Health inspection·July 23, 2021

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the NHA stated, Unfortunately we were not able to find that form [The Nursing Home Transfer and Discharge Notice], it's usually in the EMR, and looks like the nurses did not do it. During a telephone interview conducted with Resident #59's spouse on 07/23/2021 at 11:39 a.m., she was asked if the facility sent her a letter, email or called her to ask her to sign the Nursing Home Transfer and Discharge Notice, Resident #59's spouse stated, I did not get anything, they did not call me, but a nurse did call me to tell me he [Resident #59] was taken to the hospital on 7/20/2021. A facility provided policy titled, Transfer or Discharge Notice, Revised December 2016, Page 01 of 02 under Policy Interpretation and Implementation was reviewed and read as follows: 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. The transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility. f. An immediate transfer or discharge is required by the resident's urgent medical needs. 3. The resident and or representative (sponsor) will be notified in writing of the following information: a. The reason for the transfer or discharge. b. The effective date of transfer or discharge. c. The location to which the resident is being transferred or discharged . e. The facility bed hold policy. 5. The reasons for the transfer or discharge will be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 2 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide a Bed Hold/Return Policy before a transfer to the hospital for one (Resident #59) and/or representative of three closed resident records sampled. Findings included: A record review of Resident #59's profile sheet revealed that he was admitted into the facility on [DATE] with diagnoses of ventricular tachycardia, chronic kidney disease, congestive heart failure, and Type II Diabetes with hyperglycemia. Record review revealed a progress dated note dated 07/20/2021(untimed) that read as follows. At 1700 (5:00 p.m.) Patient had an episode of vomiting while in bed, was seen by in house RT (Respiratory Therapist) at the time due to shortness of breath (SOB), breathing treatment was given and respiration improved. At 1820 (6:20 p.m.) the resident presented with increased respiration difficulty and O2 saturations of 80% on room air, PRN O2 (as needed) applied. sat(saturation) rose to 95%. Patient had greater confusion and restlessness. On 07/20/2021 at 1826 (6:26 p.m.), a Situation, Background, Assessment, Recommendation (SBAR) was initiated by nursing for diagnoses of altered and change in mental status and shortness of breath (SOB). A progress noted written at 18:35 (6:35 p.m.) indicated that his spouse was notified of his change in condition and transfer to the hospital, per physician order. A further record review of Resident #59's medical record revealed that it did not contain a Bed Hold/Return policy for the transfer to the hospital on 7/20/21. An interview was conducted with the Nursing Home Administrator (NHA) and Regional Nurse on 7/22/2021 at 12:01 p.m. During the interview they were informed that Resident #59 did not have a Bed Hold/Return policy in his medical record. The NHA indicated that all Bed Hold/Return policy paperwork was maintained in the documents section of the Electronic Medical Record. (EMR). The NHA revealed she could not find the form, in Resident #59's EMR, and would check with the facility business office to see if it was or was not scanned into the resident's EMR. A subsequent interview was conducted with the NHA on 07/22/2021 at 1:19 p.m. During the interview the NHA stated, Unfortunately we were not able to find that form, we looked and could not locate the Bed Hold Notice, it's usually in the EMR, and looks like the nurses did not do it. During a telephone interview conducted with Resident #59's spouse on 07/23/2021 at 11:39 a.m., she was asked if the facility sent her a letter, email, or called her regarding the Bed Hold/Return Policy. Resident #59's spouse stated, I did not get anything, they did not call me, but a nurse did call me to tell me he [Resident #59] was taken to the hospital on 7/20/2021. A facility provided policy titled, Bed-Holds and Returns, Revised 3/2017, Page 01 of 01 under Policy Statement read as follows: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold return policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 3 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0625 Policy Interpretation and Implementation: Level of Harm - Minimal harm or potential for actual harm 1. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy Residents Affected - Few 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the residents regarding bed-holds. b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or hold a bed beyond the state bed-hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer.) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 4 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews, and policy review, the facility did not ensure the care plan was followed related to 1. one (Resident #11) of two residents reviewed for tube feeding, 2. one (Resident #57) of one resident reviewed for edema, and 3. one (Resident #61) of two residents reviewed for oxygen and respiratory care. Findings included: 1. Resident #11 was admitted to the facility with diagnoses of cerebral infarction and dysphagia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 2, indicating severe cognitive impairment. Further review of the assessment reflected in Section G, Functional Status, total dependence for eating with one person physical assistance. Section K, Swallowing/Nutritional Status, reflected Resident #11 had a feeding tube. A review of the care plan in the electronic medical record dated 6/18/18, reflected a Focus for: the resident required tube feeding r/t (related to) dysphagia, swallowing problem, CVA (cerebrovascular accident). Interventions included administer tube feeding and flushes as ordered (see current physician's orders and MAR (medication administration record). Review of Nutrition/Dietary notes in the electronic medical record dated 6/30/21 revealed the following: Following resident due to NPO (nothing by mouth) status and on TF (tube feed) for nutrition and hydration needs. Has orders for PEG (percutaneous endoscopic gastrostomy) [brand name of formula] tube feedings at 60 ml/hr (milliliters/hour) times 20 hours, auto flushed with 40 ml/hr water times 20 hours. TF off from 10:00 am to 2:00 pm. Tolerates TF. Weight is 176 # (pounds) and showed a weight loss of 3.2% times 30 days. Prior to this month was stable. Recommend increase TF 70 ml/hr times 20 hours, auto flushed with 60 ml/hr times 20 hours. A review of the physician's orders in the electronic medical record reflected an order dated 6/30/21 [brand name of formula] via feeding tube at 70 cc/hr (cubic centimeters or milliliters) per hour, for 20 hours with auto flushes at 60 cc/hr times 20 hours. Off at 10:00 and on at 14:00. On 7/22/21 at 9:21 a.m. an observation was conducted. Resident #11 was lying on his back in his bed with the head of the bed raised to approximately 45 degrees. The [brand name of formula] tube feeding was running through the tubing connected to the resident's abdomen, and the rate was set at 60 ml (milliliters) an hour with a water flush set at 40 ml an hour. *Photographic evidence was obtained. On 7/22/21 at 11:29 a.m., an observation and interview was conducted with Staff A, RN (Registered Nurse) in Resident #11's room. Staff A, RN confirmed that the setting on the tube feeding pump was at 60 ml/hr and 40 ml/hr water flushes. Staff A, RN said, He has been on that rate forever. Upon reviewing the current physician order in the electronic medical record, Staff A, RN confirmed the correct setting was 70 ml per hour. Staff A, RN also confirmed the water flushes were supposed to be set to 60 ml per hour. Staff A, RN also confirmed the emar (electronic medication administration record) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 5 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflected a tube feeding rate of 70 ml per hour for 20 hours, and auto flushes at 60 ml per hour. Staff A, RN confirmed the order was dated 6/30/21, with a start date of 7/1/21. On 7/22/21 at 4:32 p.m., an interview was conducted with the DON (Director of Nursing), Regional Nurse Consultant, and NHA (Nursing Home Administrator). The DON verified that the 6/30/21 dietary note said [brand name of formula] at sixty an hour and flushes at forty an hour for twenty hours. The Regional Nurse Consultant said they increased it on 7/1/21 to seventy an hour and sixty an hour water flushes. The photographic evidence was shared with the DON at that time. She confirmed the photographic evidence revealed the setting on the tube feeding was incorrect. On 7/23/21 at 1:09 p.m. an interview was conducted with Staff B, RN unit manager. Staff B, RN said the nurse should set the tube feeding to the rate that's ordered. The Registered Dietician puts the order in. The new order should be communicated in report. Review of the policy, Enteral Nutrition, revised 11/2018, reflected the following relevant information: Policy Statement Adequate nutritional support through enteral nutrition is provided to residents as ordered. Policy Interpretation and Implementation 11. The nurse confirms that the orders for enteral nutrition are complete. Complete orders include: e. Volume and rate of administration f. the volume/rate goals and recommendations for advancement toward these goals and g. Instructions for flushing (solution, volume, frequency, timing, and 24-hour volume). 