Health inspection·July 17, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure nursing staff competency related to therapy referrals for one resident (#5) out of ten residents sampled.On 07/14/2025 at 12:30 p.m., Resident #5 was observed sitting up in his bed with his tray table in front of him. He was observed trying to drink out of a cup and spilling fluids on his shirt. On 07/16/2025 at 8:41 a.m. Resident #5 was observed sitting up in his bed sleeping, with his breakfast placed in front of him untouched. The resident did not feed self. Record review of an admission record dated 07/17/2025 revealed Resident #5 was admitted to the facility originally on 9/22/2023 and readmitted on [DATE] with diagnoses to include unspecified dementia, moderate, with psychotic disturbance, need for assistance with personal care, type 2 diabetes mellitus with diabetic neuropathy, unspecified, and failure to thrive. Review of a Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. Review of the Change in Condition (CIC) report dated 06/29/2025 revealed Resident #5's change was reported due to food and/ or fluid intake, decreased or unable to eat and /or drink adequate amounts. The CIC revealed nursing observed, evaluated, and completed the referral to therapy form to have speech evaluate Resident #5. Review of a form Referral to Therapy dated 06/26/2025 revealed Nursing referred Resident #5 to be evaluated by therapy for eating/swallowing due to holding food or medication. The referral revealed the nurse observed Resident #5 pocketing medication. Further review revealed nursing completed section one and two on the referral. On 07/16/2025 at 2:18 PM, an interview was conducted with the Therapy Director. She stated she did not receive an evaluation for Resident #5 on 6/29/2025. While reviewing the therapy referral the Therapy Director stated, The nurse who initiated the referral saved and locked the referral so, therapy was not notified through the electronic system. She stated when a referral is initiated the first section is completed by the person requesting the referral. The second section on the referral is always completed by therapy with a response. However, the nurse completed both sections on the referral, so therapy did not receive the notification. She stated the referral process is whoever requests a therapy referral completes the first section, then the referral would show in the system that the referral is in progress. Then therapy will receive notification, then therapy will complete section two on the referral. The Director of Therapy confirmed his department did not receive the referral because the nurse completed both sections and locked it in the electronic system. On 07/16/2025 at 4:00 p.m. an interview was conducted with the Director of Nurses (DON). She stated when a nurse enters a referral in electronic medical record they are supposed to complete the first section and therapy completes the second section. She stated the nurse completed the referral wrong and that was why the resident was not seen by therapy for the pocketing and swallowing concerns. She stated the nurse that initiated the referral in the system is new so she will provide the nurse with more education. She stated nurses are given education when they are hired on how to use the electronic medical record and how to complete therapy referrals. The facility did not have a policy for nursing competencies. Event ID: Facility ID: 105159 If continuation sheet Page 2 of 9 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 07/17/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interviews, resident interviews, medical record review, and facility policy review, it was determined that the facility failed to ensure all drugs and biologicals were stored in locked compartments and kept under proper temperature controls.Findings included: 1. During a tour of the Rapid Recovery Unit (RRU) medication room on 7/15/25 at 2:30 p.m. an observation of the small, locked medication refrigerator was made with the Director of Nursing (DON). The top open shelf portion of the refrigerator was observed to be covered in hard white frost. The white frost was observed to take up most of the room in the top shelf area.The thermometer inside the refrigerator was observed to read 28 degrees ( ) Fahrenheit (F). The thermometer was shown to the DON and she was asked to confirm the temperature was reading 28 F. She stated yes. She then stated I guess this refrigerator needs to be defrosted.A review of the temperature log for this refrigerator revealed temperatures were recorded twice a day which ranged from 31 F to 38 F from July 1, 2025 thru July 15, 2025. The top of this log had printed