The Citadel At Winston Salem

F-F550: Based on record review, observation, resident, and staff interviews the facility failed to protect a resident's dignity (a) when the resident was left with 3 briefs on that were soiled and saturated with urine

during the breakfast meal and (b) left to urinate in a brief after she had told a Nursing Assistant (NA) #10 she had to urinate. The resident voiced feeling dirty angry and neglected. This occurred for 1 of 1 resident (Resident #209) reviewed for incontinence care.

The Administrator was interviewed on 6-12-24 at 4:32pm. The Administrator stated NA #8 had answered Resident #209's call light at 8:15am but had not changed the resident but said if Resident #209 needed incontinence care provided at that time NA #8 should have provided the care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38920

Residents Affected - Few Based on record review, resident and staff interviews, the facility failed to complete and submit an Initial Allegation Report within 2 hours to the State Regulatory Agency for 1 of 1 resident (Resident #209) reviewed for neglect.

Findings included:

Resident #209 was admitted to the facility on [DATE REDACTED].

The 5-day Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #209 was cognitively intact and required substantial to max assistance with toileting.

Upon interviewing Resident #209 on 6-10-24 at 11:25am, the resident voiced feeling dirty, neglected, and angry being left in 3 briefs that were soiled and urine soaked while she ate her breakfast meal.

The Administrator was informed on 6-12-24 at 4:32pm by this surveyor of Resident #209's feelings of neglect, angry, and dirty' when the resident was left in 3 briefs, that were soiled, and urine soaked while she ate breakfast.

A telephone interview on 6-18-24 at 11:17AM with the Administrator stated she had not completed an Initial Allegation Report and they had investigated the situation. She stated there had not been a resolution to the investigation as to why Resident #209 had on 3 briefs and not provided incontinence care. She stated she had not reported the allegation as neglect to the state agency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38077

Residents Affected - Few Based on record review, staff and resident interviews the facility failed to involve the resident and/or resident representative in the care planning process for 1 of 1 sampled resident (Resident #94) reviewed for care plan participation.

The findings included:

Resident #94 was admitted on [DATE REDACTED] with diagnoses in part, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease and major depression.

Review of the admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #94 was assessed as cognitively intact

Review of the Social Worker Note dated 2/21/24 and authored by Social Worker Assistant #2 indicated Resident #94 was assessed as alert and oriented to self, place, time and situation. The resident was able to make needs known to staff without issue. Resident #94 was assessed as cognitively intact. The resident would remain in the facility for Long Term Care (LTC) Services. SW will continue to monitor.

Review of the resident's care plan (completion date) 3/18/24 revealed the resident was care planned for activities of daily living (ADLs), nutrition, falls, risk for pressure ulcers, discharge planning and other medical conditions.

A record review of the Quarterly MDS assessment dated [DATE REDACTED] revealed Resident #94 was assessed as cognitively intact and was dependent on staff for ADL care.

During an interview on 6/10/24 at 10:09 AM, Resident #94 indicated he was not invited to participate in the care plan meeting for the past 4 months. He further indicated he had not recalled participating in developing his plan of care.

During an interview on 6/12/24 at 11:00 AM, the Social Worker Assistant #2 stated the resident's base line care plan was completed on the phone with the resident's representative on 2/16/24. The resident's representative was the responsible party and emergency contact #1. The resident was also present and requested his representative for attendance. Resident #94's discharge planning was discussed, and he was

a long-term care resident. The Social Worker Assistant #2 stated usually after the base line care plan meeting, a comprehensive care plan meeting was completed in 5 days. During the comprehensive care plan meeting team reviewed the care plan to see if there were any changes. The resident and/or resident representative was invited to participate in the care plan. The Social Worker Assistant #2 further stated that

the resident's comprehensive care plan meeting with the resident and/or resident's representative was missed and there was no care plan meeting completed. The Social Worker Assistant #2 stated she was in contact with Resident #94's representative regarding the care plan meeting for the quarterly MDS assessments. The care plan meetings were done face to face or Virtual (over phone or online) based on their preferences and convenience.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0657 During an interview on 6/12/24 at 11:10 AM, the Social Worker Director stated the resident's admission MDS assessment was completed on 2/21/24. The resident's quarterly assessment was completed on 5/14/24. She Level of Harm - Minimal harm or indicated the Social Worker Assistant #2 was in the process of scheduling the quarterly assessment care potential for actual harm plan meeting with Resident #94's representative. The Social Worker Director stated she goes by the date of MDS assessment and the letters to residents and resident's family members were sent out based on the Residents Affected - Few MDS calendar. The Social Worker Director further stated she usually mailed out the care plan meeting letters. She indicated she had not recollected sending out the letter for comprehensive care plan meeting to

the family or the resident. Social Worker Director stated the admission staff scheduled the baseline care plan meeting for the resident and/or representative. She further stated the Social Worker department was responsible for scheduling and conducting the comprehensive and other care conferences.

During an interview on 6/12/24 at 4:09 PM, the Administrator stated the expectation was that care plan meetings and notifications were completed per the state/ federal regulations. The Administrator stated the care plan should be reviewed and revised by the interdisciplinary team after each assessment, including comprehensive and quarterly assessments. She further stated residents and/or resident representatives should be involved in the care plan meeting and make decision about their care. The Administrator further stated letters to the families should be sent out by social services for care plan meeting and accommodate

the meeting based on families' convenience as much as possible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38920 potential for actual harm Based on record review, observation, staff, and resident interviews, the facility failed to provide (1) Residents Affected - Few incontinence care to a resident dependent on staff. The facility also (2) failed to provide nail care to a resident who was dependent on staff. This occurred for 2 of 2 residents (Resident #209 and Resident #14) reviewed for activities of daily living (ADL) care.

Findings included:

1. Resident #209 was admitted to the facility on [DATE REDACTED] with multiple diagnoses that included enterocolitis and diabetes.

The 5-day Minimum Data Set (MDS) dated [DATE REDACTED] revealed Resident #209 was cognitively intact and required substantial to max assistance with toileting. The MDS also documented Resident #209 was frequently incontinent of urine and always incontinent of bowel.

Resident #209's care plan dated 5-23-24 revealed the resident had an activities of daily living (ADL) deficit due to enterocolitis and diabetes. The goal for Resident #209 was to improve the current level of ADL function. The interventions were one staff assist for personal hygiene and toileting. Resident #209 also had

an intervention for two staff to assist the resident with transfers.

Resident #209 was interviewed on 6-10-24 at 11:25am. Resident #209 was observed to be tearful and stated

she had been laying in a soiled and urine saturated brief since 8:15am. The resident explained she had put her call light on at 8:15am (stated she knew it was 8:15am because she looked at the clock on the wall) and asked NA #8 to be changed. She stated NA #8 told her she had to wait because the breakfast trays were arriving on the unit. Resident #209 said she told NA #8 again when she delivered her tray that she needed changed and stated NA #8 told her she would get changed after breakfast. Resident #209 discussed not receiving incontinence care since the night before. She stated she still had not been changed. There was a strong urine odor observed in Resident #209's room. The resident was observed to put her call light back on for assistance.

Observation of incontinence care occurred on 6-10-24 at 11:33am with NA #4. During the observation, Resident #209 was observed to have 3 briefs and another brief was laid flat under her. It was observed that Resident #209's bowel movement and urine had seeped through all 3 briefs, the draw sheet, the cotton pad, and the fitted sheet. There were areas on the draw sheet, cotton pad, and fitted sheet that had dark yellow rings and on Resident #209's skin there were areas where her bowel movement had dried to her skin. The resident's skin was intact with no redness.

NA #4 was interviewed on 6-10-24 at 11:44am. The NA explained she had come into work late, so she had not completed initial rounds on her assigned residents. She confirmed Resident #209 was assigned to her. NA #4 stated NA #8 had not informed her when she arrived that Resident #209 needed to be changed. When discussing the condition of Resident #209, NA #4 discussed that it was not normal practice to see 3 briefs on a resident and that due to the drying of urine and dried feces, NA #4 said she did not think the resident had been changed since the night before. NA #4 explained staff could change residents even when trays were being delivered and did not know why Resident #209 had not received incontinence care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0677 During an interview with NA #8 on 6-10-24 at 11:50am, NA #8 explained the NA assigned to Resident #209 had come to work late so initial rounds were not completed on the resident. She stated at 8:15am, Resident Level of Harm - Minimal harm or #209 had put her call light on but said the resident never informed her she needed to be changed. When potential for actual harm asked, NA #8 could not state what activity she provided the resident or what the resident wanted at 8:15am when she answered her call light. She also stated when she provided Resident #209 with her breakfast tray, Residents Affected - Few the resident never told her she needed to be changed.

A telephone interview occurred with NA #9 on 6-12-24 at 7:30am. The NA confirmed she had been assigned to Resident #209 on 6-9-24 during the 11:00pm to 7:00am shift. NA #9 explained she had usually changed Resident #209 every hour because she urinates a lot. She stated she had last changed Resident #209 between 6:00am and 6:30am on 6-10-24. NA #9 discussed Resident #209 asked for 2 briefs, but the NA stated she placed one brief on the resident and laid another one down flat under the resident. NA #9 stated

she had not placed 3 briefs on the resident.

The Director of Nursing was interviewed on 6-12-24 at 2:37pm. The DON discussed staff receiving yearly training on incontinence care. She stated staff were able to provide incontinence care if the meal trays were

on the unit but that she would expect them to wash their hands prior to passing the trays. The DON discussed Resident #209 and stated no resident should have to eat their meal in a soiled and wet brief and should have been provided incontinence care when requested. She also stated it was not the facilities policy to apply more than one brief to a resident. The DON explained if the resident requested more than one brief,

the resident would be care planned for more than one brief.

The Administrator was interviewed on 6-12-24 at 4:32pm. The Administrator discussed it not being appropriate for a resident to have on more than one brief but also said she felt this may have been a one-time occurrence. She stated if Resident #209 urinated frequently, then she would expect the resident to be care planned for more frequent visits. The Administrator stated Resident #209 should have been provided incontinence care when requested and not have to eat her meal in a soiled, wet brief.

2. Resident #14 was admitted to the facility on [DATE REDACTED] with multiple diagnoses that included hemiplegia and hemiparesis affecting non-dominant side.

The quarterly Minimum Data Set, dated dated dated [DATE REDACTED] revealed Resident #14 was moderately cognitively impaired and was dependent on staff for bathing and personal hygiene. The MDS did not document any rejection of care.

Resident #14's care plan dated 5-11-24 revealed an ADL deficiency related to hemiplegia. The goal for Resident #14 was to maintain her current level of function. The interventions for the goal included total staff participation in personal hygiene and bathing.

Resident #14 was observed and interviewed on 6-10-24 at 1:12pm. Resident #14 discussed having a bath

this morning by staff however during the observation of the resident, her fingernails were observed to have a brown substance caked under her nails, her gown had dried food particles, and her fitted sheet had holes and dried food.

Observation and interview with Resident #14 occurred on 6-11-24 at 11:09am. Resident #14 discussed hospice providing her a bath this morning. Upon observation, Resident #14 was observed to have a brown substance caked under her fingernails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0677 An observation of ADL care with Resident #14 occurred on 6-12-24 at 9:41am with Nursing Assistant (NA) #11. Resident #14's skin was observed to be intact with no redness. NA #11 was observed not to clean Level of Harm - Minimal harm or Resident #14's fingernails. potential for actual harm NA #11 was interviewed on 6-12-24 at 9:57am. NA #11 discussed the steps she took providing a bath to a Residents Affected - Few dependent resident. The NA stated she usually provided nail care to her dependent residents, but she had become nervous and forgot to perform nail care on Resident #14.

