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 18 of 51 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 19 of 51 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 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,

before transfer or discharge, including appeal rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20670

Residents Affected - Few Based on record reviews and Ombudsman and staff interviews, the facility failed to provide written notification to the ombudsman of the transfer of 1 of 3 sampled residents (Resident #265) to the hospital.

This practice had the potential to affect other residents discharged .

Findings included:

Resident #265 was originally admitted to the facility on [DATE REDACTED].

The annual Minimum Data Set, dated dated dated [DATE REDACTED] indicated Resident #265 was cognitively intact.

Review of the clinical records revealed Resident #265 was transferred to the hospital on 5/10/24

per his request and physician's order related to pain and discomfort in his bilateral lower extremities. The resident was subsequently admitted to the hospital. There was no documentation indicating a written notice of transfer was provided to the ombudsman.

A telephone interview with the Ombudsman on 6/13/24 at 9:24 a.m. revealed she had not received any of the facility's May 2024's discharge summaries, including Resident #265's discharge to the hospital on 5/10/24.

During an interview on 6/13/24 at 9:39 a.m., the facility's Director of Social Work stated that it was her responsibility to send the Ombudsman a monthly list of discharged residents with their locations. She explained she usually emailed the list on the last day of every month or the beginning of the next month.

After reviewing her emails, the Director of Social Work acknowledged she had not sent the Ombudsman the list and notices of residents when discharged from the facility in the month of May 2024. The most recent email the Director of Social Work sent to the Ombudsman was on 4/11/24 of a list of residents discharged in March 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 51 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 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32394 potential for actual harm Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set Residents Affected - Few (MDS) assessment related to the Preadmission Screening and Resident Review (PASRR) Level II status for 1 of 4 residents (Resident #174) reviewed for PASRR.

The findings included:

Resident #174 was admitted to the facility on [DATE REDACTED] with a cumulative diagnosis which included paranoid schizophrenia.

Resident #174's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE REDACTED]. The Identification Information section of this MDS assessment did not report Resident #174 had a PASRR Level II determination.

Further review of the resident's electronic medical record (EMR) revealed Resident #174's care plan included

the following area of focus, in part: The resident has a Level II PASRR related to serious mental illness (Initiated 8/3/23; Revised 4/2/24).

An interview was conducted on 6/13/24 at 10:35 AM with the facility's Director of Social Work (SW). Upon request, the Director of SW reviewed Resident #174's medical record and provided a copy of the resident's PASRR Level II Determination Notification letter dated 4/17/23. This letter confirmed Resident #174 was determined to have PASRR Level II status.

An interview was conducted on 6/13/24 at 3:25 PM with the facility's on-site MDS Nurse (MDS Nurse #1).

During the interview, the MDS Nurse reported she was only responsible to conduct the MDS assessments

on newly admitted residents. She also stated the facility utilized remote nursing staff to complete the remainder of the residents' MDS assessments.

An unsuccessful attempt was made on 6/14/24 at 9:40 AM to conduct an interview with the remote MDS Nurse (MDS Nurse #2) identified as having completed the Identification Information Section on the 3/4/24 MDS related to PASRR status for Resident #174.

An interview was conducted with the facility's Director of Nursing (DON) on 6/14/24 at 12:55 PM. During the interview, the inaccurate reporting of Resident #174's PASRR status on her 3/4/24 annual MDS assessment was discussed. In response, the DON indicated the resident's MDS assessment needed to be coded accurately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 51 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 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31146

Residents Affected - Some Based on record reviews and staff interviews the facility failed to submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination 3 of 4 residents (Resident #37, Resident #102 and Resident #103) reviewed for PASRR. Resident #37, Resident #103 and Resident #102 received a new mental health diagnosis following admission.

The findings included:

1. Resident #37 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included traumatic brain injury (TBI), dementia with agitation and major depressive disorder. Upon re-admission, Resident #37 had a Level I PASRR number.

Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #37 was cognitively intact. The MDS further revealed the resident had no behaviors during the look back period.

Nursing note dated 10/19/23 and authored by Nurse # 11 revealed Resident #37 had increased agitation. Further review of the nursing note revealed Situation, Background and Assessment (SBAR) for providers.

The situation stated a change in condition were behavioral symptoms to include agitation and psychosis.

Nursing progress note dated 11/8/23 and authored by Nurse #2 revealed Resident #37 was having behaviors of hallucination and being aggressive because of the hallucinations. The note continued with orders to refer the resident to psychiatry, give 1 time dose of Haldol (an anti-psychotic medication) 1 milligram (mg) and lab work to include complete blood count (CBC), comprehensive metabolic panel (CMP).

Physician order dated 11/8/23 stated Haloperidol tablet 1mg. Give 1 tablet by mouth one time only

for mood/aggressive behaviors until 11/8/23.

Behavior note dated 2/19/24 and authored by Nurse #6 revealed Resident #37 was noted being aggressive with a visitor.

Physician order dated 2/19/24 revealed Haloperidol lactate injection solution 5mg/ml (milliliter). Inject 2.5mg intramuscularly (IM) one time only for agitation and aggressiveness for 1 day.