2. Resident #57 was admitted to the facility with a diagnosis of cardiogenic shock, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] reflected a BIMS score of 15, indicating Resident #57's cognition was intact. Further review of the assessment reflected Resident #57 required extensive assistance of two persons for bed mobility. At the time of the assessment the resident also had an unstageable pressure ulcer and venous or arterial ulcer. A review of the physician's orders in the electronic medical record reflected an order dated 6/17/21 sponge boots to bilateral heels while in bed every shift for wound care. Review of the care plan dated 7/21/21 revealed a Focus for: Resident #57 had a potential skin impairment/pressure ulcers r/t requires staff assist to turn and reposition, incontinence of bowel, incontinence of bladder, has variable or poor appetite. Interventions included apply/remove foam boots to LE (lower extremities) as ordered. A review of the medication administration record (MAR) in the electronic medical record reflected the order had been signed every day during the month of July 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 6 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0656 Level of Harm - Minimal harm or potential for actual harm On 7/23/21 at 8:52 a.m., an observation was conducted. Resident #57 was sitting up in her bed eating breakfast. She was wearing non- skid socks on her bilateral feet. The sponge boots were not on. Bilateral lower extremity edema of 3+ was noted. Her feet were not elevated, nor were any sponge boots observed in the room. In an interview with Resident #57 conducted at the time of the observation, she said they have never given her any foam boots, just the socks with the skids she is wearing. Residents Affected - Some On 7/23/21 at 8:57 a.m., an interview was conducted with Staff D, CNA (certified nursing assistant). Staff D, CNA said she put a pillow under Resident #57's feet and elevated them while the resident was in bed. Her feet start swelling toward the end of the day after she had been up a while. Staff D, CNA said the resident did not have any heel lifts that she knew of. On 7/23/21 at 12:37 p.m., an interview was conducted with Staff E, RN. Staff E, RN said, [Resident #57] went to the long term care side for a little while. When she came back to this private room she didn't come back with the sponge boots. She gets up in the morning and stays up most of the time. When she was here before she was in bed more. If the resident is in bed too much she wants them in the boots. But when she came back over to this unit she was up more, so the sponge boots 'weren't a priority on her [Staff E] shift.' She gets skin prep on her heels. She had an area on the left leg I consulted the wound care doctor and it is better. The right leg looked like she banged it and was swollen, so I called the doctor to see if we need to rule out a DVT (deep vein thrombosis). During the interview the resident's room was inspected for the sponge boots and they were not found. Resident #57 was sitting in her wheel chair in the room with shoes on. On 7/23/21 at 12:58 p.m., an interview was conducted with Staff B, RN unit manager. Staff B, RN said specialty equipment came from a company they call and have it delivered. Everybody was responsible for making sure the equipment came back with the patient when they were transferred from another room. Her heels have resolved so the sponge boots should have been taken off the orders. On 7/23/21 at 3:52 p.m., an interview was conducted with the DON, who said, They need to follow the order. 3. Resident #61 was admitted to the facility with a diagnosis of cerebral infarction, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] reflected a BIMS score of 4, indicating severe cognitive impairment. Review of the care plan dated 10/13/20 reflected a Focus for: the resident has actual/potential altered respiratory status related to: COPD (chronic obstructive pulmonary disease). Interventions included administer oxygen as ordered via O2 (oxygen) concentrator: 2 L (liters) via NC (nasal cannula) continuously and prn (as needed). Review of the physician's orders in the electronic medical record revealed an order dated 4/2/21 for oxygen at 2 liters/minute with humidification as needed every shift related to shortness of breath. On 7/21/21 at 10:48 a.m., an observation was conducted. Resident #61 was sitting in a wheel chair at the bed side in his room, wearing a nasal cannula. The setting on the concentrator was three liters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 7 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 7/22/21 at 3:13 p.m., another observation was conducted. Resident #61 was in the bed with the oxygen concentrator set at three liters. On 7/22/21 at 3:21 p.m., an observation and interview was conducted with Staff A, RN. Staff A, RN confirmed the setting on the concentrator was three liters. *Photographic evidence was obtained during the observation. On 7/22/21 at 4:53 p.m., the photographic evidence was shared with the DON. In an interview conducted at that time, she confirmed the order was for two liters and the setting in the photo was three. On 7/23/21 at 1:07 p.m., an interview was conducted with the unit manager, Staff B, RN. Staff B, RN said the nurse should be observing the oxygen flow rate when she went in the resident's room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 8 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility did not ensure proper testing and monitoring of the dishwasher sanitization solution (chlorine) for the low temperature dish machine used to wash all resident dishware for the facility. During a tour of the facility kitchen on 07/22/21 at 10:20 a.m., the low temperature dish machine was observed. The Certified Dietary Manager (CDM) was present and performed a wash, rinse, and sanitization cycle with the machine for a tray of eating utensils used by the residents. He demonstrated use of a pH (scale of how acid or basic a solution is) testing strip to measure the parts per million (ppm) of the chlorine sanitizing agent. He placed the strip on the utensils to gather the water that was collected there and measured the color of the strip against a guide to determine the ppm The test strip result was observed below 50 ppm and the CDM confirmed that reading. He said the ppm was supposed to be around 100 and confirmed the reading was not acceptable. He confirmed that kitchen staff were expected to test the pH of the sanitizer three times a day (breakfast dish cycle, lunch dish cycle, dinner dish cycle). The log for July 2021 was reviewed and revealed all entries for 7/1 - breakfast 7/22 were 100 ppm except the following: out of service dinner 7/5 breakfast - dinner 7/7; lunch 7/13-7/15 were entered as 120 ppm Photographic evidence obtained. An interview was conducted on 07/22/21 at 11:03 a.m. with the CDM. He said he had called the dish machine vendor; they had advised changing the chemical bucket and re-priming the machine, but the result was not improved. He said he primed and completed 4 cycles to no avail and the ppm results for the sanitizer were still between 25 ppm and 50 ppm He said he had informed the Administrator (NHA) and his Regional Director of Operations (RDO). He said the NHA was contacting a locksmith to come to the facility to unlock the machine so he could adjust the sanitization levels. The CDM said that once the machine was unlocked, he would have the machine vendor talk him through what to do on the telephone. Given that lunch service needed to begin soon, the CDM said that if he could get the machine fixed in time to re-wash all the dishware before lunch, he would do that, but if not, he would serve lunch with disposable ware. Concern was expressed about the dish machine log entries for chemical sanitizer accuracy given the observation conducted that day and given that he did not have access to adjust sanitizer levels for the machine. He said, I think your concern is probably correct about that, and said, ultimately the responsibility falls on me. He said his course of action would be an in-service and said he had not trained the staff himself on the process for testing and logging chemical sanitization since starting in the position at the facility. He said, I have not been testing it myself since I've been here .again ultimately the responsibility comes to me. The CDM said that part of his daily routine going forward would be to test the machine himself and said, Knowing what I know now I will actually check it myself and watch them do it .I will do it every day until I feel confident it's being done correctly. He identified that one of the kitchen staff had logged the entry for 7/22/21 breakfast but had left for the day. Lunch on 07/22/21 was served using disposable dishware. At 12:00 p.m. on 07/22/21 the CDM reported he was able to fix the chemical sanitization levels due to gaining access to locked compartment. pH test revealed in acceptable range close to 100 ppm A follow-up visit to the kitchen was conducted on 07/23/21 at 9:36 a.m. Staff H, Dietary Aide was interviewed. She confirmed her usual shift was 6:00 a.m. - 2:00 p.m. and she was responsible for washing dishes and testing and recording chemical sanitization levels. She confirmed she had worked the morning of 07/22/21 but had left her shift early. Regarding recording the ppm she said, whatever it say we put it on there .supposed to be 50 at the most. Staff H could not answer why the chemical sanitization was tested, what the results meant, or what action steps to take depending on the results. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 9 of 10 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 105159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/23/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenbriar Healthcare Rehabilitation and Nursing C 210 21st Ave W Bradenton, FL 34205 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The CDM was interviewed and confirmed that the initials entered in the log for breakfast entry on 07/22/21 were his and said, I didn't actually test it .I'm just as guilty for not testing it. He said he had entered 100 ppm because most of the other entries were 100 and he assumed that it was 100 without testing it. An interview was conducted with the kitchen RDO on 07/23/21 at 3:35 p.m. He said he was working with the dish machine vendor on the chemical sanitization process. He said he had conducted in-services with the facility kitchen staff on 06/01/21 and 07/21/21 that included process for dish machine use and testing. He provided documentation. Review revealed that on 07/15/21 kitchen staff were evaluated on low temperature machine sanitizer ppm testing. Facility policy titled Ware washing dated October 2019 revealed: It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. Policy action steps included: The Dining Services Director insures that the nutrition service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dishware .The Dining Services Director is responsible for insuring appropriate completion of temperature and/or sanitizer concentration logs as appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 10 of 10