The Director of Nursing (DON) was interviewed on 6-12-24 at 2:37pm. The DON discussed the training for

the NAs regarding bathing and stated nail care was part of the bathing process. She stated between the facility staff and hospice, Resident #14 should not have gone without her nails being cleaned for 2 days.

The Administrator was interviewed on 6-12-24 at 4:32pm. The Administrator discussed staff having tunnel vision when they are bathing a resident and forget that nail care was part of a bath. She stated she expected staff to look at the whole resident not just limbs and torso.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45276 potential for actual harm Based on record review, resident and staff interviews the facility failed to ensure a resident attended an Residents Affected - Few infectious disease clinic appointment at an outside facility for 1 of 1 sampled resident reviewed for medically related social services (Resident #616).

The findings included:

Resident #616 was admitted on [DATE REDACTED] with diagnoses that included pneumonia, diabetes, latent tuberculosis, and chronic kidney disease.

Review of Resident #616's hospital discharge summary 02/29/24 revealed an infectious disease clinic appointment scheduled for 03/11/24.

Resident #616's admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed she was cognitively intact.

There was no evidence in the medical record that Resident #616 attended her 03/11/24 infectious disease clinic appointment scheduled for 03/11/24 as noted on the hospital discharge summary.

The medical record indicated Resident #616 was discharged from the facility on 03/13/24.

A phone interview was conducted on 06/10/24 at 10:20 AM with Resident #616 and she stated she was informed the transportation van was not working the morning of 03/11/24 and her appointment would be rescheduled. She stated she was not rescheduled for her infectious disease clinic appointment prior to her discharge to the hospital on 03/13/24.

An interview was conducted with the Resident Appointment Coordinator on 06/13/24 at 3:00 PM. She stated Resident #616's appointment was on her transportation schedule for 3/11/24 and she verified the infectious disease clinic appointment was missed. She reported the transportation van wheelchair lift malfunctioned the morning of 03/11/24 and they could not use it to transport residents. She stated the other transportation van was being used to transport dialysis residents that morning. The Resident Appointment Coordinator stated

she usually called the same day or next day to reschedule a missed appointment. She explained sometimes

she was not able to reschedule within a day or two because she helped escort residents to appointments.

The Resident Appointment Coordinator said Resident #616 was not rescheduled for her infectious disease clinic appointment before she was discharged to the hospital on 3/13/24.

An interview was conducted with the Administrator on 06/14/24 at 2:00 PM. The Administrator stated the Resident Appointment Coordinator should have rescheduled the appointment in a timely manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32394

Residents Affected - Few Based on observations, interviews with a representative from the dispensing pharmacy and facility staff, and

record reviews, the facility failed to ensure a medication (a topical anti-fungal powder) was available for application as ordered by a physician, resulting in multiple doses of the prescribed medication being missed for 1 of 4 residents (Resident #416) observed during the medication administration observation.

The findings included:

Resident #416 was discharged from a hospital to the facility on [DATE REDACTED] with a diagnosis which included cirrhosis of the liver. His hospital Discharge Medication List (dated 5/30/24) indicated Resident #416 should discontinue use of 250 milligram (mg) terbinafine (an oral antifungal medication) previously taken and initiate

the use of 2 percent (%) miconazole powder (a topical antifungal medication) to be applied topically two times daily.

The resident's admission orders to the facility included a medication order dated 5/30/24 for 2% miconazole powder to be topically applied to folds of the skin twice daily for dry skin (Start Date 5/31/24). The order was created and confirmed by Nurse #3 on 5/30/24. Further review of Resident #416's electronic medical record (EMR) included a 5/30/24 Admitting Daily Skin Assessment which reported the resident had Dry skin to feet .

An Admission Data Collection Note (also dated 5/30/24) included a notation which indicated the resident had Bruising to arms and hands, dry skin all over.

On 6/12/24 at 9:53 AM, Nurse #3 was observed as she prepared and administered five oral medications to Resident #416. At that time, the nurse reported she knew this resident's miconazole powder was not available on the medication (med) cart for administration because it had not yet been delivered by the pharmacy. A follow-up interview was conducted on 6/12/24 at 10:10 AM with Nurse #3. During the interview,

the nurse further explained that since she could not apply the miconazole powder as ordered for Resident #416, she made notations on the resident's Medication Administration Record (MAR) to indicate the medication was not available.

