Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golfview Nursing Center during CMS and state inspections, most recent first.
A resident filed a formal grievance about ants in her room, but the facility failed to document the grievance in the log, did not maintain the original grievance form, and did not provide evidence of prompt resolution. Staff were unaware of the outcome, and the process outlined in the grievance policy was not followed.
A resident alleged that a staff member spoke to her aggressively and yelled, submitting a grievance through facility channels. The grievance was passed among staff but was not documented or reported to the state agency as required by policy and law. The resident was not informed of the outcome, and the original grievance form was missing.
A resident was transferred or discharged without adequate consideration of their needs and preferences, and without proper preparation to ensure a safe transition. The facility did not complete the necessary steps to support the resident's well-being during and after the transfer/discharge.
A resident with cognitive issues sustained skin tears during an altercation with a CNA, who reported the incident internally. However, the facility failed to report the abuse allegation to authorities within the required two-hour timeframe, leading to a four-hour delay. Interviews revealed communication breakdowns and a failure to recognize the incident as an abuse allegation promptly.
A facility failed to ensure a safe and orderly discharge for a resident with psychiatric conditions, who was cleared to return from the hospital but was not accepted back by the facility. The resident's discharge plan was not evaluated, and the bed hold agreement was not honored. Despite being stable, the facility's administrator refused the resident's return, leading to the resident's discharge to another LTC facility.
A facility failed to readmit a resident after hospitalization, despite the hospital rescinding the involuntary hospitalization and deeming the resident stable. The resident, with a history of psychiatric conditions, was initially hospitalized for aggressive behavior. The facility's NHA refused readmission, citing concerns about the short hospital stay and previous behavior. The facility's policy on transfer and discharge was not followed, and there was a lack of proper documentation and communication regarding the resident's discharge and potential readmission.
A resident accused a CNA of causing bruises during care, but the facility failed to report the allegation within the required two-hour timeframe. The incident involved the resident becoming combative, and the CNA calling for help. Despite staff awareness, the report was delayed, leading to a deficiency finding.
A resident with chronic pain and bed confinement status requested therapy to regain mobility but did not receive it due to the facility's reliance on a full body mechanical lift, which caused her pain. Despite her requests and the DON's referral, therapy services were not provided, citing lack of motivation. The NHA questioned this assessment, as the resident repeatedly asked for therapy.
The facility failed to maintain complete medical records for 24 current residents. A beneficiary notice requested for a resident could not be provided because the facility did not have access to the previous electronic medical record system. The facility began using a new system in May 2023 and did not have access to records prior to 4/31/2023. Policies indicated that records should be retained for 7 years or as outlined by payer contracts, and in accordance with State and Federal regulations.
The facility failed to adhere to professional standards for food service safety, including improper storage and labeling of food in the upright freezer, unsanitary conditions and improper temperature control in the walk-in cooler, and uncleanliness and improper labeling in Station #2's nourishment refrigerator. There was also confusion regarding the responsibility for cleaning the nourishment room refrigerators.
The facility failed to provide requested medical records for a resident due to a transition to a new electronic medical record system and lack of access to the old system. Despite facility policies requiring record retention, the facility could not fulfill the request, leading to a deficiency in compliance with state and federal regulations.