Care Plan dated 3/4/24 revealed Resident #37 had the potential to be verbally aggressive (resident hit/punching others) related to dementia, ineffective coping skills, mental/emotional illness, poor impulse control and resident had a history of Post Traumatic Stress Disorder (PTSD). The goals included Resident #37 would demonstrate effective coping skills and Resident #37 would verbalize understanding of need to control verbally abusive behavior. The interventions included psychiatric/psychogeriatric consult as indicated and when the resident became agitated intervene before agitation escalates; bide away from source distress, engage calmly in conversation; if response is aggressive staff to walk calmly away and approach later.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 51 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 0644 Behavior note dated 3/3/24 and authored by Nurse #9 revealed the Resident #37 made inappropriate sexual remarks to the Medication Aide and verbalized delusional thoughts regarding implants in his ear and being Level of Harm - Minimal harm or ambushed by a family member. potential for actual harm Quarterly MDS assessment dated [DATE REDACTED] indicated Resident #37 was cognitively intact, had no behaviors Residents Affected - Some during the look back period and had a diagnosis that included Post Traumatic Stress Disorder.

Behavior note dated 5/24/24 and authored by Nurse #10 revealed Resident #37 went into two resident rooms and demanded the residents turn their tv's off. Resident #37 was educated that he could not go into other residents' rooms. The note continued with Resident #37 began swinging his cane in the hallway towards the resident in one of the rooms. Resident #37 was informed he could not use his cane to hit another person or swing it toward anyone in the facility. Resident #37 then called the nurse a racial slur and began swinging his cane towards the nurse. The nurse was able to get the cane and escorted Resident #37 back to his room. The Assistant Director of Nursing (ADON) was made aware.

Nursing note dated 5/28/24 and authored by Nurse #2 started the nurse had spoken with Resident #37's family about his verbal and physical aggression towards staff and resident. A new order was received for Ativan 3 times a day (TID).

Patient centered care follow note dated 5/28/24 revealed Resident #37 was seen for an acute visit due to nursing staff complaint of agitation. Resident #37 stated he had been feeling more agitated lately. There were no new recommendations identified on the follow up note.

Review of SBAR Summary for providers dated 6/2/24 and authored by Nurse #4 indicated a change in condition that was identified as behavioral symptoms to include agitation and psychosis. The note continued with nursing observations, evaluation and recommendations were Resident #37 was observed being verbally aggressive with staff. Charged staff member resulting in loss of balance and fall without injury. Resident continued verbally aggression shortly after occurrence. The on-call Nurse Practitioner (NP) indicated to send resident to emergency room (ER) for evaluation. The recommendations stated send Resident #37 to ER for evaluation following combative/aggressive behavior.

Review of Resident #37's medical record revealed a new application for PASRR had not been completed

after the resident was diagnosed with PTSD and demonstrated a change in behaviors.

Interview with the Social Worker on 6/13/24 at 11:00 am revealed she was responsible for submitting information to North Carolina Medicaid Uniform Screening Tool (NC MUST-an online platform used to complete PASRR applications) when a resident experienced a change in condition regarding behaviors that may be associated with mental illness. She further indicated she had a number of residents during her audit that were in need of being screened or re-screened. She indicated she was aware of an increase in behaviors with Resident #37 and indicated with his change in condition he would need to be screened to determine if there would be a change in his PASRR I status.

In a continued interview with the Social Worker on 6/13/24 at 11:20 am indicated Resident #37 was not identified during her audit and had not had a request for screening by PASRR. She further stated she must have missed him during her audit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 51 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 0644 Interview with the Director of Nursing (DON) on 6/13/24 at 3:18 pm revealed the Social Woker was responsible for notifying NC MUST of residents that had a change in condition to establish a new PASRR Level of Harm - Minimal harm or level. potential for actual harm 27111 Residents Affected - Some 2. Review of Resident #102's medical record revealed documentation of a Level I PASRR determination dated 6/22/18 prior to his admission on 11/8/21. His admission diagnoses included dysphagia and hypertension.

A diagnosis of schizoaffective disorder was added on 11/1/23. Further record review did not indicate a referral for a Level II PASRR review had been made.

An interview with the Social Worker on 6/13/24 at 2:01PM revealed that she was not aware of Resident #102 had a change of diagnosis.

An interview with the Administrator on 6/14/24 at 10:40 AM revealed a new diagnosis of paranoid schizophrenia or schizoaffective disorder should be triggered for a new PASRR evaluation. She indicated that she had started an audit to make sure that the PASRR was getting done by the Social Worker. She stated maybe the audit was not as effective as she thought since one of the residents was missed by the audit.

3. Review of Resident #103's medical record revealed documentation of a Level I PASRR determination dated 7/21/17 prior to his admission on 12/17/21. His admission diagnoses included anxiety, depression, respiratory failure and diabetes mellitus.

A diagnosis of paranoid schizophrenia was added on 8/1/23. Further record review did not indicate a referral for a Level II PASARR review had been made.

An interview with the Social Worker on 6/13/24 at 2:01PM revealed that Resident #103 had the new diagnosis of paranoid schizophrenia and corporate had directed her to refer for a new PASRR. She revealed that the new diagnosis was on 8/1/23 and it should have already been referred. She indicated that she had

the stack of referrals on her desk, she was the only person with the PASRR logon, and she was behind.

An interview with the Administrator on 6/14/24 at 10:40 AM revealed a new diagnosis of paranoid schizophrenia or schizoaffective disorder should be triggered for a new PASRR evaluation. She indicated that she had started an audit to make sure that the PASRR was getting done by the Social Worker. She stated maybe the audit was not as effective as she thought since one of the residents was missed by the audit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 51 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 25 of 51 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 26 of 51 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 27 of 51 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 28 of 51 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 29 of 51 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31146 potential for actual harm Based on observation, record review and staff interview the facility failed to have cautionary signage for Residents Affected - Few oxygen (O2) use for 1 of 2 residents (Resident #176) reviewed for respiratory care.

The findings included:

Resident #176 was admitted to the facility on [DATE REDACTED] with a diagnosis that included chronic obstructive pulmonary disease (COPD).

The admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #176 was cognitively intact. She was further coded as receiving oxygen therapy.

Review of Resident #176 physician order dated 4/10/24 stated oxygen continuously at 3 liters per minute (lpm) via nasal cannula for COPD.

Observation on 6/10/24 at 10:29 am revealed Resident #176 to be in her room with O2 being delivered via nasal cannula. There was no cautionary signage observed to the entrance of Resident #176's room indicating the use of O2.

Observation on 6/11/24 at 4:26 pm revealed Resident #176 to be in her room with O2 being delivered via nasal cannula. There was no cautionary signage indicating the use of O2.

Interview and observation with Nurse #8 on 6/11/24 at 4:30 pm revealed she was assigned to Resident #176. She stated that Residents that received O2 were to have signage that identified O2 was in use on the outside of the their bedroom door. Upon observation of Resident #176's room door she confirmed it did not have O2 signage. She further stated that she was unsure if it was maintenance department or the Unit Supervisor who would place cautionary signage indicating the use of O2.

Interview with Unit Supervisor on 6/12/24 at 11:45 pm revealed there was no cautionary signage on Resident #176's door indicating the use of O2 until she had noticed the signage was missing on 6/12/24. She stated

she was told by the Director of Nursing (DON) 6/12/24 to check for cautionary signage for O2 which was when she identified Resident #176's was missing. The Unit supervisor indicated Resident #176 had been recently moved to room [ROOM NUMBER] from 212 about a month ago.

Interview with the Director of Nursing (DON) on 6/13/24 at 3:18 pm revealed cautionary signage regarding

the use of O2 should be placed on residents' doors that require O2. Resident #176 was on O2 and should have had cautionary signage. It was the responsibility of the admissions nurse or the floor nurse to ensure cautionary signage was posted for residents who utilized O2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 51 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 31 of 51 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 32 of 51 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 33 of 51 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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32394

Residents Affected - Some Based on staff and consultant pharmacist interviews and record reviews, the facility failed to act on recommendations made by the consultant pharmacist and retain documentation of the physician's review and response to the pharmacist's findings / recommendations in the resident's medical record for 1 of 7 residents whose medications were reviewed (Resident #97).

The findings included:

Resident #97 was admitted to the facility on [DATE REDACTED]. Her cumulative diagnoses included an adjustment disorder with anxiety.

A review of the resident's electronic medical record (EMR) revealed the following medication orders were received for diazepam (an antianxiety medication). Diazepam is a psychotropic medication and a controlled substance medication.

--A physician's order was received on 11/10/23 for 5 milligram (mg) diazepam to be given as one tablet by mouth every 8 hours as needed (PRN) for anxiety. The order was discontinued on 12/6/23.

--On 12/12/23, 5 mg diazepam was ordered to be given by mouth every 8 hours PRN for anxiety and/or muscle relaxant. This order was discontinued on 12/19/23.

--A physician's order was received on 12/19/23 for 5 milligram (mg) diazepam (an antianxiety medication) to be given as one-half tablet (2.5 mg) by mouth scheduled twice daily for anxiety.

--On 2/23/24, an order was received for 10 mg diazepam to be given as one tablet by mouth every 8 hours as needed for crying and/or anxiety. There was no end date or rationale documented for this PRN diazepam order to be extended beyond 14 days.

--The order for the 2.5 mg of scheduled diazepam given twice daily was discontinued on 3/22/24 and another order was received on 3/22/24 for 5 mg of diazepam to be given as one tablet by mouth scheduled twice a day for anxiety.

The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE REDACTED]. Resident #97 was reported to have intact cognition with no behaviors nor rejection of care. The Medication section of

the MDS revealed Resident #97 received an antianxiety medication during the 7-day look back period.

Resident #97's EMR indicated the physician's orders for both the scheduled diazepam (ordered on 3/22/24) and the PRN diazepam (ordered on 2/23/24) continued as active orders up through the date of the review on 6/12/24. A review of Resident #97's Medication Administration Records (MARs) revealed eight (8) doses of PRN diazepam were administered to the resident from 2/23/24 through the date of the review (6/12/24). The last dose of PRN diazepam was documented as having been administered on 6/7/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 51 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 0756 The resident's EMR also included Pharmacist Reviews / Visit Progress Notes completed by the consultant pharmacist each month from August 2023 to May 2024 on the following dates: 8/31/23; 9/30/23 10/30/23; Level of Harm - Minimal harm or 11/29/23; 12/30/23; 1/30/24; 2/29/14; 3/30/24; 4/30/24; and 5/31/24. Each of these monthly notes read: MRR potential for actual harm [Medication Regimen Review] completed: Medical Record Reviewed including: orders, available labs, progress notes. See consultant pharmacist report for consult on any noted irregularities and/or Residents Affected - Some recommendations.

A request was made for the facility to provide the consultant pharmacist reports with the noted irregularities and/or recommendations made for Resident #97 from August 2023 up to the date of the review (6/12/24).

The facility provided two pharmacist reports (Consultant Pharmacist Medication Regimen Reviews) for Resident #97. Only one report (dated 2/29/24) was related to the PRN diazepam ordered for Resident #97.

The Consultant Pharmacist Medication Regimen Review dated 2/29/24 noted the pharmacist made a recommendation to Psychiatry which read, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document a clinical rationale and a duration for the PRN order. This recommendation was signed by a Nurse Practitioner (NP) on 3/21/24 with a response that read: Continue current dose of diazepam 10 mg q 8 hrs (every eight hours) PRN for anxiety. Neither the duration of the order nor the clinical rationale for continuation of the PRN diazepam were addressed in the provider's response.

The NP who responded to the pharmacist's 2/29/24 recommendation related to PRN diazepam use for Resident #97 was not available for an interview and no longer worked at the facility.

A telephone interview was conducted on 6/13/24 at 3:23 PM with the facility's consultant pharmacist. During

the interview, the pharmacist confirmed she had made multiple recommendations to address the use of Resident #97's PRN diazepam over the last several months. The pharmacist was also informed of a concern regarding the facility's failure to retain the pharmacist's Consult Reports and/or provider responses. She stated that all the pharmacist's recommendations (without the physician's responses) were available for

review within the facility via a connection with the pharmacy's software. The pharmacist reported she typically encouraged each of her facilities to give one copy of the pharmacy recommendations to the provider while they kept a second copy in a binder. After the provider returned a signed response for the recommendation, one copy should be scanned into the resident's permanent medical record with another copy replacing the unsigned recommendation in the binder.

On 6/14/24 at 9:14 AM, additional documentation was provided by the consultant pharmacist for review. The documents included three (3) Consultant Pharmacist Medication Regimen Reviews with recommendations related to Resident #97's PRN diazepam. These three Consultant Pharmacist Medication Regimen Reviews had not been previously provided by the facility. Neither the resident's EMR nor the facility provided documentation to show Resident #97's physician reviewed or responded to the following Consultant Pharmacist Medication Regimen Reviews:

--On 11/30/23, the pharmacist made a physician recommendation which noted, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document a clinical rationale and a duration for the PRN order.

--On 1/31/24, a recommendation was made to Psychiatry which read, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document

a clinical rationale and a duration for the PRN order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 51 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 0756 --On 5/31/24, a recommendation was again made to Psychiatry which read, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please Level of Harm - Minimal harm or document a clinical rationale and a duration for the PRN order. potential for actual harm

An interview was conducted on 6/14/24 at 12:50 PM with the facility's Director of Nursing (DON). During the Residents Affected - Some interview, the DON reported she was aware that orders for PRN psychotropic medications required a stop date. The DON also stated that she was now aware that additional documentation was required to continue PRN psychotropic medications (other than antipsychotic meds) for an extended duration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 51 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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32394 Residents Affected - Few Based on staff and consultant pharmacist interviews and record reviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as needed (PRN) basis to 14 days and/or indicate the duration and rationale for the PRN order to be extended beyond 14 days, when appropriate. This occurred for 2 of 7 residents whose medications were reviewed (Resident #97 and Resident #28).

The findings included:

1. Resident #97 was admitted to the facility on [DATE REDACTED]. Her cumulative diagnoses included chronic obstructive pulmonary disease (COPD) and adjustment disorder with anxiety.

A review of the resident's electronic medical record (EMR) revealed the following medication orders were received for diazepam (an antianxiety medication). Diazepam is a psychotropic medication and a controlled substance medication.

--A physician's order was received on 11/10/23 for 5 milligram (mg) diazepam to be given as one tablet by mouth every 8 hours as needed (PRN) for anxiety. The order was discontinued on 12/6/23.

--On 12/12/23, 5 mg diazepam was ordered to be given by mouth every 8 hours PRN for anxiety and/or muscle relaxant. This order was discontinued on 12/19/23.

--A physician's order was received on 12/19/23 for 5 milligram (mg) diazepam (an antianxiety medication) to be given as one-half tablet (2.5 mg) by mouth scheduled twice daily for anxiety.

--On 2/23/24, an order was received for 10 mg diazepam to be given as one tablet by mouth every 8 hours as needed for crying and/or anxiety. There was no end date or rationale documented for this PRN diazepam order to be extended beyond 14 days.

--The order for the 2.5 mg of scheduled diazepam given twice daily was discontinued on 3/22/24 and another order was received on 3/22/24 for 5 mg of diazepam to be given as one tablet by mouth scheduled twice a day for anxiety.

The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE REDACTED]. Resident #97 was reported to have intact cognition with no behaviors nor rejection of care. The Medication section of

the MDS revealed Resident #97 received an antianxiety medication during the 7-day look back period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 51 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 0758 Resident #97's EMR indicated the physician's orders for both the scheduled diazepam (ordered on 3/22/24) and the PRN diazepam (ordered on 2/23/24) continued as active orders up through the date of the review on Level of Harm - Minimal harm or 6/12/24. A review of Resident #97's Medication Administration Records (MARs) revealed eight (8) doses of potential for actual harm PRN diazepam were administered to the resident from 2/23/24 through the date of the review (6/12/24). The last dose of PRN diazepam was documented as having been administered on 6/7/24. Residents Affected - Few

A telephone interview was conducted on 6/13/24 at 3:23 PM with the facility's consultant pharmacist. During

the interview, the pharmacist reported she had made multiple recommendations to address the use of Resident #97's PRN diazepam on each of the following dates: 11/30/23, 1/31/24, 2/29/24, and 5/31/24. Each recommendation read, in part, PRN psychotropic orders are limited to 14 days unless the prescriber deems it appropriate to extend the order. If elect to continue, please document a clinical rationale and a duration for

the PRN order.

An interview was conducted on 6/14/24 at 12:50 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she was aware that orders for PRN psychotropic medications required a stop date. The DON also stated that she was now aware that additional documentation was required to continue PRN psychotropic medications (other than antipsychotic meds) for an extended duration.

42007

2. Resident #28 was admitted to the facility on [DATE REDACTED] with diagnoses including dementia, repeated falls, major depressive disorder, and chronic diastolic heart failure.

The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE REDACTED]. Resident #28 was severely cognitively impaired and there were no behavior concerns during the 7-day look back period. The medication section showed that she received an antipsychotic medication (type of psychotropic medication).

A review of Resident #28's electronic medical record (EMR) revealed a physician's order dated 5/8/24 for Haloperidol oral tablet 2 mg, give 1 tablet every 6 hours as needed for agitation. Haloperidol is a psychotropic medication. There was no end date documented for this medication. The Nurse Practitioner wrote this order.

A review of Resident #28's May and June 2024 medication administration records revealed she had received

a dose of Haloperidol 2 mg on 5/9, 5/11, 5/13, 5/15, 5/16, 5/19 (3doses), 5/20, 5/21, 5/22, 5/24, 5/30, 6/1, 6/5, 6/8, and 6/12.

During an interview with Nurse #4 on 6/13/24 at 2:25 pm, he stated that he entered Resident #28's order for Haloperidol into the system and was unaware that prn psychotropics had to have a 14 day stop date.

During an interview with the Nurse Practitioner on 6/14/24 at 1:25 pm, she confirmed she wrote the Haloperidol order dated 5/8/24 without the 14-day stop date and stated that she was aware that all prn psychotropics had a 14 day stop date and that was how she intended the order to be entered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 51 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 0758 During an interview on 6/14/24 at 3:34 PM with the Director of Nursing (DON), she stated she was aware that orders for PRN psychotropic medications required a stop date. She stated that the Nurse Practitioner Level of Harm - Minimal harm or came in that morning and noticed there was no stop date for Resident # 28's PRN Haloperidol. The Nurse potential for actual harm Practitioner discontinued the current order and placed a new order with a 14-day stop date.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 51 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 40 of 51 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 41 of 51 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 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 32394 Residents Affected - Some Based on observations, interviews with staff, and record reviews, the facility failed to: 1) Label medications (meds) with the minimum information required, including the name of the resident, on 1 of 5 medication (med) carts observed (300 Short Med Cart); 2) Discard expired medications and/or meds without a legible expiration date on 4 of 5 medication carts observed (300 Short Med Cart, 300 Long Med Cart, 200 Long Med Cart, and 200 Short Med Cart); 3) Discard opened single-dose vials (SDV) after their initial use on 2 of 5 medication carts observed (300 Short Med Cart and 300 Long Med Cart); 4) Store medications in accordance with the manufacturer's storage instructions on 2 of 5 medication carts observed (300 Long Med Cart and 200 Long Med Cart).

The findings included:

1. An observation was conducted on 6/11/24 at 4:00 PM of the 300 Short Med Cart in the presence of Nurse #9.

The observation revealed the following medications were stored on the med cart:

a. According to the manufacturer, in-use insulin glargine prefilled pens should be stored at room temperature of less than 86 Fahrenheit (oF) and used within 28 days.

One (1) opened insulin glargine pen was observed to be stored on the medication cart. The pen was not labeled with a resident's name or the date it had been opened. When asked, Nurse #9 examined the insulin pen and confirmed it was not labeled with a resident's name or date it was opened. The nurse stated the pen would need to be discarded.

b. According to the product manufacturer, in-use insulin lispro prefilled pens should be stored at room temperature of less than 86 oF and used within 28 days.

One (1) opened insulin lispro prefilled pen was observed to have an illegible name written in a blue marker

on the pen. Initially, Nurse #9 stated she thought the insulin pen belonged to Resident #84. However, the pen was stored inside a plastic bag labeled with Resident #103's name. The pen was not labeled as to when

it had been opened or put on the medication cart. Upon further inquiry, the nurse stated the pen would need to be discarded.

c. According to the product manufacturer, in-use insulin aspart prefilled pens should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days.

One (1) opened insulin aspart prefilled pen with Resident #185's name hand-written on the pen was stored

on the med cart. The pen was also labeled with a handwritten (but illegible) date as to when it had been opened. An interview was conducted with Nurse #9 at the time of the observation. When the nurse was asked whether she could read the date the pen had been opened, she reported she could not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 51 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 0761 d. The Center for Disease Control and Prevention (CDC) Injection Safety Guidelines include information on when single-dose vials (SDVs) should be discarded. The Guidelines state, Vials that are labeled as Level of Harm - Minimal harm or single-dose or single-use should be used for only a single patient as part of a single case, procedure, potential for actual harm injection . Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor Residents Affected - Some stored for future use on the same patient.

One (1) opened 1 milliliter (ml) vial of 1000 micrograms (mcg) / ml of cyanocobalamin (Vitamin B12) for injection was observed stored on the med cart. The vial was labeled as a single dose vial (SDV). At the time of the observation, Nurse #9 was asked what her thoughts were about the opened SDV being stored on the med cart. The nurse responded by stating she would typically discard a SDV after it had been opened.

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 findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired. With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications.

2. An observation was conducted on 6/11/24 at 11:38 AM of the 300 Long Medication (Med) Cart in the presence of Nurse #5. The observation revealed the following medications were stored on the med cart:

a. According to the product manufacturer, in-use insulin lispro prefilled pens should be stored at room temperature of less than 86 degrees Fahrenheit (oF) and used within 28 days.

An opened insulin lispro pen dispensed for Resident #1 was stored on the medication cart. An illegible date was written on a yellow auxiliary sticker placed on the pen to indicate when the pen was opened. No expiration date was noted on the sticker. The yellow auxiliary sticker read, Discard after 28 days. The mini sticker on the pen included a date as to when the pen was dispensed from the pharmacy, but that date was also illegible. At the time of the observation, Nurse #5 was asked what her thoughts were about the dates on

the insulin pen. The nurse stated she could not read them.

b. According to the product manufacturer, in-use insulin aspart prefilled pens should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days.

One (1) opened insulin aspart pen dispensed for Resident #209 on 5/13/24 was stored on the med cart. The yellow auxiliary sticker placed on the pen by the pharmacy had two blanks (one blank was for the Date Opened and one for the Date Expired). Neither date was filled out. The auxiliary sticker read, Discard after 28 days. Upon review, it was determined 29 days had elapsed since the insulin pen had been dispensed from the pharmacy.

c. According to the manufacturer, in-use insulin glargine prefilled pens should be stored at room temperature (less than 86 oF) and used within 28 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 51 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 0761 One (1) opened insulin glargine pen dispensed from the pharmacy on 5/9/24 for Resident #190 was stored

on the med cart. A yellow pharmacy auxiliary sticker placed on the pen had one date written on the Date Level of Harm - Minimal harm or Expired line which read, 6/9. Upon inquiry, Nurse #5 stated that most staff usually wrote the opened date on potential for actual harm the insulin pens. However, she added that they probably should also write the shortened expiration date on

the auxiliary sticker so there would be no confusion. The nurse confirmed it could not be determined for Residents Affected - Some certain whether the insulin pen was past its expiration date.

d. The Center for Disease Control and Prevention (CDC) Injection Safety Guidelines include information on when single-dose vials (SDVs) should be discarded. The Guidelines state, Vials that are labeled as single-dose or single-use should be used for only a single patient as part of a single case, procedure, injection . Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient.

1) Two (2) opened 10 milliliter (ml) single-dose vials (SDV) of sterile water for injection was stored on the med cart. The vial of sterile water for injection was labeled for single use only.

2) One (1) opened 5 ml SDV of 1% lidocaine for injection was stored on the med cart. The vial of lidocaine was labeled for single use only.

At the time of the observation, Nurse #5 was asked what her thoughts were about the opened SDV being stored on the med cart. The nurse reported the vials needed to be discarded.

e. According to the product manufacturer, an unopened Humalog KwikPen should be stored under refrigeration between 36 oF and 46 oF until the expiration date or at room temperature (less than 86 oF) and used within 28 days.