A review of Resident #416's May 2024 and June 2024 MARs revealed the resident's miconazole was scheduled to be applied at 9:00 AM and 9:00 PM each day in accordance with the physician's orders. However, the MARs also documented the miconazole was not applied as ordered on 20 occasions between 5/31/24 and 6/12/24.

The resident's EMR and pharmacy orders were reviewed on 6/12/24 at 10:48 AM. At that time, the physician's order for 2% miconazole topical powder was listed as an Active order for Resident #416 and its status was reported as On Order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0755 An interview was conducted on 6/12/24 at 4:05 AM with the facility's Central Supply clerk. During the interview, the Central Supply clerk reported she was not aware that an over the counter antifungal powder Level of Harm - Minimal harm or was ordered for Resident #416 until that morning (6/12/24) when the Unit Manager (Nurse #2) came to the potential for actual harm Central Supply to request it. The Central Supply clerk confirmed the medication requested was an over the counter (OTC) medication and reported she had a similar antifungal powder in stock that may be used as an Residents Affected - Few alternative (with a physician's order). An inquiry was made as to what the facility's process was for an OTC medication to be sent up to the floor. In response, the Central Supply clerk stated as soon as the order was received for an OTC medication, the nursing staff was supposed to notify her so she could have it brought up to the floor. If that medication was not in the Central Supply stock, the clerk stated she would attempt to acquire it from a local retail pharmacy. However, the clerk reiterated that she relied on the nursing staff to notify her of the need for an OTC medication so she could be certain the product was available for the resident.

A telephone interview was conducted on 6/14/24 at 10:10 AM with a representative from the facility's contracted dispensing pharmacy. During the interview, the representative reported, All facilities know we do not provide OTC medications. The representative added that normally the facilities knew what they had in stock and stated, They should know what is OTC. She reported the dispensing pharmacy would not call a facility to remind them that an OTC medication was not going to be provided by the pharmacy. However, the representative added, We would document if there had been an inquiry by the facility about whether a medication would be sent out by the pharmacy. Upon request, the representative checked to see if the facility had made an inquiry about Resident #416's miconazole not being delivered since it was ordered on 5/30/24. She stated there was no documentation of an inquiry being made by the facility.

An interview was conducted on 6/13/24 at 4:01 PM with the facility's Director of Nursing (DON) and Administrator to discuss the results of the medication administration observation. At that time, the DON and Administrator were also informed of the facility's failure to obtain an OTC antifungal product ordered by the physician for a newly admitted resident (Resident #416). A follow-up interview was conducted on 6/14/24 at 12:55 PM with the DON. During the interview, the DON stated she would expect nursing staff to call the dispensing pharmacy if a medication ordered was not received so if that medication was an OTC product,

the facility could acquire it on their own.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32394 potential for actual harm Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate Residents Affected - Few of less than 5% as evidenced by 2 medication errors out of 29 opportunities, resulting in a medication error rate of 6.9% for 2 of 4 residents (Resident #74 and Resident #416) observed during the medication administration observation.

The findings included:

1. Resident #74 was admitted to the facility on [DATE REDACTED]. Her cumulative diagnoses included hypertension and

a history of cerebrovascular accident (stroke) with dysphagia (difficulty swallowing).

On 6/12/24 at 8:28 AM, Nurse #4 was observed as he prepared to administer medications to Resident #74.

The nurse collected blood glucose (sugar) monitoring supplies, checked Resident #74's blood glucose, and administered 4 units of Humalog insulin (a rapid-acting insulin) to the resident in accordance with her physician's orders.

