Inspection·November 2, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to provide adequate housekeeping and maintenance services necessary to maintain a safe, clean, sanitary, orderly, comfortable, homelike interior thought the building in common areas as well as resident rooms. The findings include: Kitchen: On 10/31/23 at 11:14 AM, an observation of the kitchen revealed several missing ceiling tiles in the kitchen, specifically over the dishwasher, above the reach in freezer, and above the fire extinguisher and 3 compartment sink. The trim around the remaining tiles appears to have dirt/dust/rust and one tile is bowing. An interview concurrent with this observation with the Certified Dietary Manager (CDM) revealed that maintenance staff is responsible for ensuring the ceiling tiles are clean and or replaced. (Photographic evidence obtained) On 11/02/23 at 11:41 AM, an observation of the kitchen revealed the above issues were still present. On 11/02/23 at 11:57 AM, an interview was conducted with the Maintenance Director while touring the kitchen area. When asked about the missing tiles in the kitchen ceiling, he stated they are going to be working on that now. He stated the ceiling tiles in the kitchen never came to his attention prior to the survey. When asked what the process is for him to know about all the maintenance issues that need to be addressed, he stated he does audits and addresses dire need issues and big issues are brought up by him during meetings. He agreed the current process in place for housekeeping and maintenance issues is not working. He stated staff are supposed to let him know if there are things that need to be addressed, but he has not been notified of these issues prior to the surveyor pointing this out. Rooms 207-210: On 10/30/2023 at approximately 11:10 AM, an initial tour was conducted of the shower room located near the nurses station and rooms 207 to 210. The floors and the walls of the shower room were covered with a thick build of a brown substance. The wall tiles of the shower and grout had a black slimy substance on them. There was a bag of soiled linens laying in a corner of the room. (photographic evidence obtained) The toilet in the bathroom connected to room [ROOM NUMBER] had a thick build of clay colored material around the grout at the bottom of the toilet. (photographic evidence obtained) The toilet in the bathroom connected to room [ROOM NUMBER] had a thick build of clay colored material around the grout at the bottom of the toilet, behind the toilet and in door jams and threshold of bathroom entrance. The floors in the bathroom also had a thick brown build up around baseboards and door jams. (photographic evidence obtained) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105824 If continuation sheet Page 2 of 6 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 105824 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Nursing and Rehab Center 13455 W US Hwy 90 Greenville, FL 32331 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 11/2/23 at approximately 11:10 AM, a second tour of the shower room located near the nurses station and rooms 209 was conducted with the Maintenance Supervisor. During this tour, the floors and the walls of the shower room were covered with a thick build of a brown substance. The wall tiles of the shower and grout had a black slimy substance on them. The bathroom connected to room [ROOM NUMBER]. The toilet was soiled with a brown substance around the rim and on the toilet seat. The bottom of the toilet had a thick build of clay colored material around the grout at the bottom of the toilet, behind the toilet and in door jams and threshold of bathroom entrance. It was also noted that paint on the door frame had a thick brown build up and was cracked (photographic evidence obtained). The surveyor pointed out the buildup on tiles. He explained that the area would be cleaned. 100 hallway: On 10/30/23 at 11:35 through 11/02/23 at 11:50 AM, observation of the 100 hallway and rooms revealed the following: room [ROOM NUMBER] had copper-colored stains inside the toilet, brown-colored substances on two flooring tiles, grey-colored stains on the wall, and water stains on the ceiling. room [ROOM NUMBER] had paint peeling off the wall, tiles in disrepair, and the bathroom door had a sticky substance and dried dripping paint. room [ROOM NUMBER] had a ceiling plank displaced and a ceiling plank with a brown-colored substance. room [ROOM NUMBER] had scratches and brown colored stains on flooring tiles, debris on corners and trim, scratches and stains on the wall, and the television screen was dirty. room [ROOM NUMBER] had a stained floor mat, debris under the sink, dirt in the bed frame, two dirty bedside drawers, and moisture-like stains on ceiling planks. room [ROOM NUMBER] had white-colored dust under the television. room [ROOM NUMBER] had stains on the wall, paint was peeling off the wall, and flooring tiles were stained and in disrepair. The common hallway duct vent had a thick layer of dark grey dust. The floors of the 100 hallway had brown and grey colored stains throughout. On 11/02/23 at 12:10 PM, an interview was conducted with the Maintenance Director while touring the 100 hallway. He stated he was in charge of the Housekeeping and Maintainance at the facility. He stated he did not keep a work log and was writing down the issues brought out to his attention by the surveyors on a piece of paper. He stated the ceiling tiles would be replaced and the floors would be deep cleaned. He stated the rooms are deep cleaned often but he did not keep record of the dates. room [ROOM NUMBER] and 104: On 10/31/23 at 02:25 PM, a brown, thick substance was observed in room [ROOM NUMBER] on the curtain room divider, nightstand, floor mats and several areas of the floor and wall. There was also some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105824 If continuation sheet Page 3 of 6 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 105824 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Nursing and Rehab Center 13455 W US Hwy 90 Greenville, FL 32331 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 0584 Level of Harm - Minimal harm or potential for actual harm paint chipping and cracked floor tiles. Residents did not have access to the closet area because extra chairs and bedside tables were stored right in front of it. On 11/01/23 at 01:38 PM, ceiling tiles were observed to be stained with a brown substance in room [ROOM NUMBER]. Residents Affected - Some On 11/02/23 at approximately 