Inspection·April 8, 2025

K 000 INITIAL COMMENTS K 000 An unannounced Fire & Life Safety relicensure survey was conducted on 04/08/2025 at Golfcrest Nursing Center, a nursing home in Hollywood, Florida in accordance with National Fire Protection Association (NFPA) 1 and 101 (2021 Edition) and applicable requirements of Florida State Fire Marshal's Rules and Regulations, Florida Administrative Code (F.A.C.) 69A-3, F.A.C. 69A-53, F.A.C. 59A-4 and Florida Statutes (F.S.) 400 Part II and F.S. 633.0215, adopting National Fire Protection Association (NFPA) 1 and 101 (2021 Edition) known as the Florida Fire Prevention Code and all NFPA referenced standards and requirements adopted per NFPA 101, Chapter 2. The following is a description of deficiencies found at the time of the visit:

K 222 NFPA 101 Egress Doors SS=D K 222 4/28/25 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (1) Locks complying with 18/19.2.2.5 shall be permitted. (2) Delayed-egress electrical locking systems complying with 7.2.1.6.1 shall be permitted. (3) Sensor-release of electrical locking systems complying with 7.2.1.6.2 shall be permitted. (4) Elevator lobby exit access door locking in accordance with 7.2.1.6.4 shall be permitted. (5) Approved existing door-locking installations shall be permitted. 18.2.2.4 through 18.2.2.7, 19.2.2.4 through 19.2.2.7 This Statute or Rule is not met as evidenced by: 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX PREFIX COMPLETE DATE

K 222 Continued From page 1 K 222 Based on observations and staff interview, the facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101, for 1 of 1 sampled main lobby doors. The findings included: On 04/08/2025 between 1:30 PM and 2:45 PM during facility tour with the Maintenance Director, the main lobby door equipped with a 15-second delayed egress lock was missing the required signage. An interview was conducted with the Maintenance Director, concurrent with the observations and the findings were acknowledged. The findings were reviewed with the Maintenance Director at the exit conference on 04/08/2025 at 3:00 PM NFPA 101 (2021 Edition) 7.2.1.6.1.1.4(a) Class III ACTIONS TAKEN TO CORRECT THE DEFICIENCY: All doors will be monitored on a monthly basis to ensure all 15 second signs are posted on the main entry exit egress exit door HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE WILL BE IDENTIFIED: A Full audit will be completed for all for all residents to ensure that all residents are provided a safe environment. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: Audits will be completed on a monthly basis to ensure the same deficient practice does not re occur. HOW THE CORRECTIVE ACITON WILL BE MONITORED: All audits will be brought to QAPI monthly thereafter.

K 353 NFPA 101 Sprinkler System - Maintenance and SS=D Testing K 353 4/28/25 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system. 19.7.6, 4.6.12, 4.6.12.1, 9.11 through 9.11.3.2, and NFPA 25 STATE FORM ess NPV221 100608 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 353 Continued From page 2

K 353 This Statute or Rule is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain their Automatic Fire Sprinkler System (AFSS) in accordance with NFPA 101 for 1 of 1 five year internal backflow preventer inspection. The findings included: On 04/08/2025 between 10:00 AM and 1:30 PM during record review with the Maintenance Director, no documentation was provided for their 1 of 1 five year internal backflow preventer inspection. An interview was conducted with the Maintenance Director, concurrent with the record review and the findings were acknowledged. The findings were reviewed with the Maintenance Director at the exit conference on 04/08/2025 at 3:00 PM. NFPA 101 (2021 Edition) 19.3.5, 19.7.6, 4.6.12, 4.6.12.1. NFPA 25 (2020 Edition) 13.7.1.3 Class III NFPA 101 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: The facility scheduled a 5year sprinkler backflow on 4/16/2025 and completed on 4/17/2025. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: A full audit was completed to identify all residents with potential to be affected by the deficient practice. The potential for harm was minimal. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: The Maintenance Director or Designee will conduct and Audit on an annual basis to ensure the 5 sprinkler backflow is in compliance. HOW THE CORRECTIVE ACITON WILL BE MONITORED: The Maintenance Director will audit compliance with the 5 Year Sprinkler Back annually for compliance. Findings will be brought to QAPI

K 918 NFPA 99 Electrical Systems - Essential Electric SS=D Syste

K 918 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this 4/28/25 STATE FORM 696 NVP221 04/08/2025 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 COMPLETE DATE

K 918 Continued From page 3 capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40-day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions includes a complete simulated cold start and automatic or manual transfer of all EES loads and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.9.1, 6.9.2, 6.9.3, 6.9.4, 6.10.18, 6.11 through 6.11.4.4 (NFPA 99), NFPA 110, NFPA 111, NFPA 70 K 918 This Statute or Rule is not met as evidenced by: Based on record review and staff interview, the facility failed to maintain and test their Essential Electrical System in accordance with NFPA 99, for 1 of 1 monthly generator conductance test. CFR(s) NFPA 110, 99 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: Maintenance Director conducted a test on 4/8/2025, 4/16/2025, & 4/21/2025 to ensure the battery conductance test is at the correct voltage and by IPS TAW Generator Company on 4/21/2025. The findings included: On 04/08/2025 between 10:00 AM and 1:30 PM during record review with the Maintenance Director, no documentation was provided for 1 of HOW OTHER RESIDENTS HAVING THE 100608 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE

K 918 Continued From page 4 1 monthly generator conductance test. An interview was conducted with the Maintenance Director, concurrent with the record review and the findings were acknowledged. The findings were reviewed with the Maintenance Director at the exit conference on 04/08/2025 at 3:00 PM. NFPA 99 (2021 Edition) 6.7.1.3.5 NFPA 110 (2019 Edition) 8.3, 8.3.6.1 Class III

K 918 POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE WILL BE IDENTIFIED: The facility conduct a full house audit to identify all residents with the potential to be affected. The potential for harm is minimum. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT RECUR: The Maintenance Director will complete the Generator Conductance test on a monthly basis. Findings and the conductance test log will be brought to QAPI for 6 months and then annually thereafter. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All findings will be brought to QAPI for six months and Annually thereafter. STATE FORM 8989 NPV221 PLAN OF CORRECTION 105009 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 ID PREFIX TAG PREFIX TAG DEFICIENCY) COMPLETION DATE

K 000 INITIAL COMMENTS

K 000 An unannounced Fire & Life Safety recertification survey was conducted on 04/08/2025 at Golfcrest Nursing Center, a nursing home in Hollywood, Florida. Golfcrest Nursing Center is not in compliance with 42 CFR 483.90 (a) & (b) and National Fire Protection Association (NFPA) 101 (2012 Edition) and Tentative Interim Amendments (TIA's) 12-1, 12-2, 12-3 and 12-4, NFPA 99 (2012 Edition) and Tentative Interim Amendments (TIA's) 12-2, 12-3, 12-4, 12-5 and 12-6 requirements for nursing homes. Initial Plan Review: 1951 Existing NFPA 220 Construction Type: II (111) Number of licensed beds: 67 Census: 64 The following is a description of deficiencies found at the time of the visit:

K 222 Egress Doors

K 222 4/28/25 SS=D CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of 04/28/2025 105809 GOLFCREST NURSING CENTER | | 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 04/08/2025 PREFIX PREFIX COMPLETION DATE

K 222 Continued From page 1 | K 222 | | locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in 105009 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 ID PREFIX TAG PREFIX TAG DEFICIENCY) COMPLETION DATE

K 222 Continued From page 2

K 222 accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.4, 19.2.2.4 This REQUIREMENT is not met as evidenced by: Based on observations and staff interview, the facility failed to maintain egress doors equipped with delayed egress locking arrangements in accordance with NFPA 101, for 1 of 1 sampled main lobby doors. The findings included: On 04/08/2025 between 1:30 PM and 2:45 PM during facility tour with the Maintenance Director, the main lobby door equipped with a 15-Second delayed egress lock was missing the required signage. An interview was conducted with the Maintenance Director, concurrent with the observations and the findings were acknowledged. The findings were reviewed with the Maintenance Director at the exit conference on 04/08/2025 at 3:00 PM NFPA 101 (2021 Edition) 7.2.1.6.1.1(4) ACTIONS TAKEN TO CORRECT THE DEFICIENCY: All doors will be monitored on a monthly basis to ensure all 15 second signs are posted on the main entry exit egress exit door. HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE WILL BE IDENTIFIED: A full audit will be completed for all for all residents to ensure that all residents are provided a safe environment. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: Audits will be completed on a monthly basis to ensure the same deficient practice does not occur. HOW THE CORRECTIVE ACITON WILL BE MONITORED: All audits will be brought to QAPI monthly thereafter.

K 918 Electrical Systems - Essential Electric Syste

K 918 SS=D CFR(s): NFPA 101 4/28/25 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying 105809 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG COMPLETION DATE DEFICIENCY)

K 918 Continued From page 3 service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) THIS REQUIREMENT is not met as evidenced by: Based on record review and staff interview, the facility failed to maintain and test their Essential Electrical System in accordance with NFPA 99, for 1 of 1 monthly generator conductance test. The findings included:

K 918 ACTION(S) TAKEN TO CORRECT THE DEFICIENCY: Maintenance Director conducted a test on 4/8/2025, 4/16/2025, & 4/21/2025 to ensure the battery conductance test is at the correct voltage and by IPS TAW Generator Company on 4/21/2025. 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 COMPLETION DATE

K 918 Continued From page 4 K 918 On 04/08/2025 between 10:00 AM and 1:30 PM HOW OTHER RESIDENTS HAVING THE during record review with the Maintenance POTENTIAL TO BE AFFECTED BY THE Director, no documentation was provided for 1 of SAME DEFICIENT PRACTICE WILL BE 1 monthly generator conductance test. IDENTIFIED: An interview was conducted with the Maintenance The facility conduct a full house audit to Director, concurrent with the record review and identify all residents with the potential to the findings were acknowledged. The findings be affected. The potential for harm is were reviewed with the Maintenance Director at minimal. the exit conference on 04/08/2025 at 3:00 PM. MEASURES PUT INTO PLACE TO NFPA 99 (2012 Edition) 6.4.1.1.13 ENSURE THE SAME DEFICIENT NFPA 110 (2010 Edition) 8.3, 8.3.7.1 PRACTICE DOES NOT RECUR: The Maintenance Director will complete the Generator Conductance test on a monthly basis. Findings and the conductance test log will be brought to QAPI for 6 months and then annually thereafter. HOW THE CORRECTIVE ACTION WILL BE MONITORED: All findings will be brought to QAPI for six months and Annually thereafter. COMPLETED 04/08/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

E 000 Initial Comments

E 000 During the Fire & Life Safety recertification survey conducted on 04/08/2025 at Golfcrest Nursing Center, a nursing home in Hollywood, FL., Emergency Preparedness was reviewed. Golfcrest Nursing Center is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 483.73, Requirement for Long Term Care Facilities. 04/28/2025