Health inspection·December 30, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interviews and record reviews, the facility did not provide prompt efforts to resolve a grievance for one (Resident #1) of two residents reviewed. Findings include: An observation on 12/30/2025 at 12:28 P.M. of Resident #1's privacy curtain in her room revealed three ants moving on the curtain. An interview was conducted on 12/20/2025 at 12:31 P.M. with Resident #1. Resident #1 said that she had filed a formal grievance on 12/22/2025 regarding ants in her room. Resident #1 provided a photo of the grievance that was written by her on 12/22/2025. A review of the facility provided grievance log for December 2025 revealed the facility did not have a grievance listed for Resident #1. An interview was conducted on 12/30/2025 at 1:15 P.M. with Staff D, Social Services (SS). Staff D, SS said Resident #1 filed a formal grievance on 12/22/2025. Staff D said she gave the grievance form to the Nursing Home Administrator (NHA) for review. Staff D said the NHA stated she would handle it [the grievance]. Staff D said she had not followed up with the NHA and did not know the outcome of the grievance. An interview was conducted on 12/30/2025 at 2:01 P.M. with the NHA. The NHA said Resident #1 filed a grievance 12/22/2025. The NHA said the grievance was regarding ants in her room. The NHA said Staff C, Plant Director (PD) observed ants in Resident #1's room. The NHA said she did not know where the original formal grievance form was for Resident #1. An interview was conducted on 12/30/2025 at 2:10 P.M. with Staff C, PD. Staff C, PD said Resident #1 had ants in her room on the walls and the resident's privacy curtain. Staff C, PD said the NHA spoke to him last week about the grievance Resident #1 filed. An interview was conducted on 12/30/2025 at 3:40 P.M. with the NHA. The NHA said she did not have the original grievance Resident #1 had written. A review of facility provided policy revised in January 2025, titled, Resident and Family Grievances showed: It is the policy of this facility to support each resident's and family member's right to voice grievances with discrimination, reprisal or fear of discrimination or reprisal. The policy's explanation and compliance guidelines showed: 2. The grievance officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; coordinating any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. 11. Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision. 12. The facility will make prompt efforts to resolve grievances. 17. All grievances should be documented on the grievance log and maintained per retention policy. 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 2 Event ID: 105409 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 12/30/2025 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)