Inspection·March 17, 2025

F 0609 chronic pain syndrome. Level of Harm - Minimal harm or potential for actual harm Review of Resident #1's care plan revised on 3/1/25, showed, Focus- The resident has self-neglect behaviors related to refusing care. Refusing ADL care. The goal showed, The resident will have no evidence of behavioral concerns (Racist Comments) by review date. Interventions included: Anticipate and meet the residents' needs, explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to change, If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Residents Affected - Few Review of the reportable log with the Nursing Home Administrator (NHA) dated 03/01/25 showed the facility reported an allegation of abuse between Resident #1 and Staff D, CNA on 03/01/25 at 4:30 p.m. The reportable showed the date and time the staff became aware of the allegation of abuse was on 03/01/25 at 10:30 a.m. An interview was attempted with Resident #1 on 03/17/25 at 10:30 a.m. Resident #1 stated she could not recall any incidents that occurred on 03/01/25. An interview was conducted on 03/17/25 at 10:42 a.m. with Resident #1's roommate who stated there was an incident that occurred between Resident #1 and Staff D, CNA, but she did not see anything because the curtain was pulled. This resident stated she was in the room at the time of the incident, and heard Staff D, CNA yelling for help and telling Resident #1, don't hit me. During an interview on 03/17/25 at 10:26 a.m. Staff B, CNA confirmed she was present during the day of the incident and heard Staff D, CNA screaming out for help. Staff B, CNA stated she ran down the hall to find where the yelling was coming from. She stated by the time she discovered where the yelling was coming from, she opened Resident #1's door and saw Staff D, CNA, standing at the foot of Resident #1's bed. During an interview on 03/17/25 at 3:02 p.m. Staff F, Registered Nurse (RN) stated on 03/01/25, Staff D, CNA came to her about 10:30 a.m. and stated Resident #1 was combative and had grabbed her and hit her. Staff F, RN stated she went directly to Resident #1 and completed assessments, notified the doctor and the family immediately. Staff F, RN stated she advised Staff D, CNA to write out a witness statement. Staff F, RN stated she notified the weekend nurse supervisor, Staff H, LPN about the incident. During an interview on 03/17/25 at 3:20 p.m. Staff H, License Practical Nurse (LPN)/Weekend Nursing Supervisor (WNS) stated she was notified by Staff F, RN Resident #1 had received a skin tear during care the morning of 03/01/25. Staff H, LPN stated sometimes skin tears do happen with care and didn't think anything of it. Staff H, LPN, stated later in the afternoon she interviewed Resident #1 and staff about how Resident #1 got the skin tears. Staff H, LPN, stated Resident #1 stated Staff D, CNA had grabbed my hands tightly during care and caused the skin tears. Staff H, LPN stated Resident #1 had two skin tears on her hand and then third skin tear on her forearm. Staff H, LPN stated once Resident #1 alleged abuse, she started the abuse reporting process. Staff H, LPN stated the abuse allegation was not reported immediately because she was not told details of the abuse allegation and had not investigated herself. During an interview on 03/17/25 at 3:30 p.m. the Director of Nursing (DON) stated she received a call on 03/01/25 around 2:30 p.m. and was informed Resident #1 had skin tears on her hand and arm. The DON stated she immediately called Staff H, LPN and told her to go interview Resident #1 and get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 2 of 11 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 03/17/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few witness statements. The DON stated that she would have been expected to have been notified about the incident when it occurred around 10:30 a.m. on 03/01/25 and not four hours later. An interview was conducted on 03/17/25 at 1:30 p.m. with the NHA. The NHA stated the DON reported the incident to her around 2:30 p.m. on 03/01/25, stating Resident #1 had skin tears and that a CNA had reported Resident #1 was combative with the staff. The NHA stated Staff H, LPN assessed the resident and found Resident #1 had skin tears on her hand. She stated Staff D, CNA was suspended pending investigation and the police and DCF (Department of Children and Services) were notified. The NHA stated Staff D, CNA's witness statement showed Resident #1 had grabbed the CNA and was hitting her. The NHA stated her findings did not find where Staff D, CNA intentionally set out to hurt Resident #1 as she was trying to get away from Resident #1 who was hitting her. The NHA stated the incident occurred on 03/01/25 at 10:30 a.m. and was not reported until 03/01/25 at 4:30 p.m. because she was not informed of the abuse allegation until a little after 2:00 p.m. The NHA stated Staff should have notified the DON and her earlier when the incident occurred. The NHA confirmed the allegation of abuse was reported 4 hours after the incident. Review of the facility's abuse education and in-service training showed the following in-service dated 02/13/25, Presenter: The Director of Nursing (DON) , Topic: Abuse, Neglect and Exploitation/Theft - It is the policy of the center that each resident has the right to be free from verbal, sexual, physical and mental abuse; corporal punishment; involuntary seclusion; mistreatment of any kind, exploitation and misappropriation of property. In addition, each resident will also be protected from those practices and omissions, which left unchecked, could lead to abuse. Further, each resident will be always treated with respect and dignity. The Center will foster an environment that recognizes the worth and uniqueness of all individuals with regards to person-centered care and to promote respect and set standards of care, Residents will not be subject to abuse by anyone, including but not limited to Center staff, other residents, consultants, volunteer staff, contract staff, family members, friends and others. 