Willow Valley Center For Nursing And Rehabilitatio

Findings included: Resident #128 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis of vertebra, lumbosacral region, Parkinson's disease, and congestive heart disease.

The admission Minimum Data Set, dated [DATE] indicated Resident #128 was cognitively intact.

Review of the facility's Safe Smoking Screening dated 4/30/24 included Resident #128 did not currently smoke.

During an interview on 6/11/24 at 1:09 p.m., Resident #128 revealed she was a smoker and since she was admitted to the facility had requested to be assessed to smoke.

The resident stated smoking calmed her and she frequently begged staff (unable to name staff) to be assessed for smoking but was always told that staff did not have time to assess her for smoking.

On 6/14/24 at 2:10 p.m.

Nurse #2 revealed she completed the Smoking Assessment on Resident #128 during the admission process and documented the resident as not being a smoker.

Nurse #2 was unable to recall if she asked the resident if she smoked.

She insisted the resident never requested to smoke until she had a roommate who smoked.

Nurse #2 stated she spoke with the nurse practitioner who felt the resident would not be a safe smoker.

The resident must be able to hold a cigarette without burning herself, sit upright without increase in pain for more than a few minutes because of chronic pain related to a sacral wound and rheumatoid arthritis.

The nurse practitioner offered nicotine patches which the resident refused.

Nurse #2 admitted that once facility staff became aware Resident #128 requested to smoke, an updated smoking assessment should have been completed at that time.

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

Based on the audit and financial review, the previous Business Office Managers had not submitted a request for the refund when the resident was discharged .

She further stated per policy discharged and expired residents' accounts should be reviewed and closed out and refunded to the resident or agency within 30 days per the conveyance policy.

A telephone interview was conducted on [DATE] at 7:45 AM, with Resident #620's family member who stated she had requested from the previous Business Office Manager and assistant the return of funds from Resident #620's social security check be returned to her when she was discharged on [DATE].

She reported the previous Business Office Manager stated the check had been returned to the social security office and Medicaid, when the family contacted the social security office, they stated they had not received any correspondences from the facility about the discharge or the request for the social security check to be returned to the home address.

She stated she again spoke with the previous BOM about the billing and address change for the check and he continued to give her the run around.

She reported Resident #620 had several bills that were not paid for the month of April resulting in the delay of bills.

She did not receive the reinstatement of the social security check until May.

The family member further stated Resident #620 had not received any refund from the facility for the April check.

She reported she had spoken with the current Business Office Assistant to resolve the issue and was told the money would be refunded in April and as of [DATE] she had not received any money.

An interview was conducted on [DATE] 10:21 AM, with the Regional Business Office Manager who shared the Business Office Managers were responsible for ensuring a financial record for expired and discharged residents were reviewed and audited monthly and all refunds dispersed to the proper agency, resident and/or representative in accordance with the federal regulations.

An interview was conducted on [DATE] 10:21 AM with the Administrator who stated the Regional Business Office Director and Business Office Managers were responsible for ensuring a financial record for expired and discharged residents were reviewed and audited monthly and all refunds dispersed to the proper agency, resident and/or representative in accordance with the federal regulations within 30 days.

During an interview with 6 members of the Resident Council (Resident #20, Resident # 111, Resident #148, Resident #156, Resident #190 and Resident #365 on 6/13/24 at 9:30 am revealed they did not receive mail on Saturdays and the facility only delivered mail Monday through Friday.

Interview with the Activities Director on 6/13/24 at 10:09 am revealed mail was sorted by the Business Office then given to the Activities Department to be delivered to residents.

Activities delivered mail to residents 5 days a week, Monday through Friday.

She stated mail was delivered to the facility on Saturdays, but the Business Office received the mail first.

Interview with the Business Office Manager and Business Office Manager Assistant on 6/13/24 at 10:50 am revealed residents would receive packages on Saturday but not mail because the business office was closed.

