. It was noted that no oxygen humidification water bottle was observed. Photographic evidence obtained. During an observation on 08/31/22 at 9:50 AM Resident #254 was wearing oxygen at 3 liters via nasal canula. Resident #254 continued to not have the oxygen humidified, as evidenced by no humidification water bottle (photographic evidence obtained). The resident also had small amount of bloody mucous in a tissue that she stated had come from her nose earlier in the morning. During an interview conducted on 08/30/22 10:18 AM with Resident #254, she stated that she told the nurses she needed bottled water for her oxygen, but the nurses told they have none. During an interview conducted on 08/31/22 at 12:50 PM with Staff C Registered Nurse (RN) when asked if Resident #254 has an order for humidified oxygen, she stated yes, the resident has an order to check humidification of oxygen. When asked if she checks the humidification water bottle per the order to see if it needs to be replaced, she said yes but did not think she did it today. The nurse and surveyor went to the bedside where the oxygen concentrator was and there was no humidification water bottle. When the nurse was asked if she could point out where the humidification water bottle was, she said there is none. When asked if she knew where the supply of humidification water bottles was kept, she stated in the treatment cart. Another unidentified nurse standing by told Staff C, the humidification water bottles are not kept in the treatment cart; they are kept in the central supply storage room. During an interview conducted on 08/31/22 at 10:48 AM with Central Supply/Scheduler, when asked if the facility has a supply of oxygen humidification water bottles, she stated they always have 5-6 bottles of sterile water for oxygen humidification. She verified this by showing the surveyor the 6 bottles in the storage room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 6 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) On 08/31/22 at 8:25 AM, medication administration observation for Resident #25 performed by Staff C, a Registered Nurse (RN) was conducted. Staff C poured the following medications: Vitamin C 500 milligrams (mg), Gabapentin capsule 300 mg (an anticonvulsant), Lactulose (a liquid laxative) 30 millimeters (ml), Famotidine (used to reduce the amount of acid in the stomach) 20 mg and Pro-Stat 15 ml (liquid protein). Observation revealed Staff C, RN, donned gloves, opened the Gabapentin capsule and poured into a medication cup, mixed it with the Vitamin C and Famotidine and crushed them together. At 8:33 AM, Staff C, RN entered Resident #25's room with a foam tray containing the crushed medication and the two liquid medications, placed the tray with the medications on top of the resident's table located in front of the resident and readily accessible to the resident. During the medication administration observation, Staff C, RN was observed exiting the resident's room, leaving all poured medications for Resident #25 on top of the table unattended. Staff C was observed outside the resident's room by the medication cart parked in the hallway and retrieving a blood pressure machine. At 8:38 AM, observation revealed Staff C assisting Resident #25 with taking the medications. The Staff C stated the resident preferred to take the medications with a straw. Observation revealed Staff C again exited the resident's room leaving the medications unattended on top of the table. Staff C walked to the medication cart, retrieved a straw, returned to the resident's bedside and proceeded to administer the liquid medications with a straw. 4. On 08/31/22 at 2:02 PM, medication administration observation for Resident #155 performed by Staff C was conducted. Observation revealed Staff C entered the resident's room with a foam tray that contained one bag of Ampicillin (an antibiotic) premixed in a saline bag, a ten (10) millimeters (ml) saline flush syringe and alcohol pads. Continued observation revealed Staff C placed the foam tray with the antibiotic and the saline syringe on top of the resident's dresser across the bed, walked approximately 10 feet away from the medications to the bathroom and returned to the bedside after one (1) minute. The foam tray with the medications was unattended, visible from the hallway and accessible to the staff and visitors. Further observation revealed Resident #155's roommate had a visitor in the room while the medications were left unattended on top of the dresser. Staff C returned to the resident's bedside completed the administration of the intravenous antibiotic, flushed the intravenous device with five (5) ml of saline using the syringe. Furthermore, observation revealed Staff C placed the saline syringe into her Fanny Pack and stated she will use it later. On 08/31/22 at 2:58 PM, during an interview, Staff C stated she threw away the previous syringe she placed in her Fanny Pack. On 09/01/22 at 12:02 PM, an interview was conducted with Staff C, who confirmed that she left the resident's medication unattended on the table/dresser. Staff C added that she did it because the surveyor was in the room. Staff C stated that resident's medications are not to be left unattended. On 09/01/22 at 3:45 PM, during an interview, the DON was apprised of findings. The DON stated the nurses are to keep an eye on the residents medication once they have poured them. Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured medications in 1 of 3 Medication carts and 1 of 2 Treatment carts, during an initial observational tour; 2) ensure that it discarded expired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 7 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications in 1 of 2 Medication Storage Rooms; and 3) ensure that it properly supervised medications, during Medication Pass Observation for 2 of 7 sampled residents observed (Resident #25 and #155). The findings included: 1) Review of the facility policy and procedure titled Medication Storage/Storage of Medication, reviewed 10/07 provided by the Director of Nursing (DON), documented in the Policy Statement: Medications and biologicals are stored properly, following manufacturer's recommendations or those of the supplier to maintain their integrity and to support safe administration. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies are locked or attended by persons with authorized access . 1) During an observational screening tour conducted on Monday 08/30/22 at 9:50 AM, it was observed that the [NAME] side medication cart A was left in front of Resident #7's room (who was just immediately located inside of his partially opened bedroom door) unlocked, un-secured and unattended and visible to other residents, staff members and visitors, at the far end of the hallway approximately thirty-seven (37) feet four (4) resident room doors away from the [NAME] nurses' station for 5-7 minutes; the nurse Staff A, a Licensed Practical Nurse (LPN), was down the hallway exiting the [NAME] nurses' station returning to the unlocked Med cart containing Nineteen (19) resident medications. Resident #7 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Depression, Hypertension, Gastroesophageal Reflux Disease and Chronic Atrial Fibrillation. He had a Brief Interview Mental Status (BIM) score of 11 (moderately impaired). Photographic evidence was obtained of the un-locked/un-attended/un-secured [NAME] side medication cart A. On 08/31/22 at 10:38 AM, an interview was conducted with Staff B, an (LPN), regarding the un-locked/un-attended medication cart and she acknowledged that medication cart was left un-locked and un-attended and it should not have been. On 08/30/22 at 3 PM, it was observed by two (2) Agency for Healthcare Administration (AHCA) surveyors that the East side wing treatment cart was left approximately five (5) feet away from the East nurses' station entrance unlocked, un-secured and unattended and visible to other residents, staff members and visitors. The day nurse, Staff C, a Registered Nurse (RN), was down the hallway approaching the East nurses' station returning to the unlocked treatment cart containing eight (8) different resident medications and multiple other over-the-counter (OTC), non-specific medications. Photographic evidence was obtained of the un-locked/un-attended/un-secured East side wing treatment cart. On 08/31/22 at 10:42 AM, an interview was conducted with Staff C regarding the un-locked/un-attended medication cart and she acknowledged that the treatment cart was un-locked, and it should not have been. The DON further acknowledged and recognized that the un-locked/un-attended medication and treatment carts should remain locked and secured, at all times, this was not done. 2) Review of facility policy titled Medication Storage, Storage of Medication dated 10/07, included (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 8 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few outdated contaminated discontinued or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock. During the medication storage task on 08/31/22 at 10:14 AM, an observation was made with Staff B Licensed Practical Nurse (LPN). In the [NAME] medication room refrigerator, it was observed that there were 3 expired medications. The first medication was Omeprazole 2mg/ml suspension labeled with date opened as 07/28/22 and to discard after 14 days (photographic evidence obtained). The second and third medications were PPD (for tuberculin skin test) 0.1cc prefilled liquid with expiration date of 08/27/22 and 08/28/22 (photographic evidence obtained). The freezer located inside the refrigerator had ice buildup on inside and outside with freezer with the freezer door not being able to be closed all the way (photographic evidence obtained). During an interview, conducted on 08/31/22 at 10:15 AM with Staff B, she stated she will ensure the expired medication are properly discarded and will inform her supervisor to make sure the freezer is defrosted. During the medication storage task on 08/31/22 at 10:31 AM with Staff K, Registered Nurse (RN), in the East medication room, it was observed that the freezer located inside the refrigerator had ice buildup on the inside and outside with freezer, with the freezer door not being able to be closed securely (photographic evidence obtained). During an interview, conducted on 08/31/22 at 10:35 AM with Staff K, she stated she will inform her supervisor to make sure the freezer is defrosted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 9 