Inspection·May 21, 2025

N 000 INITIAL COMMENTS N 000 A complaint survey, complaint #2025006120 & #2025006130 was conducted on at Golfcrest Nursing Center. The facility had no licensure deficiencies at the time of the survey. C 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX PREFIX COMPLETION DATE

F 000 INITIAL COMMENTS F 000 A complaint survey (Complaint #s 2025006120 and 2025006130) was conducted in conjunction with the Recertification revisit survey on at Golfcrest Nursing Center. The facility was not in compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. A new deficiency was identified related to the complaints. Please refer to the separate report for the findings.

F 635 Admission Physician Orders for Immediate Care SS=D CFR(s): 483.20(a) F 635 $483.20(a) Admission orders At the time each resident is admitted, the facility must have physician orders for the resident's immediate care. This REQUIREMENT is not met as evidenced by: Based on review of policy and procedure, interview and record review, the facility failed to timely order to obtain and document proper admission physician orders for immediate care involving surgical site and care, and document a resident's level; and medication for a resident; re-assess, and document routinely ordered medications to a resident, for 1 of 2 sampled residents reviewed for admission orders after surgery, Resident #1. The findings included:

F635- Admission Physician Orders for Immediate Care CFR(s): 483.20(a) ACTIONS TAKEN TO CORRECT THE DEFICIENCY: Resident #1 Discharged from the facility on HOW OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE WILL BE IDENTIFIED: /2025 LIST OF DEFICIENCIES C 105809 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX PREFIX COMPLETION DATE

F 635 Continued From page 1 Review of the facility policy and procedure titled, Observation and Record, provided by the Director of Nursing (DON) reviewed, documented in the "Policy Statement: Observation and Record UDA will be completed on every resident as part of the admission process. , will be re-observed and recorded any time a resident states that his/her, level has changed/when medication or dosage is changed, or anytime the resident's condition significantly changes. Purpose: The management of , is essential to enhance quality of life by routinely reviewing a resident's level of , and providing and managing, control in collaboration with the attending physician/Medical Director. General Guidelines: 1. A. observation and Record UDA will be completed on every resident as part of the admission process, quarterly and upon significant change in resident status and become part of the medical record. 2. If a resident states, or shows signs that he/she is having , and does not currently have a prescribed, medication, or is not receiving relief from current type dosage frequency of, medications; and this is considered unstable, the nurse will contact the attending physician to discuss, observations and interventions and develop a plan of care to better control the, ". Record review of the facility policy and procedure titled, Assisting the Nurse in Examining the Resident, provided by the DON reviewed, documented in the "Policy Statement: ...Purpose: The purposes of this procedure are to examine the condition of the resident's body and to observe the resident's performance ...Admission Notes/Admission Data Collection: Admission Notes/Admission Forms should include as a minimum documentation of the F 635 A 100% comprehensive audit of new admissions patients for the previous 30 days reviewed for timely physician orders. MEASURES PUT INTO PLACE TO ENSURE THE SAME DEFICIENT PRACTICE DOES NOT REOCCUR: 100% in-service for all licensing nursing staff to verify and put in place physician orders upon admission and to assess and document, level every shift. DON or Designee to Audit timely physician orders on admission for residents. Audit daily for 30 days and monthly ongoing re-assessments for residents with, and documentation. Audit daily for 30 days and monthly ongoing HOW THE CORRECTIVE ACTION WILL BE MONITORED: DON or designee to Report all findings of Audits to QAPI committee Monthly. SUMMARY OF DEFICIENCIES 105809 C 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 ID PREFIX TAG PREFIX TAG DEFICIENCY) COMPLETION DATE