One (1) unopened Humalog Kwikpen dispensed from the pharmacy on 6/10/24 for Resident #159 was stored

on the med cart. No date was written on the pen as to when it had been put on the med cart. When Nurse #5 was asked, she reported the unopened pen should have been stored in the med room refrigerator until it needed to be opened.

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 findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications.

3. An observation was conducted on 6/11/24 at 3:30 PM of the 200 Long Med Cart in the presence of Nurse #6.

The observation revealed the following medications were stored on the med cart:

a. The manufacturer's storage instructions printed on the box of 0.5 milligrams (mg) / 2 milliliters (ml) budesonide inhalation suspension read, in part: .Store unopened ampules in the foil envelope placed upright

in the carton .Once the foil envelope is opened, use the ampules within two weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 51 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 0761 1) One (1) manufacturer's box of 0.5 mg/ 2 ml budesonide inhalation suspension ampules dispensed from

the pharmacy on 4/23/24 for Resident #415 was stored on the med cart. The box contained one opened Level of Harm - Minimal harm or envelope with 4 ampules stored inside. The opened envelope was not dated as to when it was opened. potential for actual harm 2) One (1) manufacturer's box of 0.5 mg/ 2 ml budesonide inhalation suspension ampules dispensed on Residents Affected - Some 4/30/24 for Resident #197 was stored on the med cart. The box contained one opened envelope with 2 ampules stored inside and one ampule placed outside of the foil envelope and lying on the bottom of the box.

The opened envelope was not dated as to when it was opened.

3) One (1) manufacturer's box of 0.5 mg/ 2 ml budesonide inhalation suspension ampules dispensed on 5/11/24 for Resident #150 was stored on the med cart. The box contained 3 unopened pouches and one opened pouch with 1 ampule stored inside. The opened pouch was not dated as to when it was opened.

b. The manufacturer's storage instructions printed on the box of 0.25 mg / 2 ml budesonide inhalation suspension read, in part: .Store unopened ampules in the foil envelope placed upright in the carton .Once

the foil envelope is opened, use the ampules within two weeks.

One (1) manufacturer's box of 0.25 mg/ 2 ml budesonide inhalation suspension ampules dispensed from the pharmacy on 4/23/24 for Resident #415 was stored on the med cart. The box contained three unopened envelopes and one opened envelope with 1 ampule stored inside. The opened envelope was not dated as to when it was opened.

c. The manufacturer's storage instructions printed on the box of 0.5 mg / 3 mg ipratropium / albuterol inhalation solution read in capital letters: Store in pouch until time of use.

One (1) manufacturer's box of 0.5 mg / 3 mg ipratropium / albuterol inhalation solution dispensed from the pharmacy on 4/25/24 for Resident #143 was stored on the med cart. Two vials were stored in the manufacturer's box (not inside of a pouch). No pouch was in the box.

An interview was conducted with Nurse #6 at the time of the medication cart observation. During the interview, the nurse acknowledged the envelopes (or pouches) containing inhalation solution or suspension ampules needed to be dated when opened.

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 findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications.

4. An observation was conducted on 6/11/24 at 3:05 PM of the 200 Short Med Cart in the presence of Nurse #8. The observation revealed the following medications were stored on the med cart:

a. According to the manufacturer, in-use Fiasp insulin prefilled pens should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 51 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 0761 One (1) opened Fiasp insulin pen dispensed from the pharmacy on 4/29/24 for Resident #78 was dated to indicate it was opened on 5/5/24. Upon review, it was determined 37 days had elapsed since the insulin pen Level of Harm - Minimal harm or had been opened and it was kept past its shortened expiration date. During an interview conducted with potential for actual harm Nurse #8, the nurse was asked what her thoughts were with regards to this insulin pen. She confirmed the insulin pen was expired. Residents Affected - Some b. According to the manufacturer, in-use Lantus insulin vials should be stored under refrigeration between 36 oF and 46 oF or at room temperature (less than 86 oF) and used within 28 days.

One (1) opened Lantus insulin vial dispensed from the pharmacy on 4/18/24 for Resident #177 was stored

on the med cart. A yellow pharmacy auxiliary sticker placed on the vial containing the insulin had two blanks (one blank for the Date Opened and one for the Date Expired). Neither of the dates were filled out. The auxiliary sticker also read, Discard after 28 days. When Nurse #8 was asked how she would know whether

the insulin vial had been kept past its shortened expiration date, she stated, I wouldn't.

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 findings of the Medication Storage and Labeling facility task. Upon inquiry, the DON stated her expectation was for nursing staff to ensure a medication was on the cart at the time of its scheduled administration and to be sure the medication was not expired With regards to the medications concerns discussed, the DON reported the nursing staff required education on the appropriate storage of medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 51 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 47 of 51 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 20670

Residents Affected - Many Based on observations, record reviews, and staff interviews, the facility failed to ensure the sanitizing solution (chlorine) was maintained at the required concentration of 50 ppm (parts per million) during the final rinse cycle according to manufacturer's instructions in the low temperature dish machine; failed to maintain

the food service equipment clean, free from debris and in good working condition; failed to ensure leftover food items stored for use in the walk-in cooler and walk-in freezer were sealed, dated and labeled; and failed to ensure facial hair was covered by dietary staff during food preparation. These practices had the potential for cross-contamination of food served to residents.