information which stated, refrigerator should be between 32 F and 41 F. Observation of medications stored inside this refrigerator revealed three Mounjaro 7.5mg/0.5ml (milliliter) pens with a label that stated refrigerate, do not freeze, and one Orencia Clickject 125mg/ml pen with a label which stated, high alert, refrigerate, do not freeze.The DON was asked if these medications remained stable having been stored at 28 F. She stated I will call the pharmacy.In a second interview with the DON on 7/15/25 at 3:00 p.m., she stated I spoke with one of our pharmacists. He said the Mounjaro must be stored at 36 F to 46 F and is compromised. He told me to remove it and obtain an order to have it replaced. She was asked about the second medication in the refrigerator. She stated I will call back to ask about that one. The DON returned and stated the pharmacist said the Orencia cannot be subjected to freezing and they should discard the dose. The DON said, We will replace the dose by reordering it.On 7/16/24 at 10:15 a.m. an interview was conducted with Staff C,Licensed Practical Nurse (LPN)/Unit Manager for RRU. She was asked who checks the temperatures for the refrigerators in the medication room. She stated the night shift. She was asked who is responsible to defrost the refrigerators. She stated the night shift. She was asked how often they are defrosted. She stated it's based on pharmacy recommendations, when they say to do it, monthly. She was asked if there is a log showing the dates the refrigerator was defrosted. She stated no. She was asked when the refrigerator was last defrosted. She stated I don't know. A review of the facility policy titled Medication Storage (2017, revised as necessary) revealed:Purpose: To provide guidelines for proper storage of medications within the facility.Policy: Medications will be stored in a manner that maintains the integrity of the product ensures the safety of the residents and is in accordance with Department of health guidelines.Procedure:Medication will be stored at the appropriate temperature in accordance with the pharmacy and/or manufacturing labeling. Appropriate temperature will be determined as per the following:Cold place: 36-46 degrees FMedications requiring refrigeration will be stored in a refrigerator that is maintained between 36 -46 F.Refrigerators used for medication storage will contain a thermometer to indicate the temperature within.Temperature will be checked daily to ensure it is within a specified range. If temperature is out of range, the refrigerator thermostat will be adjusted.Refrigerator should be defrosted regularly, if required (every 3-4 weeks).A review of the medication Mounjaro, on the manufacturer's website (www.mounjarolilly.com) revealed this is an injectable medication use to treat type 2 diabetes.Under the instructions for use on the website, it stated:Storage and handling: Store your pen in the refrigerator between 36 F to 46 F. You may store your Pen at room temperature up to 86 F (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 3 of 9 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 07/17/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for up to 21 days. Do not freeze your Pen. If the Pen has been frozen, throw the Pen away and use a new Pen. A review of the medication Orencia, on the manufacturer's website (www.Orencia.com) revealed this is an injectable medication used to treat rheumatoid arthritis. Under the frequently asked questions on the website, it stated: How should I store my Orencia prefilled syringe or autoinjector? Store Orencia in the refrigerator at 36 F to 46 F until you are ready to use it. DO NOT freeze Orencia. 2. On 7/14/25 at 11:45 a.m., during an interview with Resident #3, there was a large box (approximately 3 feet by 2 feet in size) observed on the floor of his room. The box was against the wall and visible as you walked into the resident's room. The box flaps were open which exposed the contents on the top as visible. Three medication cards (the style of medication cards used by the facility) were visible at the top of the top contents. The resident was asked permission to remove the medication cards from the box, and he agreed. The medication cards were found to contain: Card 1: Tamsulosin capsules 0.4mg (milligram) (22 tablets); a prescription medication used to treat benign prostate hyperplasia.Card 2: Finasteride 5mg (25 tablets); a prescription medication used to treat benign prostate hyperplasia.Card 3: Oxycodone IR (immediate release) 20mg (5 tablets); a prescription medication used to treat moderate to severe pain. This medication is also classified as a Schedule II controlled substance by the USDEA (United States Drug Enforcement Agency.)The observation revealed each card had this resident's name on the card from [Name of Pharmacy]. The resident was asked if he knew why the medications were in his box on the floor. He stated no, I don't know, they just came with my stuff. He was asked if anyone had gone through the box. He stated no. He was asked where the box came from, and how long it's been in his room. He stated I don't know, I think it came with me when I came here. He was asked if he needed staff to assist him to go through the box. He stated no.On 7/14/25 at 3:30 p.m., The DON was asked to come to Resident #3's room. Resident #3 was observed in his room. He was asked if the DON could look in the open box on his floor, he stated yes. The DON was asked why there were medication cards in this box, unattended in the resident's room. She removed a total of 5 medication cards from the box (3 were visible right on top, 2 were under other items.) The additional two medication cards were:Card 4: Eliquis 5mg tablets (25 tablets); a prescription medication used to treat and prevent blood clots.Card 5: a second card of Oxycodone IR 20mg (10 tablets); a prescription medication used to treat moderate to severe pain. This medication is also classified as a Schedule II controlled substance by the USDEA. The DON stated the family brought this box in. She stated this box did not come with Resident #3 when he arrived to the facility on 6/26/25. The resident then stated he thought the box came with him when he arrived but stated he wasn't sure. He then stated he went through the box, but he didn't take any of the medications in the box. The DON removed the medication cards from the resident's room. In a continued interview, the DON stated the family must have brought the box in over the weekend, because she was in his room on Thursday and she stated she would have noticed this box on the floor if it were there. She stated she will have a Certified Nurse's Aide (CNA) come in to inventory the remaining items in the box. She was asked if the cards were from the pharmacy the facility uses. She stated yes, I think these went home with him when he was discharged from here to an Assisted Living Facility (ALF) on 6/11/25. She was asked to confirm what the medications were. She stated Eliquis, Tamsulosin, Finasteride, and two cards of Oxycodone. She was asked what the process is when residents or family brings items into the facility. She stated staff would add the items to the residents' inventory. She was asked if the items in this box were added to the resident's inventory. She stated no, I don't think so. On 7/14/25 at 3:50 p.m. an interview with Staff A, LPN/weekend supervisor. She was asked if she saw family bring in this box over the weekend. She stated I didn't see any visitors for Resident #3 this weekend, but I was back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 4 of 9 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 07/17/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete with activities.On 7/14/25 at 3:55pm, during an interview with Staff B, Registered Nurse (RN) who was caring for Resident #3 today, she stated she had just spoken to Resident #3. Staff B siad, he told me his family brought the box in a few days ago, but he didn't know what was in the box. A medical record review for Resident #3 revealed a Minimum Data Set assessment was conducted on 6/30/25. This assessment revealed a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment.Further medical record review revealed the following current medication orders for Resident #3:6/27/25: Tamsulosin HCl Oral Capsule 0.4 MG: one capsule by mouth daily 6/27/25: Finasteride 5mg: one tablet by mouth daily6/26/25: Eliquis 5mg: one tablet by mouth twice daily6/26/25: Oxycodone 20mg: one tablet by mouth every 6 hours as needed for chronic pain A review of the facility policy titled Medication Storage (2017, revised as necessary) revealed:Purpose: To provide guidelines for proper storage of medications within the facility.Policy: Medications will be stored in a manner that maintains the integrity of the product ensures the safety of the residents and is in accordance with Department of health guidelines.Procedure:With the exception of Emergency Drug, all medications will be stored in a locked cabinet, cart, or medication room that is accessible only to authorized personnel, as defined by facility policy.Medications will be stored in an orderly, organized manner in a clean area. (Photographic Evidence Obtained) Event ID: Facility ID: 105159 If continuation sheet Page 5 of 9 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 07/17/2025 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to report critical labs in a timely manner for one resident ( #5 ) out of ten residents sampled. On 07/14/2025 at 12:30 p.m., Resident #5 was observed sitting up in his bed with his tray table in front of him. He was observed trying to drink out of a cup, spilling fluids on his shirt. On 07/16/2025 at 8:41 a.m. Resident # 5 was observed sitting up in his bed sleeping, with his breakfast placed in front of him untouched. The resident did not feed self. Record review of an admission record dated 07/17/2025 revealed Resident #5 was admitted to the facility originally on 9/22/2023 and readmitted on [DATE] with diagnoses to include but not limited to unspecified dementia, moderate, with psychotic disturbance, need for assistance with personal care, type 2 diabetes mellitus with diabetic neuropathy, unspecified,and failure to thrive. Review of a Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had a Brief Interview Mental Status (BIMS) score of 09, which indicated Moderate cognitive impairment. Review of a Laboratory report with a collection date of 6/7/25 at 6:00 a.m. revealed the facility was notified on 6/7/2025 at 1:49 p.m. of Resident # 5's critical lab results.Review of the lab results for Resident #5 revealed the following:Sedimentation Rate results 72, millimeters per hour (mm/hr) , reference range 0-25, high ( H) final statusComplete Blood Count ( CBC) with auto DifferentialWhite Blood Count (WBC) results 13.3, kilo units per microliter ( K/uL), reference range 4.1-10.9, High (H) Final StatusRed Blood Count ( RBC) results 3.58, million per microliter, reference range 4.70-6.10, low (L) final statusHemoglobin ( HGB) results 10.0, grams per deciliter ( g/dL), reference range 14.0-18.0, low (L) final statusHematocrit ( HCT), results 31.2, percentage, reference range 42.0-52.0, low ( L), final statusPlatelet Count ( PLT), results 495, kilo units per microliter ( K/uL), reference range 130-440, high ( H), final statusNeutrophils ( NE#), results 9.8, L X10^3/u 2.0-6.9, High ( H) final statusComprehensive Metabolic Profile with eGFR Florida -Glucose , results 21 reviewed, millimeters per deciliter ( mg/dL) 70-99, critical low ( LL) final statusBlood Urea Nitrogen ( BUN) , results 34, millimeters per deciliter ( mg/dL ) 6-20, high ( H), final status. On 07/16/2025 at 12:00 p.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN)/ Weekend supervisor. Staff A stated the resident was getting weekly labs drawn by the infectious disease doctor. He was on antibiotics for an infection in his heel. He had a critical lab on 6/7/25 due to his glucose level reported as 21. Staff A, LPN stated while reviewing the labs the nurse that received the call from the lab should have notified the doctor and documented the doctor's recommendations. She stated it looks like the resident's labs were drawn at 6:00 a.m. Staff A, LPN stated the nurse took the resident's blood sugar at 7:30 a.m., with the reading showing a blood sugar level (BSL) of 118. She stated the nurse took his blood sugar again at 11:30 a.m. and his reading showed a BSL of 172. Staff A, LPN stated at that time the nurse did not need to do anything for the resident because his reading was normal. Staff A stated there were no other labs drawn on this resident because the infectious disease doctor discharged the resident from their services. She stated when she came to work the next day, she noticed the critical labs were not reviewed and reported this to the resident's doctor. Staff A, LPN stated she pulled the labs and texted the doctor and placed the results in his folder. She stated the doctor doesn't like to be notified on the weekend if it was not an emergency. On 07/16/2025 at 4:44 p.m., an interview was conducted with the Medical Director. He stated he was the provider for Resident #5. He stated the nurse should have reported the critical labs results to him when she was notified about the lab results. On 07/17/2025 at 11:00 a.m., an interview was conducted with the Director of Nurses (DON). The DON stated her expectation was nurses should report critical labs to providers when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 6 of 9 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 07/17/2025 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete they are notified about the labs. The DON stated the Medical Director does not like to be contacted on the weekends. Review of the facility policy titled, Diabetes - Clinical Protocol Revised on September 2017, revealed - Monitoring and Follow-up, 1. The physician will follow up on any acute episode associated with a significant sustained change in blood sugars or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. 