Health inspection·July 22, 2021

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, resident and staff interviews, and clinical record review, the facility failed to ensure that the pharmacy and nursing services accurately documented and administered controlled medication for one (Resident #45) of three sampled residents reviewed for pain management out of a sample of 34 residents. The findings include: On 07/22/21 at 8:00 AM, during an observation of a controlled medication reconciliation between Employee B, Licensed Practical Nurse (LPN), (outgoing night nurse) and Employee C, LPN, (oncoming day shift nurse), the narcotic count for resident #45 was found to be incorrect. A review of Resident #45's reconciliation sheet in the narcotic logbook revealed he had eight available Tramadol 50 milligrams tablets. A review of Resident #45's narcotic blister card revealed he had seven available Tramadol 50 milligrams tablets. A review of Resident #45's Medication Administration Record (MAR) for July revealed the resident received one tablet of Tramadol 50 milligrams on 7/22/21 at 7:00 AM, documented on the MAR by Employee A, LPN. Employee B, LPN and Employee C, LPN notified Employee D, LPN/Unit Manager (UM) of the incorrect Tramadol count. During an interview with Employee B, LPN and Employee D, LPN/UM on 7/22/21 at 8:15 AM, they both stated that medication is to be signed out once it is removed from the cart and before entering a resident's room. An interview was conducted on 7/22/21 at 8:20 AM with Employee D, LPN/UM, regarding the process for count discrepancies. She stated the discrepancy would be reviewed to ensure there was a discrepancy and determine the responsible parties. If the error occurred on another shift that staff member would be contacted to determine the cause of the discrepancy. On 7/22/21 at 8:35 AM, Resident #45 was interviewed with Employee D, LPN/UM present. Resident #45 confirmed he received his Tramadol medication this morning. On 7/22/21 at 8:40 AM, the Director of Nursing (DON) and Employee D, LPN/UM reported they contacted Page 1 of 4 106058 106058 07/22/2021 Woodland Grove Healthcare & Rehabilitation Center 4325 Southpoint Boulevard Jacksonville, FL 32216

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employee A, LPN, who confirmed she did not sign out the Tramadol on the reconciliation sheet in the narcotic logbook prior to administering the medication to Resident #45. On 7/22/21 at 8:45 AM, the DON was asked how controlled medications were to be signed out. She stated the nurse was to sign out the medication when removed from the cart and before going into the resident's room. On 7/22/21 at 10:00 AM, during an interview with the Administrator and DON, they confirmed Resident #45's narcotic reconciliation sheet and narcotic blister card did not match. A policy review conducted on 7/22/21 revealed that neither the Medication Administration policy (revised 3/1/21) nor the Control Drug Count policy (revised 3/1/21) included a process for signing out controlled medications. . 106058 Page 2 of 4 106058 07/22/2021 Woodland Grove Healthcare & Rehabilitation Center 4325 Southpoint Boulevard Jacksonville, FL 32216

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interview, the facility failed to ensure medical records were complete and accurately documented for three (Resident #18, #48, and #6) of five residents sampled for unnecessary medication, out of a total sample of 34 residents. The findings include: 1. Record review for Resident #18 revealed he was admitted on [DATE]. Diagnoses included but not limited to anemia, major depressive disorder, esophageal reflux without esophagitis, atrial fibrillation, pain, polyneuropathy, and type II diabetes mellitus with diabetic polyneuropathy. A review of Resident #18's physician orders revealed Pantoprazole Sodium 40 mg tablet delayed release one time a day for esophageal reflux, Apixaban 5 mg two times a day for atrial fibrillation, Tramadol HCI 50 mg tablet two times a day for pain, Diltiazem HCI 60 mg 1 tablet every 8 hours for hypertension, Gabapentin 100 mg 2 capsules every 8 hours for polyneuropathy, and Humalog solution 100 unit/ML per sliding scale for type 2 diabetes. A record review of Resident #18's Medication Administration Record (MAR) for July 2021 was conducted and revealed missing documentation for the following medications: Pantoprazole Sodium 40 mg on 7/5, 7/10, 7/18 and 7/19 Apixaban 5 mg on 7/10 Tramadol HCI 50 mg on 7/5, 7/10, 7/18 and 7/19 Diltiazem HCI 60 mg on 7/2, 7/3, 7/4, 7/5, 7/10, 7/18 and 7/19 Gabapentin 100 mg on 7/4, 7/5, 7/10, 7/18 and 7/19 Humalog solution 100 unit/ML on 7/2, 7/4, 7/5, 7/10, 7/16, 7/18 and 7/19 2. A record review for Resident #48 revealed she was admitted on [DATE]. Diagnoses included but not limited to cerebral infraction, type II diabetes mellitus, atherosclerotic heart disease, Alzheimer's disease, hypertension, behavioral disturbance, muscle weakness, cognitive communication deficit, encephalopathy, cerebrovascular disease, hyperlipidemia, other recurrent depressive disorders. A review of the physician orders for Resident #48 revealed she had orders for Seroquel 25 mg tablet 0.5 tablet 1 time a day for dementia with behavioral disturbance, Lisinopril 10 mg tablet 2 times a day for Hypertension, and Memantine HCI 5 mg tablet for Alzheimer's disease 2 times a day. A record review of Resident #48's MAR for July 2021 was conducted and revealed missing documentation for the following medications: Seroquel on 7/5 and 7/10 106058 Page 3 of 4 106058 07/22/2021 Woodland Grove Healthcare & Rehabilitation Center 4325 Southpoint Boulevard Jacksonville, FL 32216

F 0842 Lisinopril on 7/4 Level of Harm - Minimal harm or potential for actual harm Memantine HCI on 7/4 and 7/10 Residents Affected - Few 3. A record review for Resident #6 revealed she was admitted on [DATE] and was readmitted on [DATE]. Diagnoses included but not limited to spinal bifida, swelling in mass-left lower limb, anxiety disorder, neuromuscular dysfunction of bladder, insomnia due to other mental disorder, polyneuropathy, mood disorder, pain. A review of the physician orders for Resident #6 revealed she had orders for Tofranil 10 mg tablet for dysfunction of bladder, Gabapentin 400 mg capsule every 12 hours for polyneuropathy, Gabapentin 100 mg capsule every 12 hours for polyneuropathy, Buspirone HCI 7.5 mg tablet 2 times a day for anxiety disorder, Temazepam 30 mg capsule 1 time a day for insomnia, Linaclotide 290 mcg capsule 1 capsule one time a day for constipation, and Cyclobenzaprine HCI tablet 10 mg every 6 hours related to other muscle spasm. A record review of Resident #6's MAR for July 2021 was conducted and revealed missing documentation for the following medications: Linaclotide on 7/5, 7/18 and 7/19 Temazepam on 7/7 and 7/10 Buspirone on 7/7 and 7/10 Gabapentin 500 mg on 7/7 and 7/10 Tofranil on 7/5, 7/8, 7/10, 7/18 and 7/19 Cyclobenzaprine HCI on 7/5, 7/18 and 7/19 During an interview with Director of Nursing (DON) on 7/22/21 at 5:21 PM, she confirmed the documentation was missing on the MAR for Resident #18, #48 and #6, and acknowledged the nurses should sign the record when administering medication. No facility policy was provided before exiting the facility. . 106058 Page 4 of 4