Inspection visit

InspectionJanuary 19, 2024

GOLFCREST NURSING CENTERCMS #1050097 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy and procedure, observation, interview and record review, the facility failed to ensure that it followed physician's orders for medications and supplements for 2 of 6 sampled residents observed during a Medication Administration Observation (Resident #16 and Resident #166). Residents Affected - Few The findings included: Review of the facility policy and procedure titled, Medication Administration, provided by the Director of Nursing (DON) dated 04/14/23, documented in the Policy Statement: Medications are to be administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: .10. Review Medication Administration Record (MAR) to identify medications to be administered .14. Administer medication as ordered in accordance with manufacture specifications 20. Correct discrepancies and report to nurse manager . 1) Resident #16 was admitted to the facility on [DATE] with diagnoses which included Surgical Aftercare following Surgery on the Circulatory System, Cardiac Pacemaker, Hypothyroidism, Hypertension, Hyperkalemia, Gastroesophageal Reflux Disease and Hyperkalemia. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Record review revealed on 11/30/23, the physician's order documented, Multiple Vitamin Tablet, Give one (1) tablet by mouth one time a day for skin; no minerals included. (Photographic Evidence Obtained). Further record review of Resident #16's MAR dated 01/01/24 thru 01/17/24 revealed that the licensed nurses had been signing off, as giving the Multiple Vitamin tablets one (1) time a day. However, during a Medication Administration Observation conducted on 01/17/24 at 9:15 AM with Staff A, a Registered Nurse (RN), for Resident # 16, Staff A was observed preparing a daily Multivitamin tablet with Minerals, along with other ordered medications, for Resident # 16. 2) Resident #166 was admitted to the facility on [DATE] with diagnoses which included Encephalopathy, Right Bundle Branch Block, Hypertension, Diabetes Mellitus and Benign Prostatic Hyperplasia. He had a Brief Interview Mental Status (BIM) score of 11 (moderately impaired). Record review revealed on 01/02/24 a physician's order documented, Aspirin Tablet Chewable, Give one (1) tablet by mouth one time a day. (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 10 Event ID: 105009 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 01/19/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/05/24 the physician's order documented, Multiple Vitamin Tablet, Give one (1) tablet by mouth one time a day for skin; no minerals included. Further record review of Resident #166's MAR dated 01/03/24 and 01/06/24 through 01/17/24 both revealed that the licensed nurses had been signing off, as giving an Aspirin chewable 81mg one (1) tablet and a Multiple Vitamin tablet one (1) time a day, respectively. However, subsequently, on 01/17/24 at 9:24 AM, a Medication Administration Observation was conducted with Staff A, RN who was preparing a daily Multiple Vitamin tablet with Minerals and a chewable Aspirin tablet along with other ordered medications, for Resident #166 all in one (1) cup. Resident #166 proceeded to swallow whole, all of the medications provided in the cup; with no instructions or directions provided to Resident #166 by Staff A, with regards to exactly how the chewable Aspirin tablet was to be ingested, as ordered, by the Physician. On 01/17/24 at 9:39 AM, an interview was conducted with Staff A, regarding the physician's order for regular Vitamins v.s. Vitamins with minerals being administered to Residents #16 & #166, she verbalized the difference between the two, and she acknowledged that this should have been clarified with Resident #166's physician, prior to administration. And, Staff A also acknowledged that she had not provided any instructions or directions to Resident #166, with regards to exactly how the chewable Aspirin tablet was to be ingested. During a telephone interview conducted on 01/17/24 09:54 AM with the Guardian Consulting Services Pharmacy Doctor regarding the variation between a regular Multivitamin order v.s. Multivitamins with Minerals orders, as well as chewable Aspirin orders, he stated overall that in all cases, the physician's order should be followed, and orders are to be taken as written. It was initially reported to the Surveyor, on 01/17/24 at 10 AM by DON and the Regional Nurse, that the facility administered the bottle of multivitamins with minerals, as a stock medication on hand, so that everyone who gets multivitamins, gets multivitamins with minerals. Upon further interview, the Regional Nurse indicated that she was wrongfully informed regarding the above and she added that the facility did carry both regular multivitamins and multivitamins with minerals. Therefore, it was concluded Staff A, did have access to a regular multivitamin, but none was provided to either Resident #16, nor to Resident #166, during the Medication Administration Observation. A subsequent interview was conducted on 01/17/24 at 10:20 AM, with the DON, in which she indicated that another medication cart did contain an ordered bottle of Multivitamins without minerals. She also acknowledged that there was a difference between the two (2) regular Multivitamins vs. Multivitamins with Minerals. The DON further acknowledged that this should have been clarified with both Resident #16 and with Resident #166's physician as to exactly which was acceptable, prior to administration with the physician's order being followed; this was not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 2 of 10 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 