Inspection·July 20, 2022

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide a written bed hold notice for a facility-initiated emergency transfer to a hospital for one (#52) of two sampled residents. Findings included: Review of the closed medical record for Resident #52 revealed he was admitted to the facility on [DATE] and discharged to a hospital on 5/12/22. The resident did not return to the facility. There was no written bed hold notice found in the record. During an interview with the facility Director of Nursing (DON) and the Corporate Care Consultant (CCC) on 07/20/22 at 9:53 a.m., The CCC confirmed the notice was not in the closed record and stated she did not know where they were kept but would find out. An interview was conducted with the facility Social Services Director (SSD) on 07/20/22 at 10:27 a.m. She confirmed she had been working in her position at the facility since February 2022. She consulted the closed Electronic Medical Record (EMR) Resident #52 and confirmed there was no written bed hold notice there. She confirmed she knew the notice was required to be provided for any discharge or transfer to a hospital and said, the form has to be done at that time, so nursing does it. She stated she would search for the notice for Resident #52. She confirmed Resident #52 had been his own responsible party. At 1:17 p.m. on 07/20/22 the CCC followed up and confirmed there was no written bed hold notice for Resident #52's transfer to a hospital on 5/12/22. She confirmed it had not been found and therefore had not been done. Regarding the facility process/expectation she said when a resident was transferred to a hospital, nursing is responsible to give a copy of bed hold form to resident & communicate that to family. She stated the facility process for ensuring notices were provided for hospital transfers broke for whatever reason .the DON [former] thought it was being handled by Social Services and off of nursing's plate . I've got education scheduled for tomorrow on this with the nursing staff. Review of facility policy titled, Facility Bedhold revised 11/12/18 revealed, The Facility will notify the resident/responsible party of the facility's bed hold and re-admission policies at admission and anytime a resident is transferred to the hospital .the facility will provide written notice of the bed hold and re-admission policies: . Before a resident's transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 2 of 9 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 07/20/2022 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 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 observations, interviews, and record review, the facility failed to ensure respiratory care including oxygen therapy and nebulizer treatment was provided in accordance with professional standards of practice including storage, dispensing, and maintaining infection control measures for three (Residents #2, #19, #43) of three sampled residents: 1. Resident #19 was receiving oxygen therapy at a setting not in accordance with physician order, 2. Resident #2 was receiving oxygen therapy without physician orders and her nebulizer delivery equipment was improperly stored, 3. Resident #43's nebulizer delivery equipment was improperly stored. Residents Affected - Few Findings included: 1. Observation was conducted 07/18/22 at 8:20 a.m. in Resident #19's room. She was in bed and was connected by nasal cannula and tubing to an oxygen concentrator at the bedside. The concentrator was on and running and the setting was at 3 liters. Observation conducted on 7/18/22 at 11:45 a.m., revealed the resident was still connected to oxygen and the setting was at 3 liters. An observation was conducted on 7/19/22 at 7:50 a.m., Resident #19 was again observed receiving oxygen therapy via nasal cannula connected to a concentrator at the bedside and set at 3 liters. Photographic evidence obtained. Review of the physician orders in Resident #19's Electronic Medical Record (EMR) revealed a physician's order for Oxygen Therapy: Oxygen via NC (nasal cannula) @ (at) 2 Liters per minute Every Shift - PRN. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 07/19/22 at 7:55 a.m. She stated she was employed PRN (as needed) by the facility and usually worked there 2 days per week. She said, I don't know people (residents) on this unit very well. She stated information about whether a resident was receiving oxygen therapy was shared in nurse to nurse reporting and said, usually when we do report they tell me who's on oxygen. Regarding Resident #19, Staff A stated she had not been given a report that the resident was receiving oxygen therapy and did not know what setting was ordered. Staff A observed the concentrator in Resident #19's room during the interview and confirmed that it was set at 3 liters. Afterwards she consulted the physician orders for Resident #19 in the Electronic Medical Record (EMR) and revealed orders were for 2 liters PRN. Regarding why the concentrator was set at 3 liters, Staff A said, I can't say what happened and I wasn't there. Staff A confirmed based on facility procedure and practice standards only a nurse could set or adjust settings for oxygen delivery. She confirmed practice standards were to consult physician orders and follow them. She stated she did not know if oxygen delivery was documented by nursing staff on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). Further review of Resident #19's medical record revealed the MAR for July 2022 had an entry template for oxygen administration but there was no documentation entered that oxygen therapy had been administered for any dates in July. The care plan for Resident #19 revealed a focus area for .requires oxygen due to SOB (shortness of breath) with history of pulmonary hypertension making her at risk for respiratory complications. Care plan interventions included Oxygen as ordered. An interview was conducted with the facility Director of Nursing (DON) and the Corporate Care Consultant (CCC) on 07/19/22 at 4:12 p.m. They consulted the EMR for Resident #19 and confirmed the physician orders revealed 2 liters PRN. The DON confirmed oxygen delivery settings should match what was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 3 of 9 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 07/20/2022 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ordered by the physician. They both confirmed only a nurse could manage and change settings and it was the nurse who was responsible for ensuring proper settings in accordance with physician orders. The CCC stated her expectation would be for a nurse to round on every patient at the start of shift and confirm oxygen delivery and settings were correct. 2. During an interview with Staff A on 07/19/22 at 8:02 a.m., she said Resident #2 was supposed to be receiving oxygen therapy. During the interview, Resident #2 was observed being wheeled out of her room and past the nurse's station by a staff member. She was not connected to any oxygen and there was no portable oxygen delivery tank present. Staff A stated Resident #2 was noncompliant with her oxygen and always wanted to go smoke and stated the reason she did not have portable oxygen was because she was on her way to go smoke. An observation was made in Resident #2's room on 07/19/22 at 8:05 a.m. The resident was not present in the room. An oxygen concentrator was observed at bedside, on and running, and set at 3 liters. The oxygen tubing and nasal cannula were on the floor. A nebulizer mask and tubing was observed on a bedside table. They were not stored in a bag and the mask was on the floor. Photographic evidence obtained. On 07/19/22 at 8:10 a.m., Staff A observed Resident #2's room and confirmed observations of the concentrator set at 3 liters, oxygen tubing and cannula on the floor, and nebulizer tubing and mask improperly stored. She stated the nebulizer mask and tubing should be stored in a bag and dated. She stated she would get a new mask and a new nasal cannula and tubing since both were on the floor. An observation and interview were conducted with Resident #2 in her room on 07/19/22 at 10:37 a.m. She was observed in bed wearing a nasal cannula that was attached to the oxygen concentrator at bedside. The concentrator was set at 3 liters. During the interview a staff member entered the room and the resident asked to be transferred to her wheelchair so she could go outside and smoke. The resident stated she did not wear oxygen when out of her room to go smoke and said, I can be off it for an hour. Regarding portable tank option for out of room activities other than smoking she said, I wish I had one. A review of Resident #2's medical record was conducted. The resident's face sheet revealed an admission diagnosis of chronic obstructive pulmonary disease (COPD) with acute exacerbation. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which meant the resident was not cognitively impaired. Section O of the MDS did not reveal any documentation that the resident was receiving respiratory treatments. There was no physician order for oxygen therapy. Review of the Care plan for Resident #19 revealed a focus area for .impaired oxygen gas exchange related to COPD and has a continuous oxygen requirement. Care plan interventions included Oxygen as ordered. An interview was conducted with the DON and CCC on 07/19/22 at 4:01 p.m. The DON consulted Resident #2's EMR and confirmed there was no physician order for oxygen. She said, she just came back last night [from hospital] and obviously it didn't get restarted. She said, the nurse told me she had missed some standing orders today .I thought she would have fixed it by now. Regarding portable oxygen delivery device for out of room activity other than smoking, both confirmed one should be provided due to the resident's need for continuous oxygen support. 