Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenbriar Healthcare Rehabilitation And Nursing C during CMS and state inspections, most recent first.
The facility's activities program was overseen by an individual who lacked the required qualifications and certification, as confirmed by both the staff member and the administrator. Facility policy mandates that the activities program be directed by a qualified professional, but this standard was not met.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident with moderate dementia and other complex medical needs was not evaluated by therapy for swallowing and eating concerns because a nurse incorrectly completed both sections of the electronic referral form, preventing therapy from being notified. The facility lacked a policy for nursing competencies, and the nurse involved was new to the system.
A resident with multiple health conditions had critical lab results, including a dangerously low glucose level, that were not promptly reported to the physician by nursing staff. The LPN who received the results did not notify the provider or document recommendations, and the issue was only identified the following day by another nurse. Both the DON and Medical Director confirmed that critical labs should be reported immediately, but the facility lacked a specific policy for this process.
An ARNP failed to use proper PPE and perform hand hygiene while caring for a resident on Special Contact Precautions for C-diff, entering and exiting multiple rooms without following required infection control protocols. The ARNP was unaware of the resident's isolation status and misunderstood precaution signage, leading to noncompliance with the facility's infection prevention policy.
A resident with severe cognitive impairment was burned by hot coffee during a social hour in a facility. The coffee was served without checking the temperature, and the resident spilled it on herself. Staff failed to document the incident or notify the physician promptly, and the resident's family was not informed immediately.
A resident suffered a coffee burn, but the LTC facility failed to notify the physician and the resident's representative in a timely manner. The Medical Director was informed a day later, delaying treatment, and the responsible party was not informed at all. Staff interviews revealed a lack of communication and documentation, with the LPN assuming the ADON would notify the necessary parties. The facility's policy on prompt notification was not followed.
Unqualified Staff Directing Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required by both facility policy and regulatory standards. Review of the employee roster showed that the current Activity Director, Staff M, had been employed since December 2024 but did not possess the necessary qualifications for the position at the time of the survey. During interviews, Staff M confirmed he was serving as the activities director without any formal qualifications, though he was enrolled in classes to obtain certification. The Nursing Home Administrator acknowledged awareness of the requirement for a licensed, qualified professional to oversee the activities program and confirmed that Staff M was not yet certified. Facility policy also specifies that the activities program must be under the direct supervision of a qualified professional, which was not the case at the time of the survey.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a deficiency related to the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Ensure Nursing Staff Competency in Therapy Referral Process
Penalty
Summary
Nursing staff failed to ensure proper competency in completing therapy referrals for a resident with multiple medical conditions, including moderate dementia, diabetes with neuropathy, and failure to thrive. The resident was observed having difficulty drinking without spilling and not feeding himself, with records indicating decreased food and fluid intake and concerns about pocketing medication. Nursing staff initiated a referral to therapy for evaluation of eating and swallowing issues, but the process was not completed correctly. The nurse who initiated the referral completed both the nursing and therapy sections of the electronic referral form and locked it, preventing the therapy department from being notified or able to respond. As a result, the therapy department did not receive or act on the referral, and the resident was not evaluated for the identified swallowing and eating concerns. The facility did not have a policy for nursing competencies, and the nurse involved was new to the facility.
Failure to Timely Report Critical Lab Results
Penalty
Summary
A deficiency occurred when the facility failed to report critical laboratory results in a timely manner for one resident. The resident, who had a history of moderate dementia, type 2 diabetes with neuropathy, and failure to thrive, was observed with changes in eating and self-care behaviors. Laboratory results collected in the early morning showed several critical and abnormal values, including a critically low glucose level of 21 mg/dL, elevated sedimentation rate, high white blood cell count, low hemoglobin, low hematocrit, and other abnormal findings. The facility was notified of these critical results in the afternoon of the same day. Despite receiving notification of the critical lab values, the nurse on duty did not immediately report the results to the resident's physician or document any recommendations. The nurse monitored the resident's blood sugar levels, which were within normal range later that morning, and determined that no further action was needed at that time. The following day, another nurse noticed the critical labs had not been reviewed or reported and subsequently notified the physician. Both the Medical Director and the Director of Nursing confirmed that the expectation was for nurses to report critical lab results to providers as soon as they are notified. The facility did not have a specific policy for reporting critical labs.