Failure to Promptly Resolve and Document Resident Grievance
Penalty
Summary
A resident reported the presence of ants in her room and filed a formal grievance regarding this issue. The grievance was submitted on 12/22/2025, and the resident provided a photo of the written grievance. However, a review of the facility's grievance log for December 2025 did not show any record of this grievance. Staff interviews confirmed that the grievance was submitted to the Nursing Home Administrator (NHA) by Social Services, but there was no follow-up or documentation of the outcome. The NHA acknowledged receiving the grievance and stated that the Plant Director observed ants in the resident's room, but the original grievance form could not be located. The facility's policy requires that all grievances be documented, tracked, and resolved promptly, with evidence of the results maintained for at least three years. Despite these requirements, the facility failed to document the grievance in the log, did not maintain the original grievance form, and did not provide evidence of prompt resolution. Staff involved were unaware of the outcome, and the process outlined in the facility's grievance policy was not followed.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident was reported to the appropriate state agency in accordance with state law and facility policy. A resident filed a grievance alleging that a staff member, the Plant Director, was aggressive and yelled at her. The grievance was submitted to the Activities Director, who then passed it to the Social Services Director, and subsequently to the Nursing Home Administrator (NHA). Despite this, the resident was not informed of the outcome, and the original grievance form could not be located by the NHA. Interviews with involved staff confirmed the sequence of reporting, but none were aware of any further action or outcome regarding the grievance. A review of facility records revealed no documentation of the grievance for the relevant month, and the facility's policies require that all allegations of abuse, neglect, or mistreatment be reported to the state survey agency and other officials within five working days. The investigation found that the facility did not follow its own procedures or state law in reporting the alleged abuse, as there was no evidence that the incident was reported to the governing agency or that the results of any investigation were submitted as required.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation that indicated the resident's individual requirements and choices were not fully considered or addressed during the transfer/discharge planning process. As a result, the resident was not properly prepared for a safe transition, and the necessary steps to ensure their well-being during and after the transfer/discharge were not completed as required.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe for a resident who had sustained skin tears during an altercation with a Certified Nursing Assistant (CNA). The incident occurred when the resident, who had a history of cognitive and behavioral issues, became combative with the CNA, resulting in the CNA grabbing the resident's arm to protect herself. The resident later alleged that the CNA's actions caused the skin tears. The incident was first reported internally at 10:30 a.m. by the CNA involved, but the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were not informed until approximately 2:30 p.m., leading to a delay in the official reporting of the abuse allegation to the authorities. The facility's policy mandates that such allegations be reported within two hours, but the report was not made until 4:30 p.m., four hours after the incident was initially reported internally. Interviews with staff revealed a breakdown in communication and reporting procedures. The Licensed Practical Nurse (LPN) on duty did not immediately recognize the incident as an abuse allegation and failed to initiate the reporting process promptly. The DON and NHA both acknowledged that they should have been notified earlier, and the facility's training materials clearly outlined the requirement for immediate reporting of abuse allegations.
Plan Of Correction
1. The allegation related to Resident #1 was reported promptly upon notification to Administrator/Coordinator and within 2-hour timeframe. CNA was suspended immediately upon notification of allegation by Director of Nursing. Resident #1 received appropriate interventions, including emotional support and follow-up assessments. Resident #1 remained at her behavioral baseline, in no mental anguish, and participating in her normal activities. 2. Administrator/Designee interviewed all alert and oriented residents on Staff D CNA's assignment were interviewed on and all not alert and oriented residents had skin assessments completed to observe for any possible signs of. No other residents were affected. Administrator/Designee conducted staff interviews on to identify any possible concerns. No concerns identified. A comprehensive review of all incidents over the last 90 days was completed by Director of Nursing/Designee to identify any potential un-reported allegations. No new findings were identified. 3. Administrator/Designee educated all staff on Neglect and Misappropriation Reporting Policies and Procedures and completed Post-Test. All education and post-tests were completed by or prior to their next scheduled shift. Administrator/Designee to educate all new hires on Policies and Procedures and post-test completed during new-hire orientation. DON/Designee completed written coaching with Staff F, Weekend Supervisor and Staff H, RN to ensure moving forward reporting process is followed. Administrator implemented random interviews with residents, staff, and families to be conducted by different members of the Interdisciplinary Team weekly x 3 months to ensure no events go un-reported. Administrator/Designee will review completed interviews daily to determine if any concerns need to be reported. 