F 635 Continued From page 2

F 635 admission of a resident (as they may apply): ...f. Vital signs and condition of resident upon admission (i.e., weak, alert, etc.) g. Time physician was notified of the admission. h. Time physician's orders were received and verified .... i. Medications were ordered from the pharmacy ...." Record review revealed Resident #1 was admitted to the facility on at 6:46 PM with diagnoses that included Encounter for other Orthopedic Aftercare and with to multiple sites to include bone and Resident #1 had been previously admitted to the Hospital on he was status-post (s/p) second (2nd) major surgery performed on records, as being Independent with * Skills for Daily Decision Making"--Made decisions regarding tasks of daily life. A telephone interview was conducted on at 2:25 PM, with Resident #1's family member regarding the resident's care and treatment upon admission to the facility on at 6:46 PM. The resident's family member stated Resident #1's medication was never given to him, and he said that the resident told him that he had all over his body, while family members were waiting there in the resident's room with him. The family member stated one (1) of his other family members spoke to the Supervisor at the time, but he said that the nurse gave no solution. Review of Resident #1's progress notes dated documented the day after admission to the facility, a family member called 911 to send the resident to the hospital because she felt 105809 C 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 635 Continued From page 3

F 635 Resident #1's needs could not be met at the facility. The resident was transported to the hospital at 12:07 PM. On at 6:12 AM Resident #1's Hospital's Physician's History and Physical documented, "Medications ... ( ) Contin 15mg extended release (ER) to give one (1) tablet (15mg) by two (2) times daily. Indications: Non-acute, ( ) non-acute Care, ... ( ), non-acute, ( ) five (5) mg every eight (8) hours as needed for up to 30 days. Indications: Non-acute Record review dated at 1:43 PM of Resident #1's Hospital's Advanced Practice Registered Nurse's Progress Notes also documented, "1. Patient to continue with release (ER) scheduled every eight (8) hours for ( ) Contin 15mg extended control. Patient to have mg every six (6) hours as needed for five (5) moderate/severe breakthrough, ... For the safety of the patient we ask that you not make any changes in their medications without speaking with us. If you feel that the medications need to be addressed, please feel free to contact us. We are always open to conversation .... Further record review of both the 3008 Agency for Healthcare Administration (AHCA) Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form and of the facility's Admission Nursing Data Collection form dated documented that Mental/ Status of Resident #1 at transfer was: Alert, oriented to person, place time and situation and follows instructions. C 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 635 Continued From page 4

F 635 Review of the Minimum Data Set (MDS) assessment, Section GG "Functional Abilities and Goals" documented the resident was dependent for all of the following: Self-care, oral hygiene, toileting, shower/bath, upper body , lower body , putting on/taking off footwear, personal hygiene, mobility, roll left and right, chair-to-bed-to-chair transfer, toilet transfer, tub/shower transfer; with , on both sides. Review of the Physician's Order Sheet (POS), Medication Administration Record (MAR), Treatment Administration Record (TAR), and the progress notes dated to failed to document any "on-going" assessments for , levels being done, for this resident. There was no alternative , medication, and "as needed", medication ordered for this resident, during his facility stay. There was no documented evidence in the facility's record to show that the facility had contacted the physician to obtain orders for , medication, to address the resident's care needs (not entered in facility computer system until the next day on ), nor were there any orders to address the resident's surgical site care with staples. Record review of the facility's Nursing Admission/Quarterly Observation form, section C2 pages five (5) and six (6), " Interview," revealed that this section had not even been started or completed by Staff A, Registered Nurse (RN), working on on the 7 PM to 7 AM 105809 C 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 635 Continued From page 5 shift.

