Willow Valley Center for Nursing and Rehabilitatio

Inspectors wroteBased on record reviews, and interviews with facility staff, pharmacy staff, and hospice staff, the facility failed to protect a resident's right to be free from misappropriation of a narcotic medication, Hydrocodone-Acetaminophen, prescribed for pain management. This was for 2 of 2 residents reviewed for medication misappropriation (Resident #2 and Resident #3).

Inspectors wroteBased on record review, and interviews with staff, hospice staff, and pharmacy staff, the facility failed to implement their abuse policy regarding the investigation and reporting of an allegation of misappropriation of the narcotic medication Hydrocodone-Acetaminophen for 2 of 2 residents reviewed for misappropriation of medication (Resident #2 and Resident #3).

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately document the administration of Hydrocodone Acetaminophen, a narcotic medication, on the medication administration record for 1 of 2 residents reviewed for accurate narcotic documentation (Resident #2).

Inspectors wroteBased on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a blood glucose meter (glucometer) assigned to Resident #11 and used a glucometer that was assigned to another resident, Resident #141, to check Resident #11's blood glucose level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #11's blood glucose level and would have had no way to know if another staff member had previously disinfected the glucometer assigned to another resident. Glucometers can become contaminated with blood and must be disinfected after each use with an approved product and procedure. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to keep food preparation areas, floors and food service equipment clean, free from debris and/or dried spills during two kitchen observations. The facility failed to clean the ceiling vents located over the food preparation and food service areas. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the garbage and refuse was disposed of and keep 4 of 4 dumpsters and 1 of 1 grease interceptor container, and surrounding dumpster area clean and free from debris. This practice had the potential to attract pests and rodents.

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council and communicate the facility's efforts to address grievances voiced during Resident Council meetings for 2 of 2 consecutive months: June 2025, and July 2025.

Inspectors wroteBased on record review and staff interviews, the facility failed to notify the North Carolina Medicaid Uniform Screening Tool (NC MUST), that is the State Mental Health or Intellectual Disability Authority, when a significant change in condition was identified for a resident with a mental disorder and failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation for PASRR Level II for 2 of 3 residents reviewed for significant change in condition (Resident #10 and Resident # 204).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure residents were provided clean footwear for 1 of 5 residents dependent on staff for Activities of Daily Living (ADL) care (Resident #4). Findings Included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included Dementia and enlarged prostate gland with an indwelling catheter. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was assessed as severely cognitively impaired with no behaviors or rejection of care. Resident #4 was assessed as requiring substantial / maximum assistance for toileting hygiene and partial / moderate assistance personal hygiene. The care plan dated 7/3/25 revealed Resident #4 was care planned for ADL self-care deficit related to Dementia. [...]

Inspectors wroteBased on record reviews, responsible party and staff interviews, the facility failed to provide written conclusions and resolutions of grievances reported by the Responsible Party (RP) for 1 of 1 resident (Resident #225) reviewed for grievances.

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to maintain walls, floors, baseboards in good condition, and rooms free from debris in 9 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], Room#327, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on 6 of 8 resident halls. In addition, the facility failed to maintain floors 3 of 8 halls and a ceiling in 1 of 4 common areas in good condition.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to keep a urinary catheter drainage bag from touching the floor to reduce the risk of infection for 1 of 1 resident reviewed for urinary catheter (Resident #6).

Inspectors wroteBased on record review and staff interviews, the facility failed to safely assist a resident with incontinence care causing injury to 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 received care by Nurse Aide (NA) #1 and fell from her bed to the floor and sustained a closed fracture of the right hip.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, record review, staff, and resident interviews, the facility failed to protect a resident's right to be free from neglect when Resident #209 was (a) 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 neglect.

Inspectors wroteBased 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.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain clean and sanitary floors and walls (bathroom of rooms #321 and #509), maintain clean and sanitary shower curtains (rooms #503, #509, #512, and #525), maintain clean and sanitary privacy curtains (rooms #302, #321, #503, #504, and #506), ensure the toilet was clean and in good repair (room [ROOM NUMBER]), maintain doors and walls in good repair (rooms #424, #517, #525, and #528), maintain privacy curtain ceiling tracks in good repair (rooms #504 and #506), maintain bathtubs/showers clean and in good repair (rooms #506, #507, #516, #517, and #525), maintain furniture in good repair (rooms #409, #513), and maintain the ceiling and polyvinyl chloride pipe (PVC) in good repair (room [ROOM NUMBER]) for 4 of 4 halls (200 hall, 300 hall, 400 hall, and 500 hall ) reviewed for safe, clean, and homelike environment.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased on a meal test tray observation and interviews with the Dietary Manager (DM), the facility failed to 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.

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure the handrails in the facility corridors were properly secured to the walls, repaired and free from sharp edges on 3 of 4 floors where handrails were present.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to honor a resident's request to be assessed for smoking for 1 of 3 sampled residents (Resident #128) reviewed for choices.

Inspectors wroteBased on observation, staff interviews, and record review the facility failed to maintain personal privacy by failing to prevent exposure of a resident's body parts during incontinence care for 1 of 3 residents (Resident #168) reviewed for personal privacy. The reasonable person concept was applied to this deficiency as individuals have the expectation of privacy during incontinence care.

Inspectors wroteBased on record review, family interviews, and staff interviews the facility failed to record a grievance and to make efforts to resolve the grievance for 1 of 3 residents reviewed for grievances (Resident #36).

Inspectors wroteBased 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.

Inspectors wroteBased 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 .

