Inspection·August 31, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan for Resident 1 to receive a consult with psychiatric (specialist in providing mental, emotional, medical or behavioral care) services were implemented. This failure resulted in the potential for Resident 1 to have compromised psychosocial well-being and at risk of another altercation with another resident. Findings: Review of the clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions, and relate to others). A review of Resident 1's behavior care plan initiated on 7/11/23, by the Director of Nursing (DON), indicated Resident 1 was at risk of having psychosocial well-being problems because of an encounter with another resident. The care plan indicated an intervention for Resident 1 to have a consult with psychiatric services. A review of Resident 1's behavior care plan initiated on 7/16/23 by the DON, indicated Resident 1 had another altercation with another resident. The care plan again indicated the same intervention for Resident 1 to have consult with psychiatric services. During an interview on 7/31/23, at 2:22 p.m., with Licensed vocational nurse (LVN 1), LVN 1 stated, Resident 1 had a verbal altercation with Resident 2 on 7/11/23. LVN further stated Resident 1 had the behavior of getting verbally aggressive. During an interview on 7/31/23, at 2:55 p.m., with Social Services Director, SSD stated, Resident 1 has a behavior of picking a fight and wanted to go to anger management (class). SSD acknowledged that Resident 1 should have had the psychiatric services consultation. During an interview on 7/31/23, at 4:16 p.m., DON stated Resident 1 was not referred for psychiatric services yet. During a review of the facility's policy and procedure (P&P) titled, Care Planning-IDT Care Planning Conference, dated 2008, the P&P indicated, To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable (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 08/31/2023 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)