4. Administrator/Designee will complete daily audits of all incident reports x4 weeks then 3x a week audits for 3 months or until substantial compliance is achieved. Non-compliance in the reporting process will result in corrective training and disciplinary actions. Results of audits will be taken to monthly QAPI x3 months or until substantial compliance is achieved.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who wished to return to the community when medically cleared. The resident's discharge plan was not evaluated, and her wish to return to the community was not honored. An involuntary hospital transfer was rescinded, but the facility did not document any attempts to ensure a safe and orderly transfer back to the facility. The resident remained in the hospital for an additional 17 days awaiting an appropriate discharge location, and the bed hold agreement was not honored without documentation of the cause. The resident, who had a history of psychiatric conditions including PTSD, conversion disorder, depression, schizophrenia, anxiety, bipolar disorder, and insomnia, was admitted to the hospital for altered mental status and aggressive behavior. Despite being deemed stable and cleared to return to the facility by the hospital's psychiatry services, the facility's administrator refused to accept the resident back, citing previous aggressive behavior. The facility did not respond to multiple attempts by the hospital to contact them regarding the resident's discharge. The facility's policy required notification and preparation for transfer or discharge, but the Nursing Home Transfer and Discharge Notice for the resident was incomplete and lacked necessary signatures. The facility's failure to follow its own procedures and communicate effectively with the hospital resulted in the resident being discharged to another long-term care facility instead of returning to the original facility.
Plan Of Correction
1. Resident #2 was discharged to the hospital due to endangering herself or others in the facility. Resident #2 did not return to the facility. 2. Administrator/designee reviewed all discharges in the last 3 months to ensure discharge preferences were followed, bed hold agreements were completed, and Nursing Home Transfer and DC Notice forms were completed. 3. Administrator/Designee educated licensed nurses and Social Services Director to ensure Discharge policies and procedures are followed. Administrator/Designee will conduct daily audits to ensure residents' Discharge Care Plan was followed, bed hold, and Nursing Home Transfer & DC Forms are completed accurately for 4 weeks and then 3 times weekly for 3 months or until substantial compliance is achieved. 4. Administrator/Designee to report all audit findings to monthly QAPI meetings for 3 months or until substantial compliance is achieved.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit the readmission of a resident from the hospital after an involuntary hospitalization, which exceeded the bed-hold policy. The resident, who had a history of psychiatric conditions including PTSD, schizophrenia, and bipolar disorder, was initially admitted to the hospital due to aggressive behavior. Despite being deemed stable and safe to return by the hospital's psychiatric services, the facility's Nursing Home Administrator (NHA) refused to readmit the resident, citing concerns about the short duration of the hospital stay and the resident's previous behavior. The facility's policy on admission, transfer, and discharge was not adhered to, as the resident was not allowed to return despite the hospital rescinding the involuntary hospitalization. The NHA did not receive further communication from the hospital or the resident's family, and assumed the resident went with a family member. The facility's records showed an incomplete discharge notice and a bed-hold agreement that was not rescinded, indicating a lack of proper documentation and communication regarding the resident's discharge and potential readmission. Interviews with staff revealed inconsistencies in handling residents with aggressive behaviors, as other residents with similar issues were managed with 1:1 supervision and psychiatric follow-up without being involuntarily hospitalized. The facility's failure to readmit the resident after hospitalization, despite the hospital's clearance, highlights a deficiency in adhering to transfer and discharge rights, as well as a lack of consistent application of policies for managing residents with behavioral issues.
Plan Of Correction
1. Resident #2 was discharged to the hospital due to being a danger to herself and others. NHA spoke to the hospital and requested additional testing and a true evaluation be completed and then did not hear from the hospital after. Resident #2 was admitted to another Skilled Nursing Facility in the area. 2. Administrator/Designee reviewed all transfers to the hospital for the last 3 months. No other residents identified as not being permitted to return. 3. Administrator/Designee educated all licensed nurses and Social Services Director on Discharge Policies and Procedures. Administrator/Designee to conduct daily audits on all facility transfers x4 weeks and then 3 x weekly or until substantial compliance is achieved to ensure resident preferences to return to the facility are upheld. 4. Administrator/Designee to bring all audits to monthly QAPI meetings x 3 months or until substantial compliance is achieved.