Inspectors wroteBased on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to the Preadmission Screening and Resident Review (PASRR) Level II status for 1 of 4 residents (Resident #174) reviewed for PASRR.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, observation, staff, and resident interviews, the facility failed to provide (1) 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.

Inspectors wroteBased on observation, record review and staff interview the facility failed to have cautionary signage for oxygen (O2) use for 1 of 2 residents (Resident #176) reviewed for respiratory care.

Inspectors wroteBased on record review, resident and staff interviews the facility failed to ensure a resident attended an infectious disease clinic appointment at an outside facility for 1 of 1 sampled resident reviewed for medically related social services (Resident #616).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate 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.

Inspectors wroteBased on record review and staff interviews, the facility failed to document providing education of the 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).

Inspectors wroteBased on staff interview and resident council interview, the facility failed to deliver mail to residents on Saturdays for 211 Residents.

Inspectors wroteBased on staff interviews, family interview and record review of resident trust account, the facility failed to convey funds within 30 days to a discharged resident and failed to forward the balance of funds to the estate of an expired resident for 2 of 3 residents reviewed for personal funds (Resident #619 and 620).

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to prevent 1 of 3 residents (Resident #1), reviewed for accidents, from falling from bed. Resident #1 fell from the bed when it was left at the highest level by a staff member which put him at increased risk of injury.

Inspectors wroteBased on record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place following the 5/24/2022 recertification and complaint investigation survey. The deficiency was in the area of supervision to prevent accidents F689. The continued failure during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review, staff, and Nurse Practitioner (NP) interviews the facility failed to immediately notify the physician of Resident #250's unwitnessed fall that occurred on [DATE] at 1:00 p.m. The on-call physician was not notified of the fall until [DATE] at 6:50 p.m. when it was discovered the resident had an altered mental status. The facility also failed to immediately notify the physician when the ordered intervention of STAT (immediate) laboratory work and normal saline (mixture of sodium chloride and water used to treat dehydration) were not able to be completed STAT. Additionally, the facility failed to notify the physician of Resident #250's tube feeding that was found leaking on the floor and in the bed. These failures resulted in a delay in the physician's initial assessment and initiation of treatment. Resident #250 was discovered unresponsive in her bed on [DATE] at 9: [...]

Inspectors wroteBased on record review and staff, Nurse Practitioner (NP) and Medical Director interviews the facility failed to ensure a resident had on-going comprehensive assessments completed after a resident with functional quadriplegia experienced a second unwitnessed fall on [DATE] at 1:00 p.m. and then later that same day had altered mental status due to suspected dehydration. A Physician video visit was conducted on [DATE] at 6:50 p.m. to evaluate the resident due to altered mental status. At that time the physician noted the resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. The physician ordered STAT (immediately) laboratory blood work and intravenous (IV) normal saline (mixture of sodium chloride and water used to treat dehydration). The STAT blood work was not collected until the morning of [DATE]. [...]

Inspectors wroteBased on record review and staff, Registered Dietician (RD), Speech Therapy (SLP), Nurse Practitioner (NP) and Physician interviews, the facility failed to maintain the hydration status for 1 of 2 residents reviewed for tube feedings (Resident # 250). When it was determined the resident was dehydrated, the facility failed to administer ordered fluids immediately, and failed to complete STAT (immediate) laboratory orders to assess the resident and provide information to the physician for needed treatment. [...]

Inspectors wroteBased on resident and staff interviews, and review of the Resident Council Minutes, the facility failed to respond to repeat concerns related to dietary issues voiced by residents during Resident Council meetings for 3 of 4 months (April 19, 2023, June 22, 2023, July 19, 2023).

Inspectors wroteBased on observations, record reviews, and staff interview, the facility failed to provide residents with the correct portion sizes as specified by the menus and the meal production worksheets for 1 of 1 meal observation. This practice had the potential to affect all residents with regular consistency diets.

Inspectors wroteBased on test tray observation, record reviews and interviews with residents and the Dietary Manager (DM), the facility failed to serve food that was palatable and at temperatures acceptable to 1 of 5 Halls (400 Hall). This practice had the potential to affect other residents.

Inspectors wroteBased on observations, record review, resident and staff interview, the facility's Quality Assessment and Performance Committee (QAPI) failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint investigation survey conducted on [DATE], recertification/revisit and complaint survey conducted on [DATE] and the recertification and complaint investigation survey conducted on [DATE]. This was for five deficiencies in the areas of: Advanced Directives (F578), Notification of Changes (F580), Quality of Care (F684), Nutrition/Hydration Status Maintenance (692), and Menus Meet Residents Needs (F803) which were originally cited during the recertification and complaint investigation survey conducted on [DATE] and recited during the current recertification and complaint investigation survey conducted on [DATE]. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to determine on admission a resident's desired advanced directives throughout the medical record for 3 of 35 residents (Resident #189, # 399, and # 8) reviewed for advanced directives.

Inspectors wroteBased on staff interviews and medical record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within 14 days after the facility determined a significant change occurred for 1 of 1 residents (Resident #8) reviewed for Hospice.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to accurately document Preadmission Screening and Resident Review (PASARR) status and dental status on the Minimum Data Set (MDS) assessment. This occurred for 1 of 35 residents reviewed for accuracy of assessments (Resident #31).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments no later than 14 days after the Assessment Reference Date (ARD, the last day of the look-back period) for 9 of 53 residents (Residents #76, #104, #149, #165, #185, #141, #112, #171, and # 31) reviewed for resident assessments.