Inspection·August 24, 2023

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to provide a Notice of Transfer Discharge for 3 of 3 residents reviewed for Transfer Discharge Notices. (Residents #53, #77 and #94) The findings include: A record review for Resident #94 revealed that the resident was admitted on [DATE] and was transferred to the hospital on 5/21/23 due to a change in condition. There was no evidence that Resident #94 or the responsible party was provided a Notice of Transfer/Discharge or a Bed Hold Policy upon transfer to the hospital. A record review for Resident #77 revealed that the resident was admitted on [DATE] and was transferred to the hospital on 8/11/23 due to a change in condition. There was no evidence that Resident #77 or the responsible party was provided a Notice of Transfer/Discharge or a Bed Hold Policy upon transfer to the hospital. A record review for Resident #53 revealed that the resident was admitted on [DATE] and was transferred to the hospital on 8/4/23 due to a change in condition. There was no evidence that Resident #53 or the responsible party was provided a Notice of Transfer/Discharge or a Bed Hold Policy upon transfer to the hospital. On 08/24/23 at 11:53 AM, an interview was conducted with the Director of Nursing (DON). When asked to provide the documentation that these residents received the Notice of Transfer/Discharge and Bed Hold Policy, she stated she was not aware if this was provided to the Ombudsman or the resident at the time they were transferred out of the facility to the hospital. She confirmed this documentation was not in the medical record. On 08/24/23 at 12:07 PM, an interview was conducted with the Social Services Director (SSD), who provides the Discharge Transfer logs to the Ombudsman on a monthly basis. She stated she has never known or been trained to send any other forms with the residents or to the ombudsman. She was not aware of the Discharge/Transfer Notice form. At this time, the SSD confirmed the facility has not been completing these forms for any residents who have been transferred out to a higher level of care ever since she started in this position. She stated was not aware that this notice and the bed hold policy must be provided to the residents upon transfer because the facility intended to readmit the residents. 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 2 Event ID: 106045 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 106045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/24/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brynwood Health and Rehabilitation Center 1656 South Jefferson Street Monticello, FL 32344 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)