Inspection·May 16, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included: proper storage and labeling in the upright freezer, proper cleanliness and temperature of the walk-in cooler, and proper cleanliness and labeling of one (Station #2) of two nourishment refrigerators. This had the potential to affect 47 residents receiving food service from the kitchen. The findings included: On 05/14/24 at approximately 09:00 AM, an initial tour of the kitchen revealed the upright freezer had several open bags of vegetables in the freezer door with no date. One of the bags was observed to be punctured. Additional bags of frozen food items were also undated on the shelves. Interview at the time of observation with the Dietary Manager revealed it was difficult to place dates on packages because the stickers come off and marker does not adhere to cold wet bags. Observation of the walk-in cooler revealed a liquid puddle was present on the floor next to a crate containing bags of onions. When the crate was moved, liquid and food debris were observed under the crate and storage shelves Interview at the time of observation with the Dietary Manager revealed she was unaware of the area prior to the observation. She stated she would clean it and have maintenance check for the source. Observation on 05/14/24 at 5:32 PM revealed the walk in cooler still contained liquid and debris on the floor where the crate was observed approximately 8 hours earlier. The Dietary Manager confirmed she had not cleaned the area observed during the initial tour. Observation of the thermometer in the walk-in cooler revealed the temperature was 52 degrees Fahrenheit. On 05/15/24 at 10:40 AM, the walk-in cooler was observed with a thermometer reading of 36 degrees Fahrenheit. Interview with the contracted Registered Dietitian present during the observation revealed all food was inspected and thrown away if there was a potential safety issue to include all eggs and dairy products. Observation of the contents of the walk in cooler revealed the bulk of items was fresh produce. The food debris from the previous day had been removed. 05/16/24 at 09:00 AM, observation of Station #2's nourishment refrigerator revealed a take-out container dated 5/12/24 with a resident's last name. A covered bowl of mashed potatoes and gravy with no date or name. The freezer contained frost and an open frozen bottle of soda. Food debris in both the refrigerator and freezer was observed. On 05/16/24 at 09:50 AM, the Dietary Manager reported the nurses were responsible for cleaning of nourishment room refrigerators, and the Director of Nursing reported this was dietary's responsibility. On 05/16/24 at 10:12 AM , a telephone interview with the contracted Registered Dietician revealed there was no facility policy specific to cleaning of nourishment refrigerators. The Registered Dietitian reported this would fall under the Dietary/Kitchen Policy for maintenance and cleaning of dietary equipment. She stated a separate policy was not needed and this task would be added to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 2 of 4 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 05/16/2024 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 0812 cleaning schedule. Level of Harm - Minimal harm or potential for actual harm Photographic evidence was obtained. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 3 of 4 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 05/16/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview, record review, and facility policy review, the facility failed to maintain complete medical records for 24 current residents out of a total resident census of 47. Residents Affected - Many The findings included: On 5/14/24 at 3:00 PM, a beneficiary notice was requested for Resident # 21. On 5/15/24 at 10:07 AM, the Interim Nursing Home Administrator (NHA) stated the facility could not provide Resident #21's beneficiary notice because the facility did not have access to the resident's full medical record. The Interim NHA stated the facility did not have access to the previous electronic medical record system used by the facility, which is where this document would be held. On 5/15/24 at 5:27 PM, the Medical Records Director (MRD) stated the facility began using a new electronic medical record system in May 2023. The MRD stated the facility did not have access to any residents' medical records prior to 4/31/2023. A review of the current census revealed 24 of 47 current residents were admitted to the facility prior to 4/31/2023. A review of the facility's undated policy titled Administration-Record Retention revealed medical records will be retained for a period of 7 years from the date of discharge or period outlined by payer contracts, whichever is longer. A review of the facility's undated policy titled Administration-Medical Records revealed the facility will retain medical records in accordance with State and Federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 4 of 4