Inspection·March 16, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and facility policy and procedure review, the facility failed to implement their abuse prohibition policy for reporting allegations of abuse for one (Resident #300) of one resident reviewed for abuse, from a total of 28 sampled residents. Failure to report abuse allegations may place the resident at risk of harm. Residents Affected - Few The findings include: During an interview with Resident #300 on 03/13/2023 at 1:58 PM, she stated the staff rip my clothes off and handle me roughly. She stated the staff were mean to me. When asked to identify the staff that were doing this to her she stated, Honey, I don't know their names. When asked if she reported this to anyone, she stated, I reported it to all of them! During an interview on 03/15/2023 at 11:40 AM with the Director of Nursing (DON), she stated she had not received any reports of abuse allegations. She stated she would look again. She returned to the interview at 1:20 PM and stated she had no reports of abuse. A review of Resident #300's face sheet revealed she was admitted on [DATE]. Her diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, asthma, history of transient ischemic attack (TIA), dysphagia, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, lack of coordination, muscle weakness, major depressive disorder, gastric ulcer, seasonal allergic rhinitis, peripheral vascular disease, tinea unguium, osteoarthritis, hypertension, chronic kidney disease, urinary tract infection, history of Corona Virus 2019 (COVID-19), diaphragmatic hernia without obstruction or gangrene, history of falling and overactive bladder. (Copy obtained) A review of the the resident's Care Plan, dated 02/23/2018 and updated on 03/11/2023, revealed problem areas including: Activities of Daily Living (ADL) Self-Care Deficit related to dementia, weakness, impaired mobility, non-ambulatory, dependent on staff for transfers; The resident has Impaired Cognitive Function or Impaired Thought Processes related to dementia, history of hallucinations; The resident has Potential to be Physically Aggressive related to dementia-combative, throwing items at staff, verbally aggressive at times with staff; Potential to be Verbally Aggressive; The resident is dependent, cognitively able to express Leisure/Activity Preferences for meeting emotional, intellectual, physical and social needs; The resident has Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia. The care plan did not indicate that the resident confabulated (to fill in gaps in memory by fabrication) allegations of abuse/harm against the staff. (Copy obtained) (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 6 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 03/16/2023 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)