Health inspection·July 9, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of three sampled residents' (Resident 1 and Resident 3) rooms were maintained in a comfortable and safe temperature level when Resident 1 and 3's room air temperