Health inspection·August 23, 2023

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on interviews, medical record review, and facility policy review, the facility failed to provide a discharge summary for one (Resident #1) of three residents reviewed for discharge, out of a sample of 7 residents. At discharge, Resident #1 was given another person's discharge paperwork potentially hindering him from receiving continuous and coordinated, person-centered care. The findings include: A review of the medical record for Resident #1 revealed an admission date of 6/16/23, and the resident was discharged home on 7/8/23. The resident's diagnoses included hemiplegia (affecting left side), CVA, a fib, seizures, GERD, and major depressive disorder. An admission Minimum Data Set (MDS) assessment, dated 6/22/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. Resident #1 required extensive assistance with activities of daily living (ADLs). A review of Resident #1's nursing summary of stay stated, Resident is discharging home with spouse on 7/8/23. Discharge instructions to be given. A copy of the discharge summary provided by the Administrator did not reveal the resident or resident's representative signature. On 8/22/23 at 4:15 pm, a phone interview was conducted with the wife of Resident #1. She stated that when her husband was discharged from the facility on 7/8/23, he was given someone else's paperwork. She explained they didn't realize it wasn't his discharge summary until two days later when he was at his primary care physician for his follow up appointment. She explained that she called the facility to tell them about the error and the facility asked her to shred the paperwork. During the call she also requested the facility send her the correct paperwork. However, she still has not received her husband's discharge paperwork, and that has delayed his outpatient therapy. On 8/23/23 at 2:40 pm, an interview was conducted with the Administrator. When she was asked what residents receive in regard to discharge paperwork. She replied, They get a list of their medications and a summary of their stay with their home health information, durable medical equipment, where they are going, and upcoming appointments. When asked if the resident or their representative sign the discharge paperwork, she replied, Yes, they are supposed to sign it. When asked if there were there two copies of the discharge paperwork, she replied, Typically, we should keep a signed copy, sometimes the nurses will end up giving them both copies. When asked if a resident doesn't receive a copy of their discharge paperwork at discharge, can they get a copy after discharge, she replied, Yes, and if their physician calls, we can also fax them a copy. When asked if any residents had ever received the the wrong discharge paperwork, she replied, Yes, that did happen once recently. I spoke with her and asked her to please shred the paperwork or bring it to me, she choose to shred it. I believe (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: 105745 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 105745 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Village 4600 Middleton Park Cir E Jacksonville, FL 32224 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)