12:20 PM, an interview was conducted with the maintenance director. He stated several ceiling tiles have water stains and he said they change them all the time. When I showed him the amount of dirt behind bed B in room [ROOM NUMBER], he said he has no idea why it's so dirty. He stated the rooms get cleaned regularly but had no idea when the last time it was deep cleaned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105824 If continuation sheet Page 4 of 6 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 105824 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Nursing and Rehab Center 13455 W US Hwy 90 Greenville, FL 32331 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to provide the recommended Pneumococcal Vaccine in accordance with national recommendations of the Center for Disease Control's (CDC's) Advisory Committee on Immunization Practices (ACIP) recommended adult immunization schedule for Pneumococcal Vaccines to 4 of 5 sampled residents. (Residents #9, #1, #42, #36) Residents Affected - Few The findings include: On 11/1/23, a record review was conducted of the face sheet of Resident #9. Her date of birth was on 3/14/1944. Resident #9 was [AGE] years old at the time of the survey. Her original admission date was on 6/2/2010. Resident #9's most recent readmission was on 10/7/22. According to the face sheet, Resident #9 had a diagnosis of Adult failure to Thrive, Feeding Difficulties, Muscle Weakness, Frontotemporal Neurocognitive Disorder, Heart Failure, Dementia, Essential Hypertension, and Nutritional Anemia. A vaccine Consent to receive an Influenza vaccine and Pneumococcal vaccine was signed on 9/12/23. According to the immunization record Resident #9 received a flu vaccine on 10/12/23. There was no pneumococcal vaccine entered on the record. On 11/1/23, a record review was conducted of the face sheet for Resident #1. His date of birth was on 10/15/1950. Resident #1 was [AGE] years old at the time of the survey. His original admission date was on 5/19/2020. His most recent readmission was on 2/20/23. According to the face sheet, Resident #1 had a diagnosis of Type II Diabetes Mellitus, peripheral vascular disease, Essential Hypertension, and Atherosclerotic Heart Disease, Tobacco use, Dementia, and unspecified viral hepatitis C. A vaccine Consent to receive an Influenza vaccine and a pneumococcal vaccine was signed on 9/12/23. According to the immunization record, Resident #1 received a flu vaccine on 10/12/23. There was no pneumococcal vaccine entered on the record. On 11/1/23, a record review was conducted for Resident #42. His date of birth was on 12/2/1942. At the time of the survey he was [AGE] years old. His date of admission was on 3/1/23. Resident #42 has diagnosis of Coronary Artery Disease, Essential Hypertension, Hyperlipidemia, Alzheimer's, Cerebrovascular Accident with Hemiplegia and Hemiparesis, Malnutrition, and Anemia. A vaccine Consent for the Influenza vaccine and pneumococcal vaccine was signed on 9/12/23. According to the immunization record, Resident #42 received a flu vaccine on 10/12/23. There was no pneumococcal vaccine entered on the record. On 11/1/23, a record review was conducted of the face sheet for Resident #36. His date of birth was on 5/30/48. Resident #36 was [AGE] years old at the time of review. His original admission date was on 8/7/2019. His most recent readmission was on 9/26/23. According to the face sheet, Resident #36 had a diagnosis of Alzheimer's disease, Adult Failure to Thrive, Dementia, Poly Neuropathy, Cirrhosis of the liver, Essential Hypertension, and Atherosclerotic Heart Disease. A review of the vaccine consent forms for Resident #36 was conducted. A consent to receive a pneumococcal vaccine was signed on 8/7/19 and on 9/12/23. According to the immunization record, Resident #36 received a dose of pneumococcal vaccine on 11/17/19. There was no record that Resident #36 received the recommended follow up dose of pneumococcal vaccine after signing the consent on 9/12/23. On 11/2/23, a review of the pneumococcal vaccine policy dated March 2022 was conducted. The policy stated that, prior to admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and, when indicated, are offered the vaccine series within 30 days of admission to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105824 If continuation sheet Page 5 of 6 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 105824 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Greenville Nursing and Rehab Center 13455 W US Hwy 90 Greenville, FL 32331 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 0883 the facility unless medically contraindicated or the resident has already been vaccinated. Level of Harm - Minimal harm or potential for actual harm On 11/2/23 at approximately 11:00 AM, an interview was conducted with the Director of Nursing (DON). The consents and immunization records of Residents #9, #1, #42, and #36 were reviewed with the DON. She explained that the Minimum Data Set Nurse (MDS Nurse) does the vaccinations. She explained that they had planned to order the pneumococcal vaccines but have not gotten them together yet. The surveyor pointed out that the facility's Pneumococcal Vaccine Policy stated that residents would be reviewed for eligibility and receive the pneumococcal vaccine within 30 days of admission to the facility. When asked if residents #9, #1, #42, and #36 should have had their pneumococcal vaccines, the DON agreed. Residents Affected - Few On 11/2/23 at approximately 12:30 PM, an interview was conducted with the Minimum Data Set Nurse (MDS) Nurse. She explained that she had planned to order the pneumococcal vaccine vaccines next week. The residents received flu vaccines in October and they wanted to wait a month before giving the pneumococcal vaccine in November. She did not provide an explanation as to why the Influenza vaccines and the pneumococcal vaccine were not given on the same day. The surveyor pointed out that the facility's Pneumococcal Vaccine Policy stated that residents would be reviewed for eligibility and receive the pneumococcal vaccine within 30 days of admission to the facility. The MDS explained that the residents would be getting their vaccines soon. The current Center for Disease Control's (CDC's) Advisory Committee on Immunization Practices (ACIP) recommended adult immunization schedule for pneumococcal vaccines was reviewed with the DON. The immunization schedule can be located at: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105824 If continuation sheet Page 6 of 6