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to follow the approved menu for potentially 53 of the 56 facility residents that included 38 of the 39 sampled facility residents. Residents Affected - Some The findings include: During the review of the approved menu for the lunch meal of 08/30/22 , the following were noted to be served for the meal to regular diet, mechanical soft diets, renal diets, and pureed diets: ½ cup - Sauteed [NAME] Beans ½ cup - Chopped [NAME] Beans ½ cup - Sugar Snap Peas ½ cup - Parmesan Noodles ½ cup - Chocolate Pudding Parfait ½ cup - Mashed Potatoes ½ cup - Pureed Marinated Chicken Thigh During the observation of the lunch meal in the main kitchen and interview with the lunch cook on 08/30/22 at 11 AM, the following were noted: (a) Observation noted that a tong was being utilized for a serving of green beans. The menu documented a 4 ounce (#8 scoop) be utilized as a standard portion. Observations noted that the portion size being served varied for residents. (b) Observation noted that a 2-ounce portion of ground green beans was being served. The menu documented that a 4 ounce (#8 scoop) be utilized as standard portion. (c) Observation noted Sugar Snap Peas were not prepared or served. The cook stated that the peas were not available and an alternate vegetable was not prepared. (d) Observation noted that spaghetti with parmesan cheese was being served in place of Parmesan Noodles. The cook stated that the spaghetti was not available. It was also noted that a ½ cup portioning serving utensil was not being utilized as per the approved menu. The spaghetti was noted to be served with tongs and the portion was guessed. (e) Observation noted that chocolate pudding was being served with a number #12 scoop (2 ounces) instead of the approved menu documented portion of 4 ounces (#8 scoop) . It was also noted that plain chocolate pudding was served instead of the chocolate parfait. The cook stated that she was unaware that the menu documented Chocolate Pudding Parfait and also stated she did not have knowledge of how to prepare the parfait. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 10 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0803 Level of Harm - Minimal harm or potential for actual harm (f) Observation noted that a 2 ounce portion (#12 scoop) of mashed potatoes was being served. The menu documented a 4-ounce (#8 scoop) portion. (g) Observation noted that a 2 ounce (#12 scoop) of pureed chicken was being served to pureed diets. The menu documented a 4 ounce (#8 scoop) portion. Residents Affected - Some During the lunch observation on 08/30/22, the surveyor reviewed the approved menu with the cook (Staff G) and confirmed that the menu and portion sizes documented, were not being followed. A review of the menu issues noted that on 08/30/22, it was noted that 53 of the 58 facility residents ate by mouth. Of the 53 residents who ate by mouth , 38 of the 39 residents were noted to be on the Stage 2 Sample. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 11 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review, it was determined that the facility failed to prepare pureed foods in a form designed to meet the individual needs of 3 of 3 sampled residents with physician ordered pureed/dysphagia diet (Resident's #3, #25, and #49) . The findings included: 1) During the review of the approved menu for the lunch meal of 08/30/22, it was noted that sauteed green beans were to be served for physician ordered pureed diets. During the observation of the lunch meal on 08/30/22, in the main kitchen it was noted that there was a small pan of what appeared to be a green vegetable located in the steam table. The breakfast/lunch cook identified the pureed vegetables as green beans, and that there were 2 residents that were to be served the pureed green beans. Further observation noted that there were visible large pieces of green beans in the mixture. The surveyor pointed out the pieces of green beans in the mixture and confirmed the surveyors observation. Further discussion noted that the breakfast/lunch cook was unaware that the pureed mixture is required to be smooth due to residents with diagnoses of dysphagia and the potential for silent aspiration if eaten. The cook also also stated she has been employed for approximately 3 months and has had no training on the preparation of pureed foods. At the request of the surveyor, a taste test of the pureed green bean mixture was conducted and the results confirmed large pieces of green beans within the pureed mixture. The surveyor informed the cook that the pureed green beans was not pureed in a form to meet the needs of residents of residents requiring pureed foods. 