Delayed Reporting of Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect within the required two-hour timeframe for a resident. The incident involved a Certified Nursing Assistant (CNA) and a resident, where the resident accused the CNA of grabbing her arm and causing bruises. The facility's policy mandates immediate reporting of such allegations, especially if they result in serious bodily injury, but the report was delayed. The incident began when the resident requested assistance from the CNA, who was attending to another resident at the time. Upon returning to assist the resident, the CNA reported that the resident became combative, grabbing the CNA's shirt and hitting her. The CNA called for help, and other staff members responded. The resident later alleged that the CNA had grabbed her arm tightly, causing bruises. The incident was not reported to the Nursing Home Administrator until several hours later, despite staff being aware of the situation earlier in the day. Interviews with staff revealed that the CNA involved was suspended during the investigation, and the Director of Nursing was informed of the incident later in the afternoon. The delay in reporting was attributed to a lack of immediate investigation and communication among staff. The resident's care plan noted self-neglect behaviors and a history of refusing care, which may have contributed to the incident. However, the facility's failure to adhere to its reporting policy resulted in a deficiency finding.
Plan Of Correction
1. The allegation related to Resident #1 was reported promptly upon notification to Administrator/Coordinator and within 2-hour timeframe. CNA was suspended immediately upon notification of allegation by Director of Nursing. Resident #1 received appropriate interventions, including emotional support and follow-up assessments. Resident #1 remained at her behavioral baseline, in no mental anguish, and participating in her normal activities. 2. Administrator/Designee interviewed all alert and oriented residents on Staff D CNA's assignment were interviewed on and all not alert and oriented residents had skin assessments completed to observe for any possible signs of. No other residents were affected. Administrator/Designee conducted staff interviews on to identify any possible concerns. No concerns identified. A comprehensive review of all incidents over the last 90 days was completed by Director of Nursing/Designee to identify any potential un-reported allegations. No new findings were identified. 3. Administrator/Designee educated all staff on Neglect, and Misappropriation Reporting Policies and Procedures and completed Post-Test. All education and post-tests were completed by or prior to their next scheduled shift. Administrator/Designee to educate all new hires on Policies and Procedures and post-test completed during new-hire orientation. DON/Designee completed written coaching with Staff F, Weekend Supervisor and Staff H, RN to ensure moving forward reporting process is followed. Administrator implemented random interviews with residents, staff, and families to be conducted by different members of the Interdisciplinary Team weekly x 3 months to ensure no events go un-reported. Administrator/Designee will review completed interviews daily to determine if any concerns need to be reported. 4. Administrator/Designee will complete daily audits of all incident reports x4 weeks then 3x a week audits for 3 months or until substantial compliance is achieved. Non-compliance in the reporting process will result in corrective training and disciplinary actions. Results of audits will be taken to monthly QAPI x3 months or until substantial compliance is achieved.
Failure to Provide Requested Therapy Services
Penalty
Summary
The facility failed to preserve the quality of life related to therapy services for a resident who expressed a desire to regain strength and mobility. The resident, who was admitted with multiple medical diagnoses including chronic pain and bed confinement, reported that she had not received therapy for over a year despite her requests. She expressed a desire to participate in therapy to regain the ability to sit on the side of her bed and use her wheelchair, but stated that the CNAs had not been assisting her as expected. The resident also mentioned that the use of a full body mechanical lift caused her significant pain, leading to a hospital visit. Interviews with the Director of Therapy and the Director of Nursing (DON) revealed discrepancies in the facility's response to the resident's requests for therapy. The Director of Therapy indicated that the resident was screened but not picked up for therapy services due to her refusal to use the full body mechanical lift, which was deemed necessary for therapy. The DON, however, had put in a referral for therapy services and questioned the therapy department's decision, as the resident had expressed a desire for therapy and could potentially have experienced a decline in her condition. The Nursing Home Administrator (NHA) noted that the resident was documented as lacking motivation, which was cited as a reason for not providing therapy services. However, the NHA was uncertain about this assessment, given the resident's repeated requests for therapy. The facility's policy on providing specialized rehabilitative and restorative services was not effectively implemented, as the resident's care plan and therapy needs were not adequately addressed, leading to a deficiency in maintaining the resident's quality of life.