01/19/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 provide nutritional supplements as ordered, for 1 of 9 sampled residents reviewed for nutrition, Resident #57. Residents Affected - Few The findings included: Record review revealed Resident #57 was admitted to the facility on [DATE]. According to the resident's most recent 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #57 had a Brief Interview for Mental Status score of 10, indicating that the resident was 'moderately' cognitively impaired. The resident's diagnoses at the time of the assessment included: Hip fracture, Seizure disorder, Bipolar disorder, Chronic lung disease, History of falling, Osteoporosis without pathological fracture, Hypothyroidism, Vitamin D deficiency, Constipation and Pain. The assessment documented that the resident had no swallowing disorders, no dental concerns and the resident was able to eat independently with setup and clean up assistance. Record review revealed Resident #57's dietary orders included: 12/28/23 - Regular diet, Regular texture, Regular/Thin consistency - fortified foods with all meals for Diet. 12/11/23. - House shake - with meals for nutrition support. 01/08/24 - Snack BID (twice daily) (2PM & HS (bedtime) Snack) - two times a day for nutrition support. Resident #57's care plan for nutrition, initiated on 11/13/23, documented, The resident has nutritional problem or potential nutritional problem (SPECIFY) r/t (related to) medical dx (diagnosis) infections, dementia, osteoporosis, fx (fracture), hypothyroidism, seizures. The goal of the care plan was documented as, The resident will maintain adequate nutritional/hydration needs maintain CBW (current body weight) +/- 3-5%. With a target date of 02/28/24. Interventions included: o Provide and serve diet as ordered. o Provide and serve supplements as ordered o Provide, serve diet as ordered. Monitor intake and record q (every) meal. During an observation of breakfast served to the residents in their rooms, on 01/17/24 at 7:49 AM Resident #57 was observed in bed with breakfast on her overbed table eating independently. The resident was served hot cereal, biscuit, sausage, hash browns and fluids. During the observation, the resident stated that she usually did not eat the hot cereal, as she didn't care for it. It was noted that the resident was not served a 'House Shake' as ordered. During an observation of breakfast being served to the residents in their rooms, on 01/18/24 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 3 of 10 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 01/19/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 7:53 AM, Resident #57 was observed with breakfast on her overbed table. It was noted that the resident did not receive the 'House Shake' with breakfast. Resident #57 stated that she was not aware that she was supposed to receive supplements. During an interview, on 01/18/24 at 7:54 AM, with the Food Service Director (FSD), when asked about providing the supplements to the residents, the FSD stated that the House Shakes were kept in the cooler in the kitchen and placed on the tray to be included with meals. When asked how the kitchen staff would be aware of the order for the House Shake, the FSD stated that the order would be reflected on the tray ticket that accompanied the meals. During an interview, on 01/18/24 at 10:53 with the Registered Dietitian (RD), the RD confirmed that the order for House Shakes for Resident #57 was for each meal. Review of Resident #57's tray tickets, that accompanied the meals, revealed that the order for House Shakes was not reflected on the tray tickets. A review of Resident #57's ADL (Activities of Daily Living) task worksheet revealed that staff were documenting that Resident #57 consumed 100% of the supplement, although it was discovered that the resident was not receiving them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 4 of 10 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 01/19/2024 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 Residents Affected - Some 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, it was determined that the approved menu was not being followed that potentially affected 55 facility residents who eat orally, which included 11 of 11 sampled residents reviewed for nutrition (Resident #7, #10, #17, #19, #33, #37, #39, #44, #45, #55, and #63). The findings included: 1) During the review of the approved facility menu for the lunch meal of 01/16/24, the following were noted: * Broccoli Florets (Alternative Lunch Vegetable and to be served to Dysphagia Advanced, Dysphagia Mechanical, and Dysphagia Pureed) * Pureed Vegetable Quiche (Dysphagia Pureed Diet) * Cheese Sauce (2 ounces to be served over Vegetable Quiche (Regular Diet, Dysphagia Pureed) * Snickerdoodle Cookie - 2 ounces- (Regular Diet) Observation of the lunch tray assembly line in the main kitchen on 01/16/24 at 11 AM accompanied with the FSD (Food Service Director) and Corporate FSD noted the following: -Broccoli Florets - not prepared and no alternative was prepared. During interview with the FSD it was revealed that the Broccoli was not delivered in time for the lunch meal service. The FSD was not aware that an alternative vegetable substitute should be documented on the menu and prepared and served. -Pureed Quiche - not prepared in time for the serving of the lunch meal. Interview with FSD at the time of observation, revealed that there was not enough time to prepare the pureed Quiche. -Pureed Snickerdoodle Cookie - not prepared in time for tray line service. Interview with the FSD at the time of observation was not enough time to prepare the pureed snicker doodle cookie. -2 oz Snickerdoodle Cookie - only 3/4-ounce cookie served. -2 oz Cheese Sauce for Mechanical Soft/Pureed - not prepared or served- During an interview at the time of the observation, it was revealed that the FSD was unaware of what menu item the cheese sauce was to be prepared for. During an interview with the Corporate Registered Dietitian on 01/18/24 at 1:30 PM, it was reported that the cheese sauce was to be served over the Vegetable Quiche. 