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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 105824 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 06/04/2025 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)