Failure to Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for 24 current residents out of a total resident census of 47. On 5/14/24, a beneficiary notice was requested for a resident, but the facility could not provide it because they did not have access to the resident's full medical record. The Interim Nursing Home Administrator stated that the facility did not have access to the previous electronic medical record system, which contained the necessary document. The Medical Records Director confirmed that the facility began using a new electronic medical record system in May 2023 and did not have access to any residents' medical records prior to 4/31/2023. A review of the facility's policies revealed that medical records should be retained for a period of 7 years from the date of discharge or as outlined by payer contracts, and in accordance with State and Federal regulations.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial tour of the kitchen, several open and undated bags of vegetables were found in the upright freezer, with one bag being punctured. The walk-in cooler was observed to have a liquid puddle and food debris under a crate containing bags of onions. The Dietary Manager was unaware of the issue and did not clean the area promptly. Additionally, the walk-in cooler's temperature was recorded at 52 degrees Fahrenheit, which was later corrected to 36 degrees Fahrenheit after the food was inspected and potentially unsafe items were discarded. However, the initial unsanitary conditions and improper temperature control were noted as deficiencies. Further observations revealed that Station #2's nourishment refrigerator contained undated and improperly labeled food items, including a take-out container and a covered bowl of mashed potatoes and gravy. The freezer section had frost and an open frozen bottle of soda, along with food debris in both compartments. There was confusion between the Dietary Manager and the Director of Nursing regarding the responsibility for cleaning the nourishment room refrigerators. The contracted Registered Dietitian confirmed that there was no specific facility policy for cleaning these refrigerators, and it was suggested that this task should fall under the general Dietary/Kitchen Policy for maintenance and cleaning of dietary equipment.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to obtain and provide copies of a portion of a medical record requested for a resident. A subpoena dated 1/29/2024 required the facility to deliver medical treatment records, billing statements, and Power of Attorney documentation for the resident from 8/1/2022 to the current date by 2/28/2024. However, the Medical Records Director (MRD) reported that the facility changed to a new electronic medical record system in April 2023 and was unable to provide documents prior to 4/31/2023. The party requesting the records was not informed that records from 2022 to 4/31/2023 were missing in the provided documents. The Nursing Home Administrator (NHA) had sent an email to the corporate office about the inability to access medical records prior to 4/31/2023 due to lack of payment, but no resolution was achieved, and the facility remained without access to these records. A review of facility policies revealed that it was the facility's policy to maintain medical records for a period of 7 years from the date of discharge or a period outlined by payer contracts, whichever is longer. Despite this policy, the facility was unable to fulfill the medical record request due to the transition to a new electronic medical record system and the subsequent lack of access to the old system. The NHA had inquired about updates to allow access to the old medical record system, but no additional documentation related to access was provided. This failure to provide the requested medical records constitutes a deficiency in the facility's compliance with state and federal regulations regarding medical record retention and access.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 380 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Petersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apollo Healthcare & Rehabilitation Center | 1.1 mi | ★★★★★ | 1 | 0 |
| North Healthcare And Rehabilitation Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Marion And Bernard L Samson Nursing Center | 2 mi | ★★★★★ | 0 | 0 |
| Bayside Care Center | 2.1 mi | ★★★★★ | 7 | 0 |
| Alpine Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Golfview Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.