Mail was sorted and then given to the Activities Department to be delivered Monday through Friday when the business office was open.

Mail was sorted to ensure the facilities mail was removed before giving mail to the Activities Department for delivery.

Interview with the Director of Nursing on 6/13/24 at 3:18 pm revealed the Activities Department was responsible for delivering mail to residents.

Mail should be delivered to residents on Saturdays.

345092 07/02/2024

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

During an interview with Nurse #1 on 06/12/24 at 2:54 PM she stated the door and curtain should be closed in residents' rooms during incontinence care.

An interview was conducted with NA #1 on 06/12/24 at 3:01 PM and she stated she knew the door was broken and usually propped something against it to keep it closed to provide privacy when giving care to the resident.

She further stated she thought the privacy curtain was pulled far enough around the bed to block visibility from the hall.

She added she should have made sure the door stayed shut and pulled the curtain further around the bed before incontinence care was provided to Resident #168.

An interview was conducted with the Administrator on 06/14/24 at 2:37 PM and she stated NA #1 should have fully drawn the privacy curtain whether the door was in working order or not.

She further stated if the resident had a roommate, the curtain afforded a second layer of privacy in case the roommate wanted to enter the room.

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

would enter needed repairs into the computerized system that would notify him and his staff. He

rooms. He stated he was not aware of the issues in room [ROOM NUMBER] and was also not aware

maintenance workers to check their assigned floor for any issues.

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

SW Assistant #1 should have immediately completed a grievance form when she received the email

providing a copy of the Grievance/Concern Form to the resident/resident representative upon

345092 07/02/2024

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

Based on observation, record review, staff, and resident interviews, the facility failed to protect a

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 neglect.

Findings included: This tag is cross referenced to: 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.

345092 07/02/2024

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

Findings included: Resident #209 was admitted to the facility on [DATE].

The 5-day Minimum Data Set (MDS) dated [DATE] 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.

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

Findings included: Resident #265 was originally admitted to the facility on [DATE].

The annual Minimum Data Set, dated [DATE] 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

• 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.

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

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.

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

Review of Resident #102's medical record revealed documentation of a Level I PASRR

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.

• Review of Resident #103's medical record revealed documentation of a Level I PASRR

determination dated 7/21/17 prior to his admission on [DATE].

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.

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

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.

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

(NA) #11. Resident #14's skin was observed to be intact with no redness. NA #11 was observed not to

NA #11 was interviewed on 6-12-24 at 9:57am. NA #11 discussed the steps she took providing a bath

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.

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

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.

345092 07/02/2024

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

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] 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 [DATE].

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.

345092 07/02/2024

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

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.

345092 07/02/2024

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

required a stop date.

The DON also stated that she was now aware that additional documentation was

duration.

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

During the interview, the pharmacist reported she had made multiple recommendations to

days unless the prescriber deems it appropriate to extend the order. If elect to continue, please

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.

• Resident #28 was admitted to the facility on [DATE] 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]. 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.

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 came in that morning and noticed there was no stop date for Resident # 28's PRN Haloperidol.

The Nurse Practitioner discontinued the current order and placed a new order with a 14-day stop date.

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

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.

345092 07/02/2024

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

During an interview conducted with Nurse #8, the nurse was asked what her thoughts were with regards to this insulin pen.

She confirmed the insulin pen was expired. 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.

345092 07/02/2024

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

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.

345092 07/02/2024

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

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 ½ 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.

345092 07/02/2024

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

Findings included: Resident #182 was admitted to the facility on [DATE].

The quarterly Minimum Data Set (MDS) assessment dated [DATE] 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.

345092 07/02/2024

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

facility corridors were properly secured to the walls, repaired and free from sharp edges on 3 of 4

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.

345092 07/02/2024

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

Findings included:

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

The 5-day Minimum Data Set (MDS) dated [DATE] 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.

345092

Form Approved OMB

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