At 8:39 AM on 6/12/24, Nurse #4 was observed as he completed his preparation of five (5) medications for administration via a percutaneous endoscopic gastrostomy (PEG tube) to Resident #74. A PEG tube is a feeding tube surgically inserted into the stomach. The medications administered to the resident included one tablet of 25 milligrams (mg) carvedilol (a blood pressure medication). Each medication was observed to be crushed individually, mixed with water, and administered separately into the PEG tube with 5-10 milliliters (ml) of water instilled between each medication. No vital signs were obtained for Resident #74 prior to the medication administration.

On 6/12/24 at 8:56 AM, Nurse #4 completed the medication administration for Resident #74 and returned to

the medication cart. A review of the resident's current medication orders was completed at that time. The orders included 25 mg carvedilol to be given as one tablet via PEG tube two times a day for hypertension. In capital letters, the order also included parameters which read: Hold for SBP [systolic blood pressure] less than 110 or HR [heart rate] less than 55. Systolic blood pressure is the maximum pressure the heart exerts while beating and is represented by the top number of a blood pressure reading.

An interview was conducted on 6/12/24 at 8:58 AM with Nurse #4. During the interview, the nurse was asked when the resident had her vital signs last checked. Nurse #4 reviewed Resident #74's electronic medical

record and reported her blood pressure and heart rate were last checked on 6/11/24 (yesterday) at 11:37 AM. The nurse acknowledged he did not notice the resident's orders indicated her vital signs needed to be taken prior to administering the carvedilol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0759 An interview was conducted on 6/13/24 at 4:01 PM with the facility's Director of Nursing (DON) and Administrator to discuss the results of the medication administration observation. During the interview, the Level of Harm - Minimal harm or DON stated she needed to review physician orders with parameters attached to them so supplemental potential for actual harm documentation could be added to the Medication Administration Record (MAR) when parameters were indicated for a resident. She explained that adding the supplemental documentation on the MAR would Residents Affected - Few trigger obtaining vital signs so the parameters ordered would be observed prior to a medication's administration. A follow-up interview was conducted on 6/14/24 at 12:55 PM with the DON. At that time, the DON reported she would expect vital sign parameters to be observed and obtained in accordance with the physician orders (if written) prior to administering a medication.

2. Resident #416 was admitted to the facility on [DATE REDACTED] with a diagnosis which included cirrhosis of the liver.

On 6/12/24 at 9:53 AM, Nurse #3 was observed as she prepared and administered five (5) oral medications to Resident #416. At that time, the nurse reported this resident's miconazole powder (a topical antifungal powder) was not available on the medication (med) cart for administration because it had not yet been delivered by the pharmacy.

A review of Resident #416's current orders revealed a medication order was received on 5/30/24 for 2% miconazole powder to be topically applied to folds of the skin twice daily for dry skin (Start Date 5/31/24).

This order was created and confirmed by Nurse #3 on 5/30/24. The miconazole powder was scheduled to be applied at 9:00 AM and 9:00 PM each day in accordance with the physician's orders.

A follow-up interview was conducted on 6/12/24 at 3:00 PM with Nurse #3 in the presence of the Unit Manager (Nurse #2). During the interview, the omission of a medication (such as miconazole powder) ordered for administration (or application) was discussed. The nurses reported they understood that because miconazole powder was ordered but not given during the medication administration observation, the omission was determined to be a medication error.

An interview was conducted on 6/13/24 at 4:01 PM with the facility's Director of Nursing (DON) and Administrator to discuss the results of the medication administration observation. At that time, the DON and Administrator were informed of the facility's failure to obtain 2% miconazole powder (an over the counter or OTC medication) ordered by the physician for a newly admitted resident (Resident #416). A follow-up

interview was conducted on 6/14/24 at 12:55 PM with the DON. During the interview, the DON stated she would expect nursing staff to call the dispensing pharmacy if a medication ordered was not received. She reported that if the medication was an OTC product, the facility would need to acquire it on their own.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 20670 potential for actual harm Based on a meal test tray observation and interviews with the Dietary Manager (DM), the facility failed to Residents Affected - Some serve food that was palatable and at temperatures acceptable to 1 of 5 Halls (200 Hall). This practice had the potential to affect other residents.

