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 (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 4 Event ID: 106058 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 106058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Woodland Grove Healthcare & Rehabilitation Center 4325 Southpoint Boulevard Jacksonville, FL 32216 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)