Inspection·June 21, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure one (room [ROOM NUMBER]) of three residents ' showers inspected, was cleaned and disinfected after use. A pile of clean towels were in the bathroom sink and plastic bags with soiled items were on the floor. These failures exposed residents to contamination. Findings: During an interview on 5/2/23 at 11:21 a.m., Resident 1 stated the shower in her room was not regularly sanitized and asked staff to clean it before her showers. Resident 1 stated she was concerned with athletic (athletes) feet- a contagious condition spread through contaminated floors, towels, or clothing. Resident 1 stated she was scared she might develop toe fungus when she stepped on the shower floor with her bare feet. During an observation on 5/2/23 at 11:27 a.m., a moist, green matter, approximately the size of a half dollar, was on the shower floor in Resident 1 ' s bathroom. Inside the sink was a pile of clean towels. Underneath the sink and on the floor was a plastic bag with a resident gown inside. A pink wash basin was on top of the plastic bag. During an interview on 5/2/23 at 11:32 a.m., the Licensed Vocational Nurse (LVN) described the green matter on the shower floor as poo-poo. LVN stated clean towels did not belong in the sink and the plastic bag is supposed to go to the laundry room. During an interview on 5/2/23 at 12:17 p.m., the Certified Nursing Assistant (CNA) 1 stated she was not aware of the current state of the bathroom in room [ROOM NUMBER]. CNA 1 stated the bathroom was used by other residents that did not have showers in their own rooms. CNA 1 stated the sink is a dirty area where clean items are not placed. CNA 1 stated dirty linen in the plastic bag are supposed to be walked over to the hallway closet and placed in a barrel. During an interview on 5/2/23 at 12:57 p.m., the Infection Control nurse (ICN) stated dirty linen goes to the laundry room. In room [ROOM NUMBER] ' s bathroom, ICN identified a resident ' s dirty brief inside a plastic bag and identified the green matter on the shower floor as poop and it was not sanitary. During an interview on 5/2/23 at 1:26 p.m., CNA 3 stated when he gave his resident a shower in room [ROOM NUMBER], the towels in the sink and plastic bags were already there. CNA 3 stated the towels in the sink should not be used for residents because it was dirty and did not inform housekeeping to (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055241 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055241 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Pass Healthcare Center 3318 Willow Pass Road Concord, CA 94519 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)