1: Definitions of abuse 2: Types of Abuse 3: If abuse witnessed or expressed report to abuse coordinator immediately. 4: Facility has a 2 our window to report the allegation 5: If abuse is reported all staff must complete a witness statement 6: Resident to Resident altercation also falls under guidelines 7: Ensure that the affected and all surroundings' residents are safe 8: Theft- definition 9: Misappropriation- definition 10: For any risk, please contact DON. Review of the facility's policy Prevention of Resident Abuse, Neglect, Mistreatment or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 3 of 11 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 03/17/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm Misappropriation of Property dated 08/22/22 showed Reporting/Documentation Requirements: If the event that causes the allegation involve abuse or results in serious bodily injury, the event must be reported immediately, but no later than 2 hours after the allegation is made. Upon suspecting abuse, neglect or exploitation of a resident, the following procedure is to be followed: Residents Affected - Few 1. Immediately notify: a. Administrator b. Director of Nursing c. FL Only- Florida Abuse Hotline 1-800-96-ABUSE d. Center Risk Manager FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 4 of 11 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 03/17/2025 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 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a safe and orderly discharge from the facility for one resident (#2) of two residents reviewed for transfer and discharge rights. Residents Affected - Few Findings included: Review of Resident #2's admission Care Plan dated 12/04/24 showed the following focus and intervention areas, Resident #2, wishes to return back into the community when medically cleared. The goal showed, The resident will be able to verbalize/communicate required assistance post-discharge and services required to meet the needs before discharge. Interventions included to establish a pre-discharge plan with the resident/resident's representative/caregivers and evaluate progress and revise the plan frequently, and to evaluate the resident's motivation to return to the community. Review of Resident #2's medical record revealed the resident's discharge plan was not evaluated and her wish to return to the community when medically cleared was not honored. Resident #2's involuntary hospital transfer was rescinded on 12/13/24 and the facility did not document any attempts to ensure a safe and orderly transfer. Resident #2 remained in the hospital awaiting an appropriate discharge location for an additional 17 days. Review of record showed Resident #2's bed hold agreement was not honored and there was no documentation related to the cause. Review of a social services progress note dated 12/10/2024 showed, Spoke with the patient's [family member] regarding discharge planning. The family member stated the patient will discharge home with [them]. The family member was also educated on safe discharges, all questions and concerns were answered. Review of Resident #2's admission Record showed an admission date of 12/04/2024 with diagnoses included but not limited to, Post Traumatic Stress Disorder (PTSD), Conversion disorder (a mental health condition where psychological distress manifests aa physical symptoms that cannot be explained by a medical condition) with seizures or convulsions, Depression, Schizophrenia, Anxiety, Bipolar disorder, Insomnia, Altered mental status unspecified, Contusion to left eyelid and periocular area and Encounter for general psychiatric examination requested by authority. Review of a Bed-Hold Agreement for Resident #2 dated 12/24/24 showed, I [family member name], the representative of [Resident #2] hereby request that the facility hold his/her bed space while he/she is absent from the facility. I understand that I will be responsible for payment of the basic per diem rate. I understand the basic per diem rate is $261 per day, for maximum number of 8 days. The agreement signed by Staff F, RN showed wants bed hold per [family member]. Further review of Resident #2's record did not show documentation rescinding the agreement. Review of the Nursing Home Transfer and Discharge Notice for Resident #2 dated 12/12/24 revealed an incomplete document without signatures from the resident, resident representative and physician. The only signature was for Staff F, RN, signing on behalf of the NHA/designee, revealing Your needs cannot be met at this facility. The brief explanation showed , [involuntary hospitalization]. Review of Resident #2's Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 12/03/2024 initiated at a local hospital showed Resident #2 had a psychiatric evaluation completed on 11/14/2024 after status post an involuntary hospitalization for worsening (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 5 of 11 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 03/17/2025 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 0624 Level of Harm - Minimal harm or potential for actual harm agitation and behavioral outbursts. The review showed on 12/03/2024, Resident was deemed not necessary for the need for acute inpatient psychiatric care and recommendations were made for rehabilitative services of a lesser intensity than specialized services added to the patient's Comprehensive Person-Centered Nursing Care Plan to include: psychiatric medication management, individual therapy if cognition permits and supportive counseling. Residents Affected - Few Review of