2) During the review of the approved facility menu for the breakfast meal of 01/17/24, it was noted that a 3-ounce portion of Sausage Gravy was to be served to residents for the following diets: Regular Diet, Dysphagia Advanced Diet, Dysphagia Mechanical Diet, and Dysphagia Pureed Diet. Observation of the breakfast meal in the main kitchen on 01/17/24 at 7 AM, accompanied with the FSD and Corporate FSD, noted the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 5 of 10 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 01/19/2024 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 * A 2-ounce portion (ladle) was being served for the above-mentioned diets. Interview with the FSD at the time of the observation revealed that the breakfast cook failed to review the approved breakfast menu, to ensure that portion sizes are followed. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 6 of 10 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 01/19/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1 of 6 sampled residents (Resident #17), selected for nutrition review, received physician ordered thickened liquids (Honey), prepared in a design to meet the individual's needs. The findings included: During the review of the clinical record of Resident #17, the following were noted regarding the resident: Date of admission: re-admission on [DATE] Diagnoses: Dysphagia, Parkinsonism, Hypokalemia, Protein-Calorie Malnutrition Current physician's orders: 09/8/23: Dysphagia Pureed Diet, Honey Thick Liquids - Dysphagia 08/9/23: Magic Cup BID (twice daily) - Nutritional Supplement 01/16/24: Promod Oral Liquid 30 ml BID - Wound Care Weight History: 01/4/24 = 131 # (pounds) 12/4/23 = 139 # 10/4/23 = 146# 07/5/23 = 149 # 06/5/23 = 154# Height = 66 (inches) Body Mass Index (BMI) = 21.2 MDS (Minimum Data Set) assessment: 12/23/23 Section C: BIMS (Brief Interview for Mental Status Score) = 5 (Cognitive Impairment) Section GG: Eating = Extensive Assist Section K: Coughing/Swallowing Difficulty (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 7 of 10 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 01/19/2024 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 Mechanically Altered Diet: Food & Liquids Level of Harm - Minimal harm or potential for actual harm Care Plan Review: 12/27/23 for Nutritional Problem failed to have the following approaches: Residents Affected - Few * Pureed diet * Honey Thick Liquids * Oral Nutritional Supplements * Total Feed by Staff with Meals During the screening of facility residents on 01/16/24 at 10:30 AM, it was noted that Resident #17 had a Styrofoam cup of water, located at the bedside. Further observation noted the Styrofoam cup had the resident room and bed number documented on the cup. Observation noted that the water in the Styrofoam cup was thin and not thickened to Honey Consistency. During observation of facility residents on 01/17/24 at 11:30 AM, it was noted that Resident #17 it was again noted a Styrofoam cup of water located at the bedside. Further observation noted the Styrofoam cup had the resident's room and bed number documented on the cup. Observation noted that the water in the container was thin and not thickened to Honey Consistency. During the observation, the surveyor requested the facility's Corporate Nurse to view the Styrofoam cup at bedside and confirmed that physician ordered honey thickened liquids were not at the bedside. On 01/17/24 at 12:15 PM, an observation of the medication cart was conducted by the surveyor. The observation noted that only Nectar Thick liquids were located on the cart, for use with medication pass. Interview with the Corporate Nurse Consultant at the time of the interview noted that Honey Thick Water is not available for residents, prescribed for physician ordered Honey Thick Liquids. Interview with the Food Service Director on 01/17/24 at 1 PM noted that Honey Thickened Liquids (water, milk, and assorted juices) are not purchased and are not available for residents who are prescribed with physician ordered Honey Thick Liquids. A review of the resident's Diet Census for 01/16/24 noted that there were currently 2 residents which includes Resident #17, with physician ordered Honey Thick Liquids. The Honey Thick Liquids were being ordered for the diagnosis of Dysphagia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 8 of 10 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 01/19/2024 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, for potentially 55 of the facility's 61 residents. The findings included: 1) During the initial kitchen/food service observation tour conducted on 01/16/24 at 8:50 AM, and accompanied with the Food Service Director (FSD), the following were noted: a) Staff A was noted to be washing resident dishware in the facility dish machine. Staff A stated to the surveyor that the dish machine is at a low temperature and sanitizes by Chlorine chemical. The surveyor requested the FSD to test the final rinse chemical level. Following 3 separate Chlorine Strip tests, it was noted that there was presence of chemical in the final rinse water. The surveyor requested that the washing of resident dishware cease until the machine was properly sanitizing and to re-sanitize the washed dishes in the 3-compartment sink. A review of the chemical testing log noted