Inspection·April 25, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 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 supervise one of three residents (Resident 1) with a history of falls when, Resident 1 was not supervised and assisted to the bathroom. This failure resulted in Resident 1 sustaining a left hip fracture (broken bone), experiencing pain, and transferring to Acute Care Hospital 1 (ACH 1) for follow up care. Findings: During a record review of Resident 1's admission Record, printed on 4/25/24, the record indicated Resident 1 was admitted to the facility on [DATE], with dementia (memory loss), muscle weakness, abnormalities of gait (a person's manner of walking) and mobility, and abnormal posture. During a record review of Resident 1's Annual Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) assessment, dated 2/21/24, the MDS assessment indicated Resident 1 used a walker for mobility. The assessment also indicated Resident 1's need for supervision during activities of daily living (Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation (walk, move about), toileting, eating, transferring, and communicating.) and mobilization. The record indicated Resident 1's Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was nine (9) out of 15, indicating moderately impaired mental status. The BIMS indicated Resident 1 was unable to recall the correct year and day of the week and was able to recall recent information with cueing. During a concurrent observation and interview on 4/25/24, at 9:55 a.m., with Resident 1, Resident 1 was lying in bed and stated the bathroom in her room had an out of order sign, and she fell while trying to use the bathroom. Resident 1 stated she did not know how she fell. Resident 1 then stated she did not remember if she fell and denied pain/discomfort. During a record review of Resident 1's Physician Order, dated 5/25/23, the Physician Order indicated to monitor the resident for wandering [become lost or confused about their location]/ambulation without assistance . redirect as needed every shift for fall precautions. During a record review of Resident 1's Fall Risk Care Plan, initiated on 3/23/23, the Fall Risk Care Plan indicated, The resident is at risk for falls [related to] psychoactive drugs (drugs that (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 4 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 04/25/2024 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)