2) During the observation of the lunch meal on 08/31/22 at 11 AM, in the main kitchen, it was again noted that there was a small pan of what appeared to be a green vegetable. The cook identified the item as pureed peas. It was again noted by the surveyor that there were visible pieces of peas in the pureed mixture. At the request of the surveyor a taste test of the pureed mixture was performed and noted large pieces of peas in the mixture. The cook was informed that the pureed mixture did not meet the consistency of pureed to meet the needs of the 3 residents. A review of the diet census noted that there were currently 3 residents with physician ordered pureed diets that included: Resident #25: 09/01/22 - Change diet from mechanical soft to pureed with nectar thickened liquids 01/25/22 - Physician's diagnoses of Dysphagia 07/05/22 - Physician's diagnoses of Eating Disorder Resident #3: 08/12/22 - Physician ordered Dysphagia Pureed Diet with Fortified Foods for All Meals Resident #49: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 12 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0805 08/31/22 (re-admission) - Physician ordered Dysphagia Pureed Diet Level of Harm - Minimal harm or potential for actual harm 12/18/20 - Physician diagnoses of Dysphagia Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 13 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview, and record review, it was determined that 29 residents, including 9 sampled residents (Resident's #4, #10, #11, #21, #25, #33, #49, #104, and #254) failed to receive physician ordered Fortified Meals (High Protein/High Calorie diet). The findings included: During the review of the approved menu for the lunch meal of 08/30/22, it was noted that residents with physician orders were to receive a portion of Fortified Potatoes and review of the approved breakfast meal noted residents with fortified foods were to receive fortified Cooked Cereal (Oatmeal). During the observation of the lunch meal in the main kitchen on 08/30/22 at 11 AM, it was noted that there was a half pan of mashed potatoes to be served. Interview with the cook at the time of the observation revealed that the potatoes were regular and when asked about fortified the cook stated that she was not aware that fortified mashed potatoes were required to be made, and that residents requiring fortified mashed potatoes would receive regular. During the lunch meal, it was noted that the was no Food Service Manager in charge or available to review the meal findings. During the observation of the breakfast meal in the main kitchen of 08/31/22 at 8 AM, it was noted that there as only 1 pan of Oatmeal. The breakfast cook stated again she was unaware that Fortified Cooked oatmeal was to be prepared and that residents on Fortified foods would receive regular cooked cereal. The cook also stated that she was unaware of how to prepare fortified foods. A review of the diet census for 08/31/22 noted that there were 29 residents with current physician orders for Fortified Foods with meals. Further review noted that the list of 29 residents with current physician orders for Fortified Meals that included Resident #4, #10, #11, #21, #25, #33, #49, #104, and #254. During an interview with the facility's Registered Consultant Dietitian on 08/31/22, it was confirmed that the fortified foods were not being prepared and served as per physician orders. At the request of the surveyor the Fortified meal program was submitted by the Consultant. The review noted the following: Breakfast : Fortified Hot Cereal - review of the facility's standardized recipe noted the addition of the ingredients of whole milk, non-fat powdered milk, sugar, and margarine to increase protein/ calorie content. Lunch: Fortified Mashed Potatoes - review of the facility's standardized recipe noted the addition of the ingredients of half & half creamer and margarine to increase protein/calorie content. Dinner - Fortified Pudding - commercially prepared high protein/calorie pudding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 14 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include: ensure dishware are are chemically sanitized as per regulation, holding of foods are regulatory temperatures, maintenance of refrigeration unit to maintain temperatures as per regulation, maintenance of the exhaust hood to prevent food contamination, and failure to defrost foods as per regulation. This has the potential to affect 53 residents, who reside at the facility and eat orally. The findings include: Review of the facility policy and procedure titled, Ware Washing, revised 9/2017, provided by the Director of Nursing (DON), documented in the Policy Statement: All dishware, service ware and utensils will be cleaned and sanitized after each use. Procedures: 1. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. 2. All dish machine water temperatures will be maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. 3. Temperatures and/or sanitizer concentrator logs will be complete, as appropriate. 1) During the initial kitchen/food service observation tour conducted on 08/30/22 at 9 AM, the following were noted: (a) There was no supervisor or dietary manager on duty for the day. Kitchen staff included only 1 cook and 1 diet aide for the preparation and serving of the breakfast and lunch meals. The Food Services Director (FSD) was reportedly not available. (b) The dish machine was noted to be washing during the tour. At the surveyors request, a chemical (Chlorine) test was conducted on the machines final rinse. The test results noted that the final rinse test failed, as there was no chemical level in the final rinse water. It was also noted that the final rinse temperature of the dishmachine was noted not to meet the requirement of a minimum of 120 degrees F. The rinse water was recorded at 110 degrees F. Five more tests were conducted of the chemical final rinse of which all 5 failed. The surveyor informed the cook that the dishmachine could not be used until the chemical rinse met the requirement. (c) Trauleson Reach-I freezer #1 was noted to have door gaskets that were laden with a black mold type matter and soiled interior. The exterior of the unit was noted to be covered in dripping condensation. (d) The exterior surface of the food preparation table was noted to be black in color. (e) Observation of Artic-Air reach-in refrigerator #2 noted to have door gaskets (2) that were laden with a black mold type matter. (F) Reach-in refrigerator #3 was noted to have the gaskets pulled off of the door. There was a heavy amount of dripping condensation due to the gaskets. (g) The interior of the convection oven was noted to have a heavy build up of black carbon and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 15 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0812 grease and was nit being cleaned on a regular basis. Level of Harm - Minimal harm or potential for actual harm (h) The exterior of the exhaust hood was noted to have a build-up of grease/oil type matter along the out edge. The unknown condensation was noted to be dripping onto foods, food preparation equipment, food contact surfaces and staff result in potential of food borne illness and food contamination. Residents Affected - Many (i) Raw chicken (approx. 10 pounds) was noted to be thawing at room temperature in the sink. The internal temperature of the chicken was taken and was noted to be 60 degrees F. The surveyor informed the cook that running cold water must be used for thawing and that the raw chicken should be discarded. (j) Observation of the milk refrigerator noted that the door gasket was black mold laden. It was also noted that there was no thermometer located within the unit. Cartons of milk (48) felt room temperature to the touch. At the surveyors request he temperature of the milk was taken utilizing the facility's calibrated thermometer and was record at 52 degrees F. Staff stated that the milk was out at room temperature for the tray line for approximately 1 hour without refrigeration. The surveyor informed the cook the milk must be always held at the minimum of 41 degrees F or below. The surveyor requested that the milk cartons be discard. It was also noted that individual portions of Yogurt (32) was recorded at 48 degrees F. (k) Observation of cooking equipment (pots & pans) noted that approximately 20 pans were soiled, stained, and covered in black carbon. (l) During the observation tour, it was noted that during the testing of food temperatures with the facility's food thermometer that there were no alcohol swabs available for the sanitizing of the thermometer. The cook was noted to utilize the thermometer without sanitizing prior to use. 2) During a second tour of the main kitchen on 08/30/22 at 11 AM, the following were noted: (m) Continued chemical testing noted that 3 test failed and the machine was not chemically sanitizing resident dishware (Chlorine 50 ppm). It was noted that all resident dishware was being washed and sanitized in the 3-compartment sink. Based on the analysis/assessment of the dish machine, it was concluded that the dish machine was not sanitizing (and there was no level of chemicals noted) in the kitchen. It was further revealed that there was no log kept of how often sanitizing solution was being periodically tested to help assure that it maintained the correct concentration and none of the employees in the kitchen, were aware of how to do proper testing. The facility continued to serve meals to the residents on unsanitized/contaminated dishware on 08/29/22 and 08/30/22 until surveyor intervention, and disposable dishware was then used. On 08/30/22 at 1:30 PM, during consecutive interviews conducted with, the facility's District Manager, facility's Account Manager, the (DON) and with the Assistant Director of Nursing (ADON), it was acknowledged and recognized by all parties that the facility's kitchen dish machine was not properly sanitizing the residents dishware, the solution (PPM) parts per million was not sanitizing correctly, nor registering for the low temperature dish machine, as per regulation of (50) PPM Chlorine. (n) During the observation of the lunch meal in the main kitchen on 09/01/22 at 11 AM, temperatures (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 16 of 17 Printed: 05/28/2026 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 105009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/02/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfcrest Nursing Center 600 North 17th Ave Hollywood, FL 33020 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 0812 Level of Harm - Minimal harm or potential for actual harm of foods were taken by the facility cook, utilizing the facility's calibrated thermometer. The test revealed that cold foods were not being held at the required regulatory temperatures of 41 degrees F or below, as evidenced by the following: Egg Salad Sandwich (3) = 45 degrees F Residents Affected - Many Caesar Salad (35) = 56 degrees F Shredded Lettuce Salad with Caesar Dressing = 53 degrees F FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 17 of 17