that the level was checked for regulatory compliance of 50 Parts Per Million (PPM), of Chlorine, and noted that the machine passed the Chlorine strip test the morning of 01/16/24. On 01/16/24 at 10:00 AM, the FSD approached the surveyor and submitted a Chlorine test strip for the dish machine, that was dark black/purple in color. The FSD stated to the surveyor that the reason the dish machine failed the chemical test was that the 5-gallon chemical container was empty, and a new container was connected to the dish machine. The surveyor informed the FSD that the chemical test for the dish machine that was submitted indicated too much Chlorine. The surveyor informed the FSD that chemicals were left on the dish surface and were potentially toxic to the residents. The surveyor requested to view a new live testing of the dish machine. Two new chemical test strips again confirmed that there was a toxic level of Chlorine in the final rinse. The surveyor requested that the chemical company be contacted to service the dish machine as soon as possible. On 01/16/24 at 11:15 AM, the representative technician from the chemical company was in the facility to assess the dish machine. The representative stated to the surveyor that the 5-gallon Chlorine chemical container was empty earlier without the staff knowledge. It was further stated that the facility has low water pressure require numerous dish racks need to send through the machine until the regulatory chemical level of 50 PPM is met. A review of the repair slip left by the chemical company technician dated 01/16/24 noted documentation that the dish machine sanitizer was adjusted to 50 PPM and that the water levels in the machine were lower than previously set and had to be adjusted. b) Observation of the Artic Air Reach-in refrigerator #1 noted the following: * One gallon of Italian Dressing was noted to have a stamped manufactures expiration date of 08/30/23. The FSD stated that the dressing is still being utilized for resident meals. The surveyor requested that the dressing be discarded immediately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 9 of 10 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 01/19/2024 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 * Small pan of pineapple pieces was noted to be labeled with a preparation date of 01/07/24 and a use by date of 01/14/24. The FSD stated that the pineapple pieces were beyond the facility's policy of a 'use by date' of 7 days. The surveyor requested that the pineapple pieces be discarded. * The door gasket of the unit was noted to have a large tear of approximately 7 inches. The surveyor stated to the FSD, the gasket is required to be replaced to ensure that temperatures are held at the regulatory requirement of 41 degrees F (Fahrenheit) or below. c) Observation of the dry/canned food storage room noted the following: * One #10 can of Marinara Sauce and one #10 can of Sliced Apples located on storage shelves were both noted to have a large dent. The surveyor requested that the cans be removed from the shelf and discarded. * The floor of the storage room was noted to be heavily soiled, stained and had areas of dried food matter. 2) Observation of the main kitchen and lunch tray assembly line on 01/16/24 at 11:30 AM noted that hot foods were not being held at the regulatory temperature of a minimum of 135 degrees F. A test of the hot food temperatures utilizing the facility's digital food thermometer noted the following: Vegetable Quiche - left out at room temp (8 servings) = 120 degrees F Pork Loin -1/3 loin - left out on cutting board at room temp = 121 degrees F Pork Chunks on assembly line (10 large pieces) = 102 degrees F 3) Observation of the breakfast meal in the Main Kitchen on 01/17/24 at 7:15 AM accompanied with the FSD and Corporate FSD noted the following: *Dish Machine = low chemical level (less than 50 PPM (Chlorine). Interview with the FSD at time of observation revealed the Chemical company technician was notified of the issues for a second time. During an interview with the Chemical technician representative while in the facility on 01/17/24 at 10 AM, revealed that the dish machine water levels had to be readjusted again to ensure 50 PPM (Chlorine). 4) Observation of the tray line in the main kitchen was conducted on 01/18/23 at 11:45 AM. Temperature of foods were taken by staff utilizing the facility's calibrated digital food thermometer. The temperature testing noted that cold foods were not being kept at 41 degrees F or below. Specifically, the pan of pureed marinated green beans was recorded at 54 degrees F. The surveyor informed the Food Service Director that the vegetable was not being held at the required regulatory temperature and should not be served until the vegetable was 41 degrees F or below. A review of the production sheet for the lunch meal noted that 10 residents had physician ordered pureed diets that ordered the pureed marinated green beans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105009 If continuation sheet Page 10 of 10

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Citations

7 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
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.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0923GeneralS&S Dpotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.

FAQ · About this visit

Common questions about this visit

What happened during the January 19, 2024 survey of GOLFCREST NURSING CENTER?

This was a inspection survey of GOLFCREST NURSING CENTER on January 19, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at GOLFCREST NURSING CENTER on January 19, 2024?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·January 19, 2024