Cycle 1
Health 2024-12-12 · Fire 2024-12-12
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Monticello, FL
Brynwood Health And Rehabilitation Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies
1656 South Jefferson Street, Monticello, FL
(850) 997-1800
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
2002-05-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
94 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.14
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,894
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.47
Baseline 22.78% · Performance 21.64% · Measure score 1.47 · Achievement 0 · Improvement 1.47
Healthcare-associated infections
2.63
Baseline 6.94% · Performance 7.05% · Measure score 2.63 · Achievement 2.63 · Improvement 0
Total nurse turnover
6.37
Baseline 60.78% · Performance 37.65% · Measure score 6.37 · Achievement 6.37 · Improvement 5.94
Adjusted total nurse staffing
3.40
Baseline 4.19 hours · Performance 4.05 hours · Measure score 3.40 · Achievement 3.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.75% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 17.39% · Lower 95% interval 8.43% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 65.08% |
95.27%
30.2 pts worse
|
Numerator 41 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 42.42% |
53.69%
11.3 pts worse
|
Numerator 14 · Denominator 33 |
| Discharge mobility score | 36.36% |
50.94%
14.6 pts worse
|
Numerator 12 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 3 · Denominator 63 · Adjusted rate 3.41% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 81.58% |
8.2%
73.4 pts better
|
Numerator 93 · Denominator 114 |
| Staff flu vaccination coverage | 54.05% |
42%
12 pts better
|
Numerator 60 · Denominator 111 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 11 · Denominator 33 |
| Transfer of health information to provider | 79.17% |
95.95%
16.8 pts worse
|
Numerator 19 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 2 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.2 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.2
0.1 pts worse
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
97.8%
0.3 pts worse
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 93.7% · Q3 98.8% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.6%
1.4 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 1.2% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
3.7%
3.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.9%
2.9 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.1% · Q3 2.9% · Q4 1.4% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.3% |
15.7%
9.4 pts better
|
19.6%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.5% · Q3 2.8% · Q4 5.3% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
9.8%
3.8 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 4.0% · Q3 5.5% · Q4 4.9% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
11.7%
1.3 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 0.0% · Q3 3.3% · Q4 22.1% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.7% |
9.8%
0.9 pts worse
|
14.9%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 9.1% · Q3 7.2% · Q4 15.5% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
12.5%
13 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 26.5% · Q3 28.6% · Q4 25.3% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.1%
1.5 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 5.8% · Q3 5.5% · Q4 4.9% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.0% |
94.3%
9.3 pts worse
|
81.7%
3.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.7% · Q2 81.4% · Q3 87.1% · Q4 92.5% · 4Q avg 85.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
9.3%
2.5 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 13.5% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.3% |
94.7%
21.4 pts worse
|
79.7%
6.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
26.2%
9.9 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 18.9% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-08-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-08-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-08-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-08-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-09
E · Potential for more than minimal harm
2024-01-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-16
D · Potential for more than minimal harm
2024-01-17
F887 · Infection Control Deficiencies
Health
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.
Corrected 2024-02-16
C · Minimal harm
2023-08-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-22
C · Minimal harm
2023-08-24
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-04-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-12
D · Potential for more than minimal harm
2022-03-31
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-04-24
D · Potential for more than minimal harm
2022-03-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-24
D · Potential for more than minimal harm
2022-03-31
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-04-24
Penalties and ownership
What sits behind the stars
Ownership
Hyman, Simcha
5% Or Greater Direct Ownership Interest · Individual
Zanziper, Naftali
5% Or Greater Direct Ownership Interest · Individual
Fenelus, Rhod
W-2 Managing Employee · Individual
Gorelick, Batya
Corporate Officer · Individual
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#3
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