Failure to Follow PPE and Hand Hygiene Protocols for Resident on Contact Precautions
Penalty
Summary
A deficiency occurred when an Advanced Registered Nurse Practitioner (ARNP) failed to follow proper Personal Protective Equipment (PPE) protocols and hand hygiene while providing care to a resident on Special Contact Precautions for Clostridium Difficile (C-diff). The ARNP entered the resident's room without donning appropriate PPE or performing hand hygiene, despite the presence of a PPE cart and multiple precaution signs on the door. During the interaction, the ARNP leaned over the resident's bed, touched the bed with her clothing and items in her hands, and used a clipboard, telephone, and ink pen, which were not disinfected between uses. The ARNP then exited the room without washing her hands and proceeded to visit other residents, again failing to perform hand hygiene or use PPE as required. The ARNP was unaware that the resident was on isolation precautions and misunderstood the meaning of Special Contact Precautions, believing it only meant not to touch the resident. The resident involved had a diagnosis of Enterocolitis due to C-diff and physician orders for contact precautions and specific medication. The facility's infection prevention and control policy required staff education and adherence to proper infection control techniques, which were not followed in this instance. The Infection Control Preventionist acknowledged awareness of the incident and the need for improved education for consultant staff.
Resident Burned by Hot Coffee Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from burn hazards during a coffee social hour. The resident, who had severe cognitive impairment and required moderate assistance for eating, was served hot coffee without a lid or handles. The coffee was brewed in the activities room, and the staff did not check the temperature before serving it to the resident. The resident spilled the coffee on herself, resulting in burns, but did not express pain due to her cognitive condition. Multiple staff members were involved in the incident, but there was a lack of communication and documentation regarding the resident's condition and the incident itself. The CNAs present did not notify the nurse immediately, and the nurse did not document the incident or assess the resident's condition. The ADON and LPN were aware of the incident but did not follow up with appropriate documentation or notify the physician in a timely manner. The resident's family was also not informed about the incident until later. The facility's policies on accidents and incidents, as well as meal distribution, were not followed. The coffee was served at a temperature higher than the recommended range, and there was no immediate assessment or treatment for the resident's burns. The lack of documentation and communication among staff members contributed to the delay in addressing the resident's condition and notifying the physician.
Failure to Notify Physician and Family of Resident's Injury
Penalty
Summary
The facility failed to ensure timely notification of a physician and a resident's representative regarding a change in condition for a resident who suffered a coffee burn. The resident, who had been admitted to the facility, spilled coffee on herself during an activity, resulting in blisters and bruising. Despite the incident occurring, there were no immediate assessments, change in condition forms, or SBAR documentation completed at the time of the injury. The physician was not informed until the following day, delaying the initiation of treatment. Interviews revealed that the Medical Director was not notified of the incident until the day after it occurred, and the resident's responsible party was not informed at all. The Medical Director noted that the resident had linear bruising and deflated blisters when he assessed her the day after the incident. The responsible party expressed surprise upon learning about the coffee burns during the interview, indicating a lack of communication from the facility. Staff interviews highlighted a breakdown in communication and documentation. The LPN assigned to the resident was informed of the incident by the Assistant Director of Nursing (ADON) but did not notify the physician or the family, assuming the ADON would handle it. The Nursing Home Administrator and Director of Nursing confirmed the absence of clinical notes, treatment orders, or documentation of the incident in the resident's record. The facility's policy required prompt notification of changes in a resident's condition, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bradenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Point Pleasant | 1.3 mi | ★★★★★ | 6 | 0 |
| Aviata At Bradenton | 1.6 mi | ★★★★★ | 25 | 0 |
| Braden River Rehabilitation Center Llc | 1.8 mi | ★★★★★ | 0 | 0 |
| Manatee Springs Rehabilitation And Nursing Center | 2.7 mi | ★★★★★ | 3 | 3 |
| Riviera Palms Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.