Findings included:

1a. During the initial tour of the kitchen on 6/10/24 at 10:40 a.m., the operation of the low temperature dishwasher of the soiled breakfast dishware by dietary staff was observed. The sanitizing solution (chlorine) for the low temperature dishwasher did not register on the chlorine testing strips provided by the dietary staff.

After retesting the concentration of the chlorine solution in the dishwasher with the same results, this surveyor informed the DM (Dietary Manager) the observed dishware would have to be rewashed and sanitized: 1-rack of plates, 3-racks of lid covers, 2-racks of meal trays, and 1-rack of silverware.

During an interview on 6/10/24 at 10:45 a.m., the DM revealed that earlier that morning she tested the chlorine sanitizer in the dishwasher, and it read 50 ppm. The DM directed the 2-dietary staff to discontinue using the dishwasher and transfer the dishware to the three compartment sink to be rewashed and sanitized.

1b. During an observation of the kitchen on 6/12/24 at 1:15 p.m., there were no doors attached to the door hinges of 4 of the 10 meal delivery carts.

On 6/12/24 at 2:05 p.m., the DM revealed the doors to 4 of the 10 meal delivery carts had been in disrepair for approximately three months.

2a. On 6/10/24 at 10:46 a.m., during the initial tour, the floor of the kitchen had food particles scattered throughout and the floor area near the stove was slippery with grease. The lower wall behind the stove and convection ovens was also littered with dark grease spots. There was black grease and dried food crumbs

on the inside and outside of the two convection ovens and the deep fryer. The inside of the two plate-warmers contained food debris and bread slices. Also, next to a food preparation table a stand-alone fan with dry, gray lint covering the protective grid while in use.

2b. A follow up visit to the kitchen on 6/12/24 at 2:05 p.m. revealed the lint covered standing fan was in operation while directed at the preparation table where dietary staff was preparing sandwiches. The two plate-warmers contained food debris and plastic gloves in the bottom and clean plates. The filter on the outside of the ice machine contained thick gray lint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 51 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 0812 During an interview on 6/12/24 at 4:56 p.m., the DM stated dietary did not have a cleaning policy but had a sanitation inspection policy checklist. The checklist the DM presented for review did not document the dietary Level of Harm - Minimal harm or staff assigned to any of the cleaning tasks. She revealed the dietary department did not maintain the potential for actual harm completed sanitation checklists.

Residents Affected - Many 3. During the initial tour of the kitchen on 6/10/24 at 10:45 a.m., there was 1-unsealed and not dated box of rice on the shelf beneath the food preparation table. An observation of the walk-in cooler revealed 1-opened box with an opened bag of pork loin that was not dated; 1-resealed plastic bag of boiled eggs that was not dated, on the floor beneath the shelf; and 1-opened container of pasteurized liquid egg that was not dated.

The walk-in freezer consisted of 10-plastic bags of unidentifiable frozen items, not dated or labeled (8-resealed and 2-not sealed).

4. During a kitchen observation on 6/12/24 at 1:15 p.m., 2 of 5 dietary staff were observed with exposed/uncovered facial hair ranging from 1/2 inch to 1 inch in length. The two staff were noted to perform various food service tasks including meal production and service without hair coverings over their facial hair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 51 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42007 potential for actual harm Based on record review and staff interviews, the facility failed to document providing education of the Residents Affected - Few influenza vaccine pneumococcal vaccine and the resident's or resident representative's refusal to receive the pneumococcal vaccine for 1 of 5 residents reviewed for immunizations (Resident #182).

Findings included:

Resident #182 was admitted to the facility on [DATE REDACTED].

The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] indicated Resident #182 was severely impaired cognitively.

There was no documentation in the electronic medical record (EMR) Resident #182 had received the pneumococcal vaccine at the facility. There was also no reported history of Resident #182 receiving a pneumococcal vaccine outside of the facility prior to being admitted .

The facility was unable to provide written documentation Resident #182 or Resident #182's Representative had received education to consent to receive or refusal of administration of pneumococcal vaccine.

Attempts to interview Resident #182's Responsible Party were unsuccessful.

During an interview with the Infection Preventionist on 6/14/24 at 9:12am, she stated that she had worked in that role since July 2023 and was currently also acting as the Staff Development Coordinator. She stated that she had been working on making sure all residents had an updated Covid vaccine and a yearly influenza vaccine and had not focused as much on their pneumococcal status. She added that, previously, an agency nurse filled in the position, and she had been unable to locate several refusal forms for vaccines.

During an interview with the Corporate Nurse Consultant on 6/14/2024 at 10:15am, she stated that she was also unable to locate any documentation of consent or refusal of the pneumococcal vaccine by Resident #182 or Resident #182's representative. She added the facility should have obtained written consent or refusal for all vaccines and that should have been a permanent part of their medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 51 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 51 of 51 345092