Findings included:

An observation of the meal tray line service in the kitchen was conducted on 6/12/24 at 1:15 p.m. The temperatures of the food items on the steamtable were taken by the DM using a calibrated stem thermometer. The temperatures of the food items of regular consistency were greater than the acceptable 135 degrees Fahrenheit. The top of the plated meals was protected with lid covers, but no insulated bottoms due to the large plate size. The meals were placed in a stainless-steel meal delivery cart. The delivery cart was filled with plated meals for the residents on the 200 hall was missing the doors. The cart left the kitchen at 1:23 p.m. and arrived on the 200 long hall at 1:25 p.m. where the nursing staff immediately began serving

the residents. A test meal tray of the regular textured foods was included in the meal delivery cart.

6/12/24 at 2:05 p.m., the DM revealed that the doors to 4 of the 10 meal delivery carts have needed repair for approximately three months. She also revealed there were not enough insulated bottom plate covers to fit

the large plates used for the residents' meals. She stated smaller plates were ordered several months ago but had not been delivered. The DM indicated she had not conducted any meal test trays surveys.

On 6/12/14 at 2:32 p.m., after serving the residents of the 200 short halls, the DM and this Surveyor observed the test meal tray for palatability. The shepherd's pie was lukewarm and bland to taste. The greenbeans with corn was lukewarm to taste, flavorless and not thoroughly cooked. The DM participated in

the testing of the meal tray and acknowledged these findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 345092 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345092 B. Wing 07/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Willow Valley Center for Nursing and Rehab 1900 W 1st Street Winston-Salem, NC 27104

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 0924 Put firmly secured handrails on each side of hallways.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20906 potential for actual harm Based on observations, staff interviews and record review, the facility failed to ensure the handrails in the Residents Affected - Some facility corridors were properly secured to the walls, repaired and free from sharp edges on 3 of 4 floors where handrails were present.

The findings included:

An observation was conducted on 6/11/24 at 12:42 PM to 1:00 PM, revealed on the 500 floor the handrails were detached from the walls and needed repairs due to broken/cracked support backets and missing end caps in the corridor joining rooms 503, 507, 511, 514, 5/19, 520, 526, 527 on the hallways. The end of the handrails had sharp edges that were not covered by the endcaps. Staff and residents were observed using

the handrails in the current condition.

An observation was conducted on 6/11/24 at 1:30 PM to 1:45 PM on the 300 floor, revealed the unit handrails in the corridor joining the rooms 321, 326, 327 and near the janitor hall closet close to the dining room were loose, detached from the walls and needed repairs due to broken/cracked handrails and support brackets that had sharp or exposed edges without endcaps.

An observation was conducted on 6/11/24 at 2:00PM to 2:16 PM on the 200 floor revealed the handrails in

the corridor joining the rooms 200, 202, 204, 208, 210 and 226, the handrails were loose and detached from

the wall with small unpatched holes in the wall. There were several broken/cracked support brackets that had exposed sharp edges and exposed screws. The end caps were missing on the handrail at room [ROOM NUMBER] near the elevators.

A follow-up observation was conducted on 6/12/24 at 2:10 PM to 2:25 PM, revealed the identified handrails

in the 200 floor 300 floor and 500 floor remained in the same condition and had not been repaired. Staff and residents continued to use the handrails for support during mobilization on the units.

An interview was conducted on 6/12/24 at 2:27pm, the Maintenance Director stated he was aware of the condition of the handrails and the repairs or replacement of the broken handrails. He stated he had submitted an invoice for replacement parts for the handrails for some of the handrails that have already been replaced a few months ago. However, he further stated he did not have a system in place to monitor, replace or recheck any of the newly broken handrails. The Maintenance Director presented an invoice for new handrail parts effective on 6/14/24.

An interview was conducted on 6/14/24 at 8:00 AM, the Administrator who stated the facility Environmental Service Director and Maintenance Director were responsible for ensuring the facility was clean and structural repairs were completed for the safety of all the residents. She included a handrail and resident room audits would be done for repairs and replacement immediately based on the recent invoice dated 6/14/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 345092