Health inspection·April 11, 2024

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect one (Resident 1) of three sampled residents' right to be free from verbal and physical abuse when, Resident 2 yelled and punched Resident 1 in the face. Resident 1 sustained skin tear with flap (a traumatic wound that is caused by direct contact between the skin and another object) during an altercation in the courtyard. This failure resulted in Resident 1's increased anger and fear for his safety at the facility from Resident 2. Findings: Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 3/26/24, indicated. Resident 1 had clear speech, able to express his ideas and wants, made self-understood and understood others. Resident 1 had no physical or verbal behavioral symptoms such as hitting, kicking, pushing, screaming, cursing, and threatening others. Resident 1 used wheelchair for mobility. Resident 1's diagnosis included depression and quadriplegia (a form of paralysis that affects all four limbs plus torso from neck down). During an interview on 4/11/24, at 11:15 a.m., Resident 1 stated he was outside in the courtyard patio when Resident 2 came to the patio and made a profanity statement about beating another resident. Resident 1 stated he told Resident 2 he will not beat anyone when Resident 1 was present. Resident 1 stated Resident 2 then punched him on the left side of his head eight times and scratched his face. Resident 1 stated there was no staff present during the altercation. Resident 1 stated he was angry and fearful for his safety at the facility from Resident 2. Review of Resident 2's Minimum Data Set, dated [DATE], indicated Resident 2 had clear speech, able to express his ideas and wants, and understood what others said to him. Resident 2 used wheelchair for mobility. Resident 2's diagnosis included schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly). During an interview on 4/11/24, at 11:25 a.m., Resident 2 stated Resident 1 called him a derogatory name. Resident 2 stated Resident 1 made him mad. Resident 2 said he hit Resident 1 in the face. Resident 2 said he tried to avoid Resident 1 every time he saw him. Review of Resident 2's IDT (IDT - interdisciplinary team is a group of health care professionals with various areas of expertise who work together toward the goals of their clients) notes dated 3/13/24 indicated licensed nurse heard a loud verbal altercation from down the hall and noted Resident 1 (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 04/11/2024 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)