Golfview Nursing Center

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

Event ID:

Printed: 04/13/2026 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

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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interviews and record reviews, the facility did not ensure alleged abuse were reported to the governing agency in accordance with the State law for one (Resident #1) of two residents sampled.

Findings include: An interview was conducted on 12/30/2025 at 12:31 P.M with Resident #1. Resident #1 filed a grievance on 12/22/2025 and provided a photo. Resident #1 said Staff C, Plant Director (PD) was aggressive and yelling at her. Resident #1 had given the grievance form to Staff A, Activities Director (AD).

Resident #1 did not know the outcome of the grievance. Resident #1 had not spoken to the Nursing Home Administrator (NHA). An interview was conducted on 12/30/2025 at 1:15 P.M. with Staff D, Social Services Director (SSD). Staff D, SSD had given the grievance to the NHA on 12/22/2025. Staff D, SSD said Staff C, PD spoke rudely to Resident #1. Staff D, SSD had received the grievance form from Staff A, AD. Staff D, SSD did not know the outcome of the grievance. Staff D, SSD said the NHA had the grievance form for Resident #1. An interview was conducted on 12/30/2025 at 2:01 P.M. with the NHA. The NHA said Resident #1 filed a grievance on 12/22/2025 regarding ants in the resident's room. The NHA said Resident #1 did not like the way Staff C, PD spoke to her. The NHA did not have the original grievance form that Resident #1 completed. An interview was conducted on 12/30/2025 at 2:10 P.M. with Staff C, PD. Staff C, PD said the NHA spoke to him about the grievance for Resident #1. Staff C, PD said Resident #1 alleged I spoke to her [Resident #1] aggressively and was yelling at her [Resident #1]. Staff C, PD said if I look back on it now, maybe I was speaking harshly to the resident. An interview was conducted on 12/30/2025 at 3:00 P.M. with Staff A, AD. Staff A, AD had reported Resident #1's allegation to the NHA on 12/22/2025. Staff A, AD had given the grievance form to Resident #1; after Resident #1 completed the grievance form, had given the form to Staff D, SSD. Staff A, AD had not spoken to the NHA since reporting the allegation. Review of the facility provided grievances revealed no grievances placed by the resident for the month of December. A

review of the 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: 10: Procedure g: For investigations regarding allegations of neglect, abuse, injuries of unknow source, and/or misappropriation of resident property, a report of the investigative results will be submitted to the State Survey Agency, and other officials in accordance with State Law, within five working days of the incident. A review of the facility provided policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property showed: Mental and Verbal Abuse: .Verbal abuse includes the use of oral, written, or gestured communication. Examples of mental and verbal abuse included, but are not limited to, harassing the resident, mocking, insulting, ridiculing; yelling or hovering over

a resident with the intent to intimated. Reporting/Documentation Requirements: Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the center and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction

in long-term care centers) in accordance with State law.

Event ID:

Facility ID:

If continuation sheet