3. An observation was conducted on 07/19/22 at 7:49 a.m. in Resident #43's room. The resident was in bed being assisted with breakfast by Staff B, Certified Nursing Assistant (CNA). A nebulizer mask (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 4 of 9 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 07/20/2022 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 0695 and tubing were observed on a bedside table not stored in a bag. Photographic evidence obtained. Level of Harm - Minimal harm or potential for actual harm Review of the MAR for Resident #43 revealed nebulizer treatment was ordered every 4 hours and was documented administered as ordered on 7/19/22 at 2:00 a.m. and 6:00 a.m. Residents Affected - Few On 07/19/22 at 8:10 a.m. Staff A observed Resident #43's room and confirmed the nebulizer tubing and mask were not properly stored. She stated they should be dated and stored in a bag. An interview was conducted on 07/19/22 at 3:47 p.m. with the DON and CCC expectations for nebulizer tubing and mask storage. They confirmed both should be labeled and dated, changed weekly, and stored in a bag at the bedside when not in use. Review of facility policy titled Oxygen Administration - Nasal Cannula Clinical Practice Guideline reviewed 10/23/20 revealed: Oxygen therapy via nasal cannula is administered as ordered by a physician and includes correct flow rate, mode of delivery, and frequency. Check the resident's medical record to confirm the presence of a complete and appropriate physician's order. An interview was conducted with the CCC on 07/20/22 at 3:17 p.m. She confirmed the facility did not have a written policy for respiratory equipment storage at the bedside and said that labeling and storing equipment including tubing and masks in a bag was simply the facility's standard of practice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 5 of 9 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 07/20/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility did not ensure the medication error rate was below 5 % for one (# 23) of three sampled residents who were administered medications. This resulted in 5 errors from 26 medication administration opportunities for a medication error rate of 19.23%. Residents Affected - Some Findings Included: On 07/18/22 at 8:58 a.m., the medication administration task was conducted alongside Staff A, Licensed Practical Nurse. She prepared and administered the following medications to Resident #23: Acetaminophen 500 mg one tablet, Amlodipine 10 mg two tablets, aspirin 81 mg delayed release one tablet, Vitamin D 25 mcg one tablet, Carvedilol 25 mg one tablet, Januvia 1000 mg one tablet, Rivastigmine 1.5 mg one tablet, Gabapentin 100 mg one capsule, Tiagabine 2 mg one tablet, Simbrinza eye drops were administered to both eyes. Staff A was observed as she prepared a Levemir U-100- insulin pen by wiping the top off with an alcohol wipe. A needle was attached to top of the pen, and the dosage selector was verified and set to 25 units. Medication reconciliation of current Physician orders revealed the following: Acetaminophen tablet; 500 mg; amount: 1000 mg every 12 hours dated 06/16/2021, Amlodipine tablet; 10 mg; oral once a day, dated 05/16/2021, Cholecalciferol (Vitamin D3) capsule; 125 mcg one a day dated 05/16/2021, and Simbrinza eye drops suspension amt: I drop to left eye dated 06/23/2022. On 7/18/2022 at 1:21 p.m., an interview was conducted with Staff A. She confirmed she had administered one Acetaminophen 500 mg tablet, when two were ordered. The physician order for Amlodipine 10 mg was for one tablet, not two. She confirmed after reviewing the physician order for the Vitamin D, she had not provided the correct dosage. She additionally confirmed the eye drops were administered to both of eyes. The order was for the left eye. Staff A stated the only time you prime an insulin pen is when its first opened. I was never taught to prime the pen with insulin every time. On 07/18/22 1:36 p.m., an interview was conducted with the facility's Corporate Nurse. She said medications were to be administered as ordered. She confirmed insulin pens should be prepped prior to selecting the dosage. Review of the facility policy titled Medication Administration Subcutaneous Insulin dated 05/16. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: removing air bubbles. D. hold the pen with the needle pointing upwards E. Tap the insulin reservoir so that any air bubbles rise up towards the needle. F. Press the injection bottom all the way in. Check if insulin comes out of the needle tip. Review of the Medication Administration General Guidelines dated 09/18. Policy Medications are administered as prescribed in accordance with specifications good nursing, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Administration: 9. Verify medication is correct three (3) times before administering the medication. a. when pulling medication from the cart b. When dose is prepared c. Before dose is administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 6 of 9 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 07/20/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on observation of Medication Administration, interview with facility staff, and review of the Plan of Correction, the facility failed to ensure the Plan of Correction provided an assessment of the deficient practice related to not following the facility policy for Medication Administration, and failed to provide adequate training to nurses to ensure residents were correctly administered medications following physicians orders for four (#4, 12, 33, 60) residents of five residents observed during Medication Administration on 09/13/2022. Findings included: During a Survey to revisit the facility's correction of their deficient practice cited during the Recertification Survey (conducted from 07/17/2022 - 07/20/2022), Medication Administration was observed: -On 9/13/22 at 9:22 a.m. the medication administration task was conducted with Staff I, Licensed Practical Nurse (LPN.) She prepared to give the following medications for Resident #60. Buspirone HCL 10 mg (milligrams) 1 tab, Celecoxib cap 200 mg, Divalproex DR 500 mg 1 capsule (cap), Duloxetine HCL DR 60mg 1 cap, Eliquis 5mg tab, Entresto 24-26 mg 1 tab, Metformin 500mg 1 tab, Budesonide-Formoterol (Symbicort) 160-4.5 inhaler 2 puffs, and Tamsulosin cap 0.4mg 1 cap. The nurse was unable to find Eliquis in the medication cart. She stated, I know I can't share someone else's. She did not attempt to locate the residents Eliquis elsewhere. She proceed to administer the remaining medications. After the resident was given his Symbicort inhaler, the LPN did not have the resident rinse his mouth out as required. A medication reconciliation with current orders indicated the following order: -Eliquis 5mg 1 tablet twice a day at 9:00 a.m. and 5 p.m. The start date of the order was 8/30/22. A review of the electronic medication record did not reveal any progress notes to indicate a physician was contacted about Resident #60 not receiving the ordered dose of Eliquis. -On 9/13/22 at 10:05 a.m. Staff I, LPN prepared to give Resident #12 her ordered insulin. The Lantus insulin was administered to the resident at 10:10 a.m. A reconciliation of current physician orders indicated Lantus u-100 Insulin solution; 100 unit/milliliter(ml); 12 units subcutaneously was ordered to be administered at 9:00 a.m. -On 9/12/22 at 10:55 a.m. Staff I, LPN prepared the following medications for Resident #4: Keppra 100mg/ml (milliliters) 7.5ml, Pregabalin cap 50mg 1 cap, Magnesium Oxide 400mg 1 tab, Omeprazole DR 40mg 1 cap, Oxcarbazepine 150mg 1 tab, Paliperidone ER 3mg 1 tab, Senna plus 1 tab, Tramadol-acetaminophen 37.5-325mg 1 tab. The computer screen highlighted seven out of eight of the medications as late. Staff I was observed pouring the Keppra 7.5 ml into a medication cup. The LPN poured out too much medication. She then proceeded to pour the medication back into the original medication bottle. A medication reconciliation with current physician orders indicated the following orders: Keppra 100mg/ml 7.5ml twice a day at 9:00 a.m. and 9:00 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 7 of 9 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 07/20/2022 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 0867 Pregabalin 50mg three times a day at 9:00 a.m., 1:00 p.m., and 5:00 p.m. Level of Harm - Minimal harm or potential for actual harm Magnesium Oxide 400 mg every 12 hours at 9:00 a.m. and 9:00 p.m. Omeprazole DR 40mg at 9:00 a.m. Residents Affected - Few Oxcarbazepine 150mg every 12 hours at 9:00 a.m. and 9:00 p.m. Paliperidone Extended Release 24 hours 3 mg at 9:00 a.m. Senna 8.6 mg every 12 hours at 9:00 a.m. and 9:00 p.m. These seven medications were given 1 hour and 55 minutes past their ordered administration time. -At 12:27 p.m. Resident #4's electronic medical record was reviewed. The eMAR indicated the resident had already been administered their 1:00 p.m. does of Pregabalin. Therefore, the resident was given Pregabalin at 10:55 a.m. and prior to 12:27 p.m., less than 1 ½ hours separating the two doses instead of the ordered 4 hours. A review of progress notes did not indicate there had been any contact with the physician regarding the late medications. -On 9/13/22 at 10:55 a.m. Staff I, LPN properly prepared an insulin pen for administration to Resident #33. Staff I entered the resident's room, and the resident was sleeping. The LPN did not speak to the resident or attempt to wake her, she administered the insulin to the resident while she was sleeping. A medication reconciliation with current physician orders revealed an order for Levemir u-100 Insulin 100 unit/ml; 15 units once a day at 9:00 a.m. -An interview was conducted on 9/13/22 at 2:30 p.m. with Staff I, LPN. The LPN confirmed Resident #60 did not receive his 9:00 a.m. Eliquis. When asked if she could have gotten the medication somewhere else since it was not in the cart she stated, oh I guess I could have gotten from the E-kit. I didn't think of that (referring to the emergency drug kit.). Staff I confirmed medications are to be given up to one hour prior to the scheduled time or one hour after the scheduled time. She stated if the nurse is late, they should click administered late in the computer then depending on the medication the nurse should clarify with the doctor the timing of the next dose. She stated she did not call the doctor about the Eliquis or the late medications this morning. When discussing pouring out too much Keppra into the medication cup, she stated she should have gotten a new cup and disposed of the extra medication. She said she should never pour it back in the original bottle. Review of the Facility's Policy entitled Quality Assurance/Performance Improvement (QAPI) Program revealed a Purpose Statement: To provide a process that will enhance the care and experience for all residents, improve the work environment for stakeholders, and quality of all services provided by the facility. The Policy Statement read: It is the intent of this facility to conduct an on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, evaluate and improve the quality and appropriateness of resident care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 8 of 9 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 07/20/2022 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Under the heading of Guidelines, point # 6 read: The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those processes that significantly affect resident outcomes. Point #7 read: The QAPI committee will review, and coordinate audits and assessments based on the QAPI calendar. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. Criteria for selecting additional aspects of care for performance improvement are based on the following: c. High risk - residents are at risk of serious consequences or deprived of substantial benefits if the care is not provided correctly and in a timely fashion or on proper indication. A review of the facility's Plan of Correction for the deficient practice observed during the Recertification Survey and cited at F759, revealed the immediate correction of the wrong dosing of medications to the resident was documented with a medication error report and education to the nurse. To address the larger concern, all nurses were educated with observations conducted of the nurses during medication administration and review of the observations at the monthly QAPI meetings. A review of the QAPI meeting held on 08/24/2022 revealed the Plan of Correction was reviewed at the meeting with no status documented. The Quality Assurance interview was conducted with the Administrator, the Director of Nurses and the Regional Nurse on 09/13/2022 beginning at 4:25 p.m. during which the quality assurance review and monitoring of the corrections to the deficient practice cited was discussed. It was reported by the facility team that on 08/24/2022 a QAPI meeting was held and the correction plans for the Annual Survey were not altered and continued as planned. In an interview conducted with the Director of Nurses (DON) on 09/13/2022 beginning at 2:55 p.m., when apprised of the errors observed during the Medication Administration observation conducted beginning at 9:22a.m., the DON confirmed that she had noted the nurse was a new nurse that needed some additional training. The DON stated, I knew when I saw you with [Staff I] it could be a problem. During the QAPI meeting that began at 4:25 p.m., the DON confirmed that she had noted the nurse needed additional training but had not developed an action plan for the nurse or had paired her to work with another nurse to help improve her skills. The DON confirmed she had not observed the nurse during Medication Administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 9 of 9