Health inspection·June 4, 2025

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure proper administration related to use of resources to maintain the highest practicable physical wellbeing of each resident. Residents Affected - Many The findings included: During a Life Safety Code annual survey revisit, the surveyors requested a copy of the facility's most recent Emergency Management Plan submitted to and approved by the [NAME] County Emergency Management Office. The facility's administrator provided the surveyors with a document dated 05/08/25. Upon review of this document and documentation provided previously to the surveyors by the County Emergency Management Director, the surveyors came to find this documentation was falsified. A telephone interview was conducted with the County Emergency Management Director on 06/03/25 at 4:01 PM. She confirmed this documentation was falsified as she had not received a submission of the facility's Emergency Management Plan for review. She stated, upon submission of a plan to our office, a form is given to the facility to provide as proof that a plan has been submitted and is under review. If, for whatever reason, a form is not provided at the time a book is dropped off at our office, it is emailed to the submitting facility for their records. She further stated she had changed the county form last year with a new logo so, since the document dated 05/08/25 sported the same logo as the approved plan from 2023, she believed the documentation was falsified. An interview was conducted with the facility's administrator on 06/05/25 at 2:34 PM. She stated she did not know where the falsified letter that she provided to the Life Safety surveyors came from. She stated she found the letter inside the Emergency Plan binder. She confirmed this binder was kept in her office and she was ultimately responsible for the contents of the binder but that the maintenance director also had access to this binder. She confirmed that she is responsible for submitting an Emergency Plan for approval to the County. She stated she had not contacted the County Emergency Management Director since the annual survey or the revisit to submit an Emergency Management Plan for approval. The facility's Executive Director position description states, the Executive Director is responsible for management of the facility in a manner which exemplifies the company's standard of operational excellence. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. As Executive Director, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and Page 1 of 3 105824 105824 06/04/2025 Greenville Nursing and Rehab Center 13455 W US Hwy 90 Greenville, FL 32331

F 0835 Level of Harm - Minimal harm or potential for actual harm ensures compliance with all state and federal regulations. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. Adhere to facility policies and procedures and participate in facility quality improvement and safety programs. Residents Affected - Many 105824 Page 2 of 3 105824 06/04/2025 Greenville Nursing and Rehab Center 13455 W US Hwy 90 Greenville, FL 32331

F 0895 Have a Compliance and Ethics Program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure there was an effective compliance and ethics program in place as evidenced by a falsified Emergency Management Plan approval letter. Residents Affected - Many The findings included: During a Life Safety Code annual survey revisit on 6/3/2025, the surveyors requested a copy of the facility's most recent Emergency Management Plan submitted to and approved by the County. The facility's administrator provided the surveyors with a document dated 05/08/25. Upon review of this document and documentation provided previously to the surveyors by the County Emergency Management Director, the surveyors came to find this documentation was falsified. An interview was conducted with the facility's administrator on 06/05/25 at 2:34 PM. She stated she did not know if the facility had a Compliance and Ethics program. She stated she thought they used to have a program and that when they did, a Human Resources representative was the Compliance officer. When asked to clarify, she then stated that, she as the administrator would be responsible for compliance at the building. When asked if this duty was present in her job description, she stated it was. She stated she did not know where to find information regarding compliance and ethics and she emailed multiple Human Resources representatives. After approximately two hours, she was able to produce the following information contained in her job description, the Employee Handbook, and a policy titled Ethics. Review of the facility's Executive Director position description revealed, the Executive Director is responsible for management of the facility in a manner which exemplifies the company's standard of operational excellence. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. As Executive Director, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensures compliance with all state and federal regulations. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. Adhere to facility policies and procedures and participate in facility quality improvement and safety programs. The facility's policy titled Ethics (revision date 12/11/24) states, it is the policy of Vered Healthcare Group that all employees are governed by the company's policies and procedures and shall conduct company business in a manner which is at all times legal, ethical, and integral and the employee handbook provides general guidelines for employees in order to meet the highest standards of business conduct set forth in the policy statement. The Employee Handbook revealed a section titled Standards of Conduct. This section stated, the company expects all its employees to use good judgement and maintain the highest standards of professionalism at all time As a rule of thumb, conduct which is dishonest, illegal, or improper will not be tolerated and may be grounds for immediate discharge or other disciplinary action. #27-falsification of company documents or records. This list is intended to be representative of the types of activities, which may result in disciplinary action. 105824 Page 3 of 3