Inspection·January 17, 2024

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were required to sign and document that oxygen tubing and humidifier have been changed. The DON indicated that there was not an area in the medical record for staff to document humidifier or oxygen tubing changes. She explained there was a note on each medication cart instructing night shift (11:00 pm-7:00 am shift) to change the tubing every Wednesday night. A review of the Night Shift Nurse Duty dated 1/23/23 and posted on each medication cart was conducted. It was noted that the form stated Oxygen tubing and nebulizers are to be bagged and labeled every Wednesday. The list did not mention changing the tubing or humidifiers. (Photographic evidence obtained) On 1/17/24, a review of the oxygen administration policy dated 11/2020 was conducted. The policy recommended changing the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Humidifier bottles should be changed when empty and every 72 hours or as recommended by the manufacturer. Delivery devices are to be stored in a plastic bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106045 If continuation sheet Page 2 of 8 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 01/17/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review the facility failed to provide sufficient nursing staff to ensure residents received required assistance in a timely manner during an outbreak when 32 of the 88 residents at the facility had been placed on isolation precautions after testing positive for COVID-19 (Coronavirus Disease 2019). The findings include: Observations On 1/16/24 at approximately 10:15 AM, upon entrance to the facility, the Director of Nursing (DON) explained that there had been an outbreak of COVID-19 infections at the facility. Since 1/6/24, 32 of the 88 residents in the facility had tested positive. Upon entering the facility, 31 of the 88 residents were still under droplet isolation precautions. During the initial interview, multiple call lights could be heard going off continuously in the background. The initial tour of the facility was conducted at 11:00 AM on 1/16/24. During the tour, multiple call lights could be heard going off. There were no staff available at the nurse's station. The phone at the nurse's station was ringing continuously. There were few staff observed in the hallways. At approximately 11:20 AM, the call light in room [ROOM NUMBER] was going off. The room was on droplet isolation precautions due to COVID-19. After a few minutes, Resident #14 opened the door to the room. She was seated in a wheelchair as she waited in the door way for about 10 minutes with no mask on. Nurse B, a Licensed Practical Nurse (LPN), was at the medication cart nearby. She left the medication cart to respond to Resident #14 and explained that the door must be shut as she went into the room to assist the resident. The surveyor observed the call light from room [ROOM NUMBER] going off continuously from approximately 11:30 AM until 12:00 PM. The call light in room [ROOM NUMBER] was also going off from approximately 11:35 AM-12:10 PM. The call light in room [ROOM NUMBER] was going off as well during that time. Rooms 100-1,100-2, 101-2, 102-2, 106-1, 106-2, 110-1,111-2, 121-1, 123-1, 123-2, 130-1, 130-2, 134-1,134-2, 135-1, 135-2, 137-1, 137-2,137-3,138-1,138-2, 142-1, 142-2, 144-1, 144-2, 145-1,145-2, 151-2, and 152-2 were all observed to have been placed on droplet isolation precautions due to testing positive for COVID. Rooms 101-1,102-1, 111-1,121-2, 134-3, 135-3 were additionally on droplet precautions due to exposure to a roommate with a positive COVID test. The resident in room [ROOM NUMBER]-2 was under continuous 1:1 supervision. On 1/17/24, the call light to room [ROOM NUMBER] was going off continuously from 4:05 PM-4:34 PM. Resident interviews On 1/16/24 at approximately 11:50 AM, an interview was conducted with Resident #2. She reported that the she often must wait long periods of time to receive any response when she calls for assistance. Resident #2 said she frequently waits up to an hour or two to get assistance. She explained that response time has been worse over the past few days and also at night and on the weekends. She explained that she uses a walker and receives assistance with bathing due to issues with balance and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106045 If continuation sheet Page 3 of 8 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 01/17/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some falls. She reported that a staff member became frustrated when she asked for help with bathing a few weeks ago and told her she did not have time to assist her in the shower. Resident #2 said, I am not the only one who lives here who has problems getting help. Sometimes they tell you I am too busy to help you. On 1/16/24 at approximately 12:30 PM, an interview was conducted with Resident #8. When she was asked how she liked living at the facility, she responded by explaining that she does not like living at the facility. She stated it takes a long time to get help. She explained that she wears briefs and utilizes a walker but does not get assistance in a timely manner when she calls for help. She explained that sometimes she has to soil her brief because the wait is too long. On 1/16/24 at approximately 12:40 PM, an interview was conducted with Resident #7. She explained that staff tries to get it all done but many times the response is really slow with getting help when needed. On 1/16/24 at approximately 1:00 PM, Resident #1 explained that the staff is very slow answering call lights and it has been worse recently. Sometimes the staff are somewhat rude and frustrated. She stated that she thinks they need more staff to help. She said recently a nurse was in a rush and almost mixed up her and her roommate recently and gave the wrong medication. Her roommate realized it was not her medicine so the error did not occur. She reported that she wears briefs and receives assistance with peri care and showering. She explained that staff often rushes when assisting her with care. She said she has had problems with urinary tract infections and she thinks staff rushing through care might be a contributing factor. In addition to the slow response, staff does not take the time to provide proper care and privacy