Inspection·March 26, 2021

F 0755 The administration schedule indicated 07:00-11:00, 11:15-15:00, 19:00-23:00 Level of Harm - Minimal harm or potential for actual harm 4. On 03/25/2021 at 10:30 a.m., the Assistant Director of Nursing (ADON) was interviewed. She stated with regular routine medications the exact time of administration did not get recorded. If the medication is administered within the scheduled time of administration, the MAR would only indicate that the medication was administered. The ADON stated if the medication was scheduled for 7:00 a.m.-11:00 a.m., the medication was administered within the four hour time window. Residents Affected - Few 5. On 03/25/21 at 10:35 a.m., a telephone interview was conducted with the facility's Pharmacy Consultant. The consultant stated the administration schedules or the four hour window of administration time was a company wide policy. The consultant stated the four hour window of administration was Suppose to help medications from being given late. 6. On 03/25/2021 at 11:22 a.m., the facility policy and procedure, Medication Administration General Guidelines dated 9/18, was reviewed with the Director of Nursing (DON). Item #14 on the policy and procedure was discussed and clarified with the DON. Item #14 indicated, Medications are administered within 60 minutes of scheduled time, except before and after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to established medication administration schedule for the nursing care center . The DON stated the company policy was liberal med pass. The DON stated if the medication scheduled time is 7:00 to 11:00, per the policy, medications can be administered 60 minutes before 7 and 60 minutes after 11, which meant medications administered at 6:00 or 6:30 a.m. or 11:30 - 12:00 a.m. are acceptable if the scheduled administration time is 07:00-11:00. The policy extends the administration time to six hours. The DON stated there was no other company policy and procedure in effect at the time of the survey for medication administration 7. On 03/25/21 at 1:15 p.m., the attending physician for Resident #14 and Resident #33 was interviewed. The facility policy and procedure, Medication Administration General Guidelines dated 9/18, was reviewed with the physician. The physician's orders of Resident #14 and Resident #33 were also reviewed with him. He stated the medication administration time of four hours that is extended to six hours by the policy is Too long of a window. The MD stated, We need to look into that in QA (quality assurance). He stated, When I order twice a day, my expectation is morning and evening with at least 8-12 hours in between doses. The MD stated the administration times are now overlapping for the tiagabine three times a day for Resident #33. He stated, There is the potential for toxicity (because of the medication administration windows) especially with the residents here who have slower GFR (glomerular filtration rate - kidney filtration) and liver metabolism. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 2 of 3 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 105409 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/26/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golfview Nursing Center 3636 10th Ave N Saint Petersburg, FL 33713 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure one (Resident #32), out of five sampled residents, was free from a significant medication error when glipizide (an anti-diabetic medication) was administered after it had been discontinued by the physician. Residents Affected - Few Findings: On 3/24/2021 at 9 a.m., a medication pass observation was conducted with Staff B, Registered Nurse (RN). Staff B was observed preparing and administering medications for Resident #32. Included in the medications prepared and administered by Staff B was a tablet of Glipizide 5 mg (milligrams) XL (extended release). On 3/24/2021 at 11 a.m., Resident # 32's physician's orders and medication administration record were reviewed. The records indicated: - glipizide tablet extended release 24 hr; 2.5 mg; Amount to Administer 2.5 mg oral. Start/End date 2/25/2021 - 3/10/2021 (DC Date). - glipizide tablet extended release 24 hr; 5 mg; Amount to Administer: 1 tab; oral. Start/End Date 11/10/2020 - 3/04/021 (DC Date) On 3/24/2021 at 11:17 a.m., Resident #32's records were reviewed with Staff B and the RN Consultant. Both stated glipizide should not have been administered because it had been discontinued. On 3/25/2021 at 10:53 a.m., a telephone interview was conducted with the facility's pharmacy consultant. The consultant stated, Glipizide, if was already discontinued and administered, is a significant medication error. Review of the facility policy and procedure, Medication Administration General Guidelines dated 09/18, indicated Medications are administered in accordance with written orders of the prescriber. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 3 of 3