F 635 There was no physician's order written, nor entered to, "Check for, every shift," into the facility's computer system by Staff A, until the next day. During a side-by-side record review conducted with the Director of Nursing (DON), it was revealed that Resident #1 had not been administered any of the following physician ordered "routine" medications until the next day on , for the resident: * Oral Tablet 750 mg (3) to give 1 tablet by three (3) times a day; * Oral Tablet Chewable 81 mg to give one (1) tablet by one time a day; oral tablet one (1) gram to give one (1) tablet by three (3) times a day for fifteen (15) days; * oral tablet twenty (20) mg to give one two (2) times a day; * oral capsule 100 mg to give one (1) capsule by every twelve (12) hours as needed for * oral tablet 80 mg to give two (2) tablets by one (1) time a day; * ER Tablet Extended Release 15 mg "Controlled Drug" to give one (1) tablet by every twelve (12) hours for liquid 4 mg/0.1 ml 4 mg in nostril as needed for in one (1) nostril 4 minutes until repeat every two (2) to three (3) minutes until medical assessment; * oral tablet fifty (50) mg to give one (1) tablet by two (2) times a day; -Pilocaine External Kit 2. .5 % apply C 105809 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 ID PREFIX TAG PREFIX TAG COMPLETION DEFICIENCY) DATE

F 635 Continued From page 6

F 635 to affected area , two (2) times a day for The listed medications were not placed into the facility's computer system until the next day on An interview was conducted on at 3:36 PM, with Staff D, RN working on the 7 AM to 7 PM shift, regarding Resident #1's admission to the facility. Staff D stated that she only took the report from the hospital over the phone at change of shift, and she said that she reported this to the next shift. Staff D added that if a resident is admitted after 6 PM on the day shift, the evening/night shift would take over and handle "following up with the new admission. Staff D stated she had not actually seen the resident at all that night. Staff D explained part of the admission process, that if a resident does not come with a prescription and states they are in , then the nurse would contact the Medical Director to get the order/script to be faxed to pharmacy. Staff D stated a resident comes into the facility with the history and summary report, the nurse would review the report and go to the Point-Click-Care (PCC) computer system, and under "progress notes" would enter a brief admission summary, discuss the diagnosis, vital signs and, if there are any ordered etc. Staff D stated that a , assessment is done along and in conjunction with the vital signs and is added to the admission summary report. An interview was conducted on at 3:54 PM with Staff A, regarding Resident #1's admission to the facility. Staff A acknowledged that she recorded a nursing progress note entry at 6:46 PM, ".... admit, awake, alert, oriented to C 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX PREFIX COMPLETION DATE

F 635 Continued From page 7 F 635 person, place, time and situation (AAOX4) .....surgical site upper with forty-one (41) staples, cover with no s/s noted ... 18 French drainage clear yellow 500cc .." Staff A was asked the potential for this resident's, needs and contact the physician to obtain orders for his surgical site, management and care. Staff A stated that she forgot to do so. When asked, Staff A stated she did not reassess the resident for, . When asked if a "newly" admitted resident with a recent surgical history comes to the facility, when she expects them to come to the facility having a script for some type of routine or as needed, medication, Staff A said, "yes." When asked if the nurse should re-assess and document the resident's, , upon admission Staff A, responded, "yes," but she acknowledged that she had not done so." When asked if she documented that Resident #1 was administered any of his ordered medications, during her shift, Staff A stated "no, not to her knowledge." During a telephone interview conducted on at 5:16 PM with Resident #1's primary physician, he was asked if the doctor would be contacted or notified by the facility, of the resident's admission needs. The resident's doctor stated that the nurses ordinarily reach out to him, regarding medications and other orders. The DON acknowledged on at 5:04 that, if a resident is transferred to the facility from a hospital needing, medication, she would expect them to have a script or the nurse is expected to contact the "on call" Medical Director's service, who in turn would notify the Pharmacy to obtain their medications. The DON C 105809 05/21/2025 GOLFCREST NURSING CENTER 600 NORTH 17TH AVE HOLLYWOOD, FL 33020 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETION DATE

F 635 Continued From page 8 further stated that the nurse is expected to do a assessment and evaluation on the resident, upon admission to the facility. The DON ended by saying Resident #1 should have received his ordered medication and that the nurse should have re-assessed, and documented the resident's , level, during his facility stay.

F 635