while providing care. On 1/16/24 at approximately 1:20 PM, Resident #4 said the food is often cold by the time they get it. She tries not to call much because she knows how busy they are. She explained that her roommate helps her quite a bit. She mentioned again that it always takes a long time to get help. Her roommate is going to be discharged soon and she worries how it will be when she has to rely on staff to assist her. On 1/17/24 at approximately 9:48 AM, an observation and interview was conducted in room [ROOM NUMBER]-1 with Resident #11. room [ROOM NUMBER] was under droplet precautions to prevent transmission of COVID 19. Resident #11 said sometimes it takes 10-15 minutes for someone to respond, sometimes much longer. On 1/17/24 at approximately 10:00 AM, Resident #13 was interviewed about care and services. He indicated that he is blind and needs extra help. The resident explained that once in a while it takes a very long time to get help and that is the main problem. Staff interviews On 1/15/24 at approximately 4:00 PM, an interview was conducted with Staff C, a Certified Nursing Assistant (CNA). CNA C explained that she often works the evening and overnight shift. She was asked about her normal assignment. She explained that she often has 18 residents to care for. She explained if a CNA has 18 residents, then 12 of those residents might need complete assistance with care. Some residents require more than one staff member to assist them. She went on to explain that 18 residents is a lot to manage. Staff C said it has been consistently short staffed for the year that she has worked at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106045 If continuation sheet Page 4 of 8 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 01/17/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/17/24 at approximately 9:00 AM, an interview was conducted with Nurse F, a Licensed Practical Nurse (LPN). LPN F explained that they have enough nurses but they need more direct care staff, especially with the recent outbreak of COVID residents being sick and on isolation. They have also had an increase in staff members missing work as well. She explained that the evening and overnight shifts really could use extra staff. Staff struggles to get everything done. When they can't get everything done, they usually pass on what is not completed to the next shift. She explained that the nurses try to help keep up with answering call lights and assist with direct care when they can. On 1/17/24 at approximately 11:15 AM, a follow-up interview was conducted with LPN F. LPN F reported that she has 29 residents today and this is a usual assignment. Most of the time she gets her work completed. The unit managers help and she stays late to complete her work if she needs to. She reported that one resident is currently under 1:1 supervision due to exit seeking behavior which takes up more direct care resources. She reported that there is often call ins and the facility has to make arrangements to cover. On 1/17/24 at approximately 12:20 PM, an interview was conducted with Staff Member K, medical records personnel. She reported she has worked at the facility for more than 10 years. She reports that she works more on the administrative side but helps with feeding and passing trays. She said PBJ (Payroll Based Journal) hours are met but she does not think resident requirements are met. She explained that 90 percent of the time, the work cannot be accomplished. She explained that, due to lack of staff, residents have not been getting showers at times. She voiced concerns with prevention of pressure sores and residents experiencing weight loss. She explained that it is overwhelming and staff is burned out and morale is low. She explained she does pick up shifts as needed. She stated evening and overnight shifts need the most help. She reported that there has been a high turnover in staff due to the workload and other factors. Staff Member K explained that she has been feeling anxious because residents are not getting the care that they need. On 1/17/24 at approximately 12:30 PM, an interview was conducted with Nurse I, another LPN, regarding care and services at the facility. LPN I explained that sometimes medication pass runs over allotted time frame. She feels like they could use one more nurse on day shift. She explained that all the work can be accomplished on good days. Evening and overnight shifts often need extra help. On 1/17/24 at approximately 12:45 PM, an interview was conducted with Staff M, another CNA, who explained that recently they have had less CNA staff working. There have been staff calling in frequently. There has been a lot of turnover in staff recently. CNA M stated that when there are 7 CNAs working on day shift, they can usually get everything done, but today there are only 6 CNAs. She explained that this is the worst she has seen it in the more than 10 years she has worked full time at the facility. She also explained there is too much to do to get everything done. She stated if she is not able to finish her work, she worries about retaliation from management. On 1/17/24 at approximately 1:00 PM, an interview was conducted with CNA L. She works at the facility as needed. She works 16-hour shifts. She explained that she believes the facility is mostly short staffed. If she is not able to complete her work, she lets the nurse know and they pass whatever is left on to the next shift. If they will not help, she will stay and finish whatever needs to be completed. On 1/17/24 at approximately 1:30 PM, an interview was conducted with CNA H . She reported that CNA assignments often range between 15-18 residents at a time. CNA H stated at times it is hard to for them to complete the work. She explained that there are not enough CNA's employed at the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106045 If continuation sheet Page 5 of 8 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 01/17/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete She was asked if the facility increased available staff due to all of the residents on isolation and sick with COVID-19. She said they actually had less staff today. On 1/17/24 at approximately 11:13 AM, an interview was conducted with Staff G, the facility's Scheduler. She stated that, in addition to doing the scheduling, she was also working at the desk to assist with answering phones and watching out for call lights. She was asked if there were staff out today. She explained that two CNA's had called in. They got one covered but she was still looking for coverage for the other. She was asked to describe staffing the last two days. Normally she schedules 8 CNA's for day shift, but that there were 6 CNA's today and 7 yesterday on day shift. The scheduler did not indicate that extra staff were provided to care for the increased needs for all of the residents who were COVID positive. No information was provided that the facility considered increasing available staff to cover for extra needs with so many residents on isolation precautions for COVID. Event ID: Facility ID: 106045 If continuation sheet Page 6 of 8 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 01/17/2024 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)