5. The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia. The Nurse administration stated they did not have a specific policy related to reporting critical labs. Event ID: Facility ID: 105159 If continuation sheet Page 7 of 9 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 07/17/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility did not ensure proper Personal Protective Equipment (PPE) for Contact Precautions were used for one resident (#60) out of thirty-three residents sampled. Residents Affected - Few Based on observation, interviews and record review, the facility did not ensure proper Personal Protective Equipment (PPE) for Contact Precautions were used for one resident (#60) out of thirty-three residents sampled. On 7/15/2025 at 12:42 p.m., an observation was made of Staff L, Advance Nurse Practitioner, Geri-Med psychotherapist. Staff L, ARNP, entered Resident #40’s room without proper donning of appropriate PPE and/or handwashing. Outside Resident #40’s room was a cart containing PPE and three signs on the door for “Special Contact Precautions”. An observation was made of Staff L, ARNP, entering Resident #40’s room, leaning over her bed while interviewing the resident, touching the side of the bed with her clothing and items in her hands. Staff L, ARNP, was observed holding a clipboard with papers, a telephone and an ink pen in her hands. On 7/15/2025 at 12:46 p.m., Staff L, ARNP exited Resident #40’s room without washing her hands and walked across the hallway to the next resident in room [ROOM NUMBER]-B. An observation was made of Staff L, ARNP, during her rounds with the resident in 39-B. Staff L, ARNP, placed her clipboard with papers on the resident’s bedding and her telephone and ink pen were in her hand. Staff L, ARNP, exited room [ROOM NUMBER]-B without performing proper hand hygiene (alcohol based or soap and water) upon exiting or entering the next room. Staff L, ARNP, crossed the hallway to enter room [ROOM NUMBER] and was observed leaning against the footboard of the resident in 41-A. Staff L, ARNP, was observed moving to interview the resident in 41-B while the resident was eating her lunch. Staff L, ARNP, was observed exiting room [ROOM NUMBER] without hand hygiene (alcohol based or soap and water). At this time, the Director of Nursing (DON) arrived, and instructed Staff L, ARNP about Special Contact Precautions. Staff L, ARNP, stated she was unaware Resident #40 was on any isolation precautions and stated to the DON she did not notice the signs on the door and stated she thought Special Contact Precautions meant not to touch the resident. The DON educated Staff L, ARNP, of proper handwashing before entering and exiting any residents’ room and Resident #40 required hand hygiene with soap and water due to a diagnosis of Clostridium Difficile. Staff L, ARNP, expressed understanding of the directions and proceeded down the hallway without performing hand hygiene. The DON stated she would speak to Staff L, ARNP again. On 7/17/2025 at 11:41 a.m., an interview was conducted with the Infection Control Preventionist (ICP) during the Infection Control task. The ICP stated she was aware of the observations involving Staff L, ARNP. The ICP stated she has to do a better job addressing and educating the consultant staff members who come into the facility. A record review of Resident #40’s admission Record showed an initial admit date of 4/28/2025 with a readmit date of 6/08/2025. Diagnoses for Resident #40 include but are not limited to Enterocolitis due to Clostridium Difficile (C-diff), not specified as recurrent. A record review of Resident #40’s current physician orders include but are not limited to: · Contact precautions for C- diff every shift and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 8 of 9 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 07/17/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm · Vancomycin HCL 25 milligrams/milliliter solution reconstituted, give 5 milliliters by mouth every six hours for Infection for nine days. A review of the facility’s policy and procedure titled, “Infection Prevention and Control Program” revised in October 2018 showed the following policy statement: Residents Affected - Few An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. … 3. The infection prevention and control program is a facility -wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. … 11. Prevention of Infection a. Important facets of infection prevention include: 3. Educating staff and ensuring that they adhere to proper techniques and procedures FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105159 If continuation sheet Page 9 of 9