Health inspection·August 17, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure prompt efforts were taken to resolve a grievance for one (Resident #12) of one resident reviewed on the facility's grievance process. Findings included: A review of the facility's Grievance Log dated June 2023 showed an entry for Resident #12 dated 06/14/23. The entry showed Resident #12's grievance was about Resident deliveries. The column on the grievance form titled,disposition of grievance was left blank. A review of Resident #12's Grievance Form dated 06/14/23 showed Resident indicted a package was delivered in February and Resident did not receive package. Order was tracked and package was shown to be delivered. This was a wrist blood pressure cuff. The grievance follow up showed, Resident re-ordered a wrist blood pressure cuff back in [DATE]. We cannot reimburse resident, however we could have re-ordered the cuff. During an interview on 08/17/23 at 9:50 a.m., Staff Q Social Service Director (SSD) stated Resident #12's grievance started back in February 2023. Staff Q stated the grievance remained un-resolved in June 2023 when she took over as grievance officer. In June 2023, Staff Q followed up with Resident #12's missing property but informed Resident #12 there was nothing the facility could do as the facility did not replace resident's missing property so, Resident #12 chose to re-order the blood pressure again. Staff Q stated the grievance remained unresolved as there was nothing the facility could do for Resident #12. During an interview on 08/17/23 at 10:00 a.m., Resident #12 stated she had ordered a blood pressure cuff in February 2023 but never got it. Resident #12 stated the package tracker said the package was delivered to the facility. Resident #12 stated when she asked for the package the facility stated the package was missing. Resident #12 stated in June 2023, [Staff Q] discussed the missing blood pressure cuff with me but told me I would need to reorder my blood pressure cuff as the facility did not replace missing items. During an interview on 08/17/23 at 11:00 a.m., the Director of Nursing (DON) stated the facility did replace missing items for residents. The Staff Q was a fairly new employee and would need to be educated on the facility's policy and procedures for missing resident items. The DON stated Resident #12 would be reimbursed, and the SSD would be educated prior to the survey team leaving the facility today. (continued on next page) 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 6 Event ID: 105634 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 105634 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gulfside Health and Rehabilitation Center 1100 N Pine St Clearwater, FL 33756 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)