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with residents and staff, and review of immunization records, the facility failed to offer provide education and offer COVID 19 vaccines in a timely manner for 5 of 5 sampled residents. (Residents #9, #10, #11, #12, and #13) The findings included: On 1/16/24 at approximately 10:15 AM, the Director of Nursing (DON) explained that there had been an outbreak of COVID infections at the facility. Since 1/6/24, 32 of the 88 residents in the facility had tested positive for COVID. As of today (1/16/24), 31 of the 88 residents were still under droplet isolation precautions. On 1/16/23. a review of records for the sample residents was conducted. The record of Resident #9 revealed that he was admitted to the facility on [DATE]. His record did not contain proof that the resident had ever received a COVID vaccine. A declination form was provided indicating that Resident #9 verbally declined the vaccine on 3/23/23. There was no further documentation that the resident had been offered or provided education regarding a booster covid vaccine since 3/23/23. Resident #10 was admitted on [DATE]. The pharmacy record and immunization record for Resident #10 revealed that he received dose 1 of the COVID vaccine on 6/13/22. A declination form was provided indicating that Resident #10 verbally declined the vaccine on 3/23/23. There was no further documentation that the resident had been offered or provided education regarding a booster covid vaccine since 3/23/23. Resident #11 was admitted to the facility on [DATE]. There was a form that indicated Resident #11 consented to receive the COVID vaccine on 3/23/23. Review of the immunization record of Resident #11 revealed that he received a COVID vaccine on 3/31/23. There was no further documentation that the resident had been offered or provided education regarding a booster COVID vaccine since 3/31/23. On 1/8/24, Resident #11 tested positive for COVID-19. Resident #12 had been admitted to the facility on [DATE]. The record of Resident #12 had a form indicating the resident verbally consented to receive the COVID vaccine on 3/23/23. A review of the immunization record of Resident #11 revealed that he received the COVID vaccine on 3/31/23. There was no further documentation that the resident had been offered or provided education regarding a booster vaccine since 3/31/23. Resident #13 was admitted to the facility on [DATE]. His record had a COVID vaccine card that indicated he received the Moderna COVID vaccine on 1/15/21 and 2/12/21. According to the pharmacy record and immunization record for Resident #13, the last COVID vaccine was administered on 11/12/21. A declination form was provided indicating that Resident #13 verbally declined the covid vaccine on 3/23/23. There was no further documentation that the resident had been offered or provided education regarding a booster vaccine since 3/31/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106045 If continuation sheet Page 7 of 8 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 01/17/2024 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)

F 0887 Level of Harm - Minimal harm or potential for actual harm On 1/17/23 at approximately 2:00 PM, an interview was conducted with Resident #9. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 2:10 PM, an interview was conducted with Resident #10. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. Residents Affected - Few On 1/17/23 at approximately 2:15 PM, an interview was conducted with Resident #11. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 2:20 PM, an interview was conducted with Resident #12. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 2:30 PM, an interview was conducted with Resident #13. The resident indicated he would be interested in receiving education and taking the updated COVID vaccine. On 1/17/23 at approximately 3:00 PM, an interview was conducted with the Director of Nursing (DON) regarding the last date residents at the facility were educated and offered a COVID vaccine booster. She explained that some residents received the bivalent booster at the facility last year. She said the updated COVID vaccine with the new antigens that came out in September of 2023 has not yet been offered at the facility. The DON mentioned that staff at the health department came out to help with the COVID outbreak at the facility last week. They offered to help provide resident education. She explained that the facility did provide Flu and Pneumococcal vaccines in October of 2023 but no COVID vaccines were provided at that time. The DON said that the residents at the facility declined the COVID vaccine in October but she did not provide any declamation statements for the COVID vaccine or proof that education was provided in October. The Director of Nursing did provide emails dated 12/27/23 and 1/4/24 from a Center for Medicare and Medicaid Services (CMS) contractor quality advisor regarding COVID vaccine compliance. The email dated 12/27/23 stated that the nursing home was 0% up to date with the updated COVID vaccine as was reported in National Healthcare Safety Network (NHSN). The email noted that the nursing home with a 0% vaccination rate have also had increased rates of COVID 19 cases. The email dated 1/4/24 offered resources to increase vaccine compliance with the updated COVID vaccines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106045 If continuation sheet Page 8 of 8