Resident #2's physician order review report dated 3/17/25 showed orders for psychiatry and psychology services as needed, effective 12/06/24. Review of a minimum data set (MDS) for Resident #2 dated 12/12/24 showed the resident was unable to complete a Brief Interview for Mental Status (BIMS) assessment. The mental assessment revealed the resident had a memory problem and was moderately impaired - decisions poor, cues and supervision required. Review of an Occupational Therapy evaluation and plan of treatment note, certified period 12/6/24 -1/3/25 showed, transition/discharge plan was for patient to return to ALF (Assisted Living Facility). Under reason for therapy, the assessment summary showed a goal to, . facilitate independence with ADLs (activities of daily living) in order to facilitate ability to live in an environment with least amount of supervision and assistance, be able to return to prior level of living, facilitate follow- through with techniques and strategies and facilitate safe transition to next level of care. Under complexities, barriers likely to impact discharge to next level showed, None noted. Review of Resident #2's psychiatric evaluation note dated 12/10/2024 showed the following: Patient is a [AGE] year-old female with history of schizoaffective disorder bipolar type, anxiety, borderline personality disorder, and PTSD being seen by psychiatry for initial psychiatric evaluation. She was recently admitted to the hospital for altered mental status with change in behavior, throwing herself on the floor and banging her head with aggressive behavior. She was placed under an involuntary hospitalization. She was treated for acute psychosis and once stabilized was admitted to [name of facility] nursing center on 12/04/2024 for continuance of care. During evaluation, patient was pleasant and cooperative throughout the interview.She denies any current suicidal or homicidal ideation, plan, or intent . Patient's nurse reports that she has been compliant with her medications this morning thus far and staff has not observed her with any psychotic features including hallucinations, delusions, self-dialogue, and paranoia. Review of Resident #2's Medication Administration Record (MAR) for the month of December 2024 showed the resident was compliant with her medication with no entries for the resident refusing her medications. On 3/17/2025 at 2:05 p.m., a telephone interview was conducted with Staff L, Case Manager at the local hospital where Resident #2 was admitted . Staff L stated Resident #2 was admitted on [DATE] through the emergency department secondary to an involuntary hospitalization initiated by the facility. Staff L read from the resident's medical record and stated, the resident was seen by the emergency department physician and noted with no behaviors. Staff L stated the resident was seen by psychiatry services via telehealth on 12/13/2024 at 9:46 a.m. and deemed okay to return to the facility. Staff L stated the involuntary hospitalization was rescinded. Staff L stated while in the emergency department, the resident was noted with no behavior issues. Staff L stated, according to the resident's hospital medical record, a call was placed to the facility's administrator on 12/13/2024 at 10:00 a.m. informing her the involuntary hospitalization was rescinded, and the resident was good to discharge back to her facility. Staff L reading the medical records stated, the NHA stated the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 6 of 11 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 03/17/2025 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 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not welcomed back after assaulting her nurse and throwing furniture. Staff L stated there were numerous attempts to contact the facility but return calls were never received. Staff L stated Resident #2 was eventually discharged to another local long term nursing home facility on 12/30/2024. On 3/17/2025 at 5:20 p.m., an interview was conducted with Staff E, RN. Staff E, RN stated she had a resident currently with aggressive behaviors and was assigned 1:1 supervision. Staff E, RN stated this other resident was aggressive towards staff and would wander into other residents' rooms. Staff E confirmed the facility had other residents with aggressive behaviors, including refusing Haldol injections and were not placed under involuntary hospitalizations. Staff E stated residents with such behaviors are placed on 1:1 supervision and are followed closely by psych. Review of Resident #2's psychiatric evaluation note dated 12/11/2024 showed the following, [Resident #2 said I feel sad and anxious, I do not know why. I want to get out of here and live with my [family member] Under patients strengths, the assessment showed, can benefit from structured care. Review of Resident #2's psychiatric evaluation note dated 12/11/2024 signed at 8:48 a.m. by the psychiatric provider showed a treatment plan with recommendations as follows: 5. Nursing staff is to monitor patient for changes in mood and behavior and contact psychiatry if patient begins to exhibit any signs of depression, anxiety, or behaviors. Nursing staff was advised to continue to document behaviors appropriately. 6. Case was discussed today with nursing staff who will assist with implementing the plan of care. 7. Goals of treatment include: remission of psychiatry symptoms and behavioral disturbances using lowest effective dose of medication, minimizing SE (side effects) and promptly detecting and addressing any psychotropic medication complications. 8. Gradual dose reduction is not recommended at this time as patient's baseline behavior is still being determined and she is noted with agitation and breakthrough symptoms. Gradual dose reduction is likely to cause a decompensation in patient's mental status. 9. Follow -up in 1 to 2 weeks or sooner if needed. On 3/17/2025 at 1:28 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated in general the AHCA (Agency for Health Care Administration) transfer form is provided to a resident or the family/POA (power of attorney). She stated if they are not present, they obtain consent via phone. She stated if they were to discharge a resident, a 30 - day discharge notice is issued. The NHA stated, we have all parties sign discharge paperwork usually for those that are getting discharged , including transfer to hospital. The NHA stated if a bed was available they would return to whatever bed is available. She stated they try to pack up their belongings and try to keep in touch with the hospital and hopefully the resident can go back to the same bed upon returning. Review of an undated facility policy and procedure titled, Admission, Transfer and Discharge - Notice requirements before Transfer/Discharge showed an intent statement: It is the policy of the facility to notify the resident and or their legal guardian of the transfer and or discharge before the transfer or discharge occurs in accordance with state and Federal regulations. The procedure showed: 2. The facility will provide sufficient preparation and orientation to residents to ensure safe and orderly transfer and or discharge from the facility. 3. If the information in the notice changes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 7 of 11 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 03/17/2025 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 0624 prior to effecting the transfer or discharge, the facility will update the recipients of the notice as soon as practicable once the updated information becomes available. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 8 of 11 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 03/17/2025 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit readmission from the hospital for one resident (#2) of two residents reviewed for transfer and discharge rights. Findings included: Review of the facility's policy and procedure titled, Admission, Transfer and Discharge- Transfer and Discharge Requirements showed an intent statement: It is the policy of the facility to ensure residents are treated equally regarding transfer, discharge, and the provision of services, regardless of their payment source in accordance with state and federal regulations. On 3/17/2025 at 2:05 p.m., a telephone interview was conducted with Staff L, Case Manager at the local hospital where Resident #2 was admitted . Staff L stated Resident #2 was admitted on [DATE] through the emergency department secondary to an involuntary hospitalization initiated by the facility. Staff L read from the resident's medical record and stated, the resident was seen by the emergency department physician and noted with no behaviors. Staff L stated the resident was seen by psychiatry services via telehealth on 12/13/2024 at 9:46 a.m. and deemed okay to return to the facility. Staff L stated the involuntary hospitalization was rescinded. Staff L stated while in the emergency department, the resident was noted with no behavior issues. Staff L stated, according to the resident's hospital medical record, a call was placed to the facility's administrator on 12/13/2024 at 10:00 a.m. informing her the involuntary hospitalization was rescinded, and the resident was good to discharge back to her facility. Staff L reading the medical records stated, the NHA stated the resident was not welcomed back after assaulting her nurse and throwing furniture. Staff L stated there were numerous attempts to contact the facility but return calls were never received. Staff L stated Resident #2 was eventually discharged to another local long term nursing home facility on 12/30/2024. Review of Resident #2's admission Record showed an admission date of 12/04/2024 with diagnoses included but not limited to, Post Traumatic Stress Disorder (PTSD), Conversion disorder (a mental health condition where psychological distress manifests as physical symptoms that cannot be explained by a medical condition) with seizures or convulsions, Depression, Schizophrenia, Anxiety, Bipolar disorder, Insomnia, Altered mental status unspecified, Contusion to left eyelid and periocular area and Encounter for general psychiatric examination requested by authority. Review of Resident #2's Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report dated 12/03/2024 initiated at a local hospital showed Resident #2 had a psychiatric evaluation completed on 11/14/2024 after status post an involuntary hospitalization for worsening agitation and behavioral outbursts. The review showed on 12/03/2024, Resident was deemed not necessary for the need for acute inpatient psychiatric care and recommendations were made for rehabilitative services of a lesser intensity than specialized services added to the patient's Comprehensive Person-Centered Nursing Care Plan to include: psychiatric medication management, individual therapy if cognition permits and supportive counseling. Review of Resident #2's physician order review report dated 3/17/25 showed orders for psychiatry and psychology services as needed, effective 12/06/24. Review of a minimum data set (MDS) for Resident #2 dated 12/12/24 showed the resident was unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 9 of 11 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 03/17/2025 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few complete a Brief Interview for Mental Status (BIMS) assessment. The mental assessment revealed the resident had a memory problem and was moderately impaired - decisions poor, cues and supervision required. Review of Resident #2's admission Care Plan dated 12/04/24 showed the following focus and intervention areas, Resident #2 is placed under an involuntary hospitalization. Interventions included allowing the resident to make decisions about treatment regime, to provide a sense of control, educate the resident to voice out feelings of harming self and others/suicidal ideation and encourage as much participation/interaction by the resident as possible during care activities. A second focus in the same care plan showed Resident #2, wishes to return back into the community when medically cleared. The goal showed, The resident will be able to verbalize/communicate required assistance post-discharge and services required to meet the needs before discharge. Interventions included to establish a pre-discharge plan with the resident/resident's representative/caregivers and evaluate progress and revise the plan frequently, and to evaluate the resident's motivation to return to the community. Review of Resident #2's psychiatric evaluation note dated 12/10/2024 showed the following: Patient is a [AGE] year-old female with history of schizoaffective disorder bipolar type, anxiety, borderline personality disorder, and PTSD being seen by psychiatry for initial psychiatric evaluation. She was recently admitted to the hospital for altered mental status with change in behavior, throwing herself on the floor and banging her head with aggressive behavior. She was placed under an involuntary hospitalization. She was treated for acute psychosis and once stabilized was admitted to [name of facility] nursing center on 12/04/2024 for continuance of care. During evaluation, patient was pleasant and cooperative throughout the interview.She denies any current suicidal or homicidal ideation, plan, or intent . Patient's nurse reports that she has been compliant with her medications this morning thus far and staff has not observed her with any psychotic features including hallucinations, delusions, self-dialogue, and paranoia. Review of Resident #2's Medication Administration Record (MAR) for the month of December 2024 showed the resident was compliant with her medication with no entries for the resident refusing her medications. Review of Resident #2's progress note dated 12/12/2024 at 12:47 p.m. by Staff F, Registered Nurse (RN) showed, Resident is physically aggressive towards nursing staff, hit nurse in the back despite giving as needed intramuscular Haldol, which was given at 11:45 a.m. due to resident yelling, I want to get out of here and being agitated and knocked over table on smoking patio, punching walls, and threw a remote control, was not redirectable and is likely to further injure staff and other residents. The involuntary hospitalization was initiated by the psychiatric provider after speaking with the resident on phone/video. Police and emergency medical transport were called, and the resident was taken to a local hospital. Family member agreed to hold bed. Review of the Nursing Home Transfer and Discharge Notice for Resident #2 dated 12/12/24 revealed an incomplete document without signatures from the resident, resident representative and physician. The only signature was for Staff F, RN, signing on behalf of the NHA/designee, revealing Your needs cannot be met in this facility. The brief expanation showed, [involuntary hospitalization]. Review of a Bed-Hold Agreement for Resident #2 dated 12/24/24 showed, I [family member name], the representative of [Resident #2] hereby request that the facility hold his/her bed space while he/she is absent from the facility. I understand that I will be responsible for payment of the basic per diem rate. I understand the basic per diem rate is $261 per day, for maximum number of 8 days. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 10 of 11 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 03/17/2025 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few agreement signed by Staff F, RN showed wants bed hold per [family member]. Further review of Resident #2's record did not show documentation rescinding the agreement. On 3/17/2025 at 5:20 p.m., an interview was conducted with Staff E, RN. Staff E, RN stated she had a resident currently with aggressive behaviors and was assigned 1:1 supervision. Staff E, RN stated this other resident was aggressive towards staff and would wander into other residents' rooms. Staff E confirmed the facility had other residents with aggressive behaviors, including refusing Haldol injections and were not placed under involuntary hospitalizations. Staff E stated residents with such behaviors are placed on 1:1 supervision and are followed closely by psych. On 3/17/2025 at 1:28 p.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated Resident #2 was placed under an involuntary hospitalization on 12/12/2024 for escalating behavior both physically and verbally towards the staff. The NHA stated she received a phone call on the morning of 12/13/2024 from the local hospital stating the resident's involuntary hospitalization had been rescinded and could return to their facility. The NHA stated she had tried to communicate her concern for the resident's short stay at the hospital and wondered how the resident could be better in less than twenty-four hours. The NHA stated she spoke to a case manager but could not recall who she spoke to but stated it was someone in the emergency department because the resident was still in the emergency department. The NHA stated she did not receive any further calls from the hospital, and she assumed Resident #2 went with her family member. The NHA stated she could not confirm if she had reached out to the resident's family member. The NHA stated she had asked the hospital for evidence to prove the resident was safe to return and as far as she could recall, the hospital never called her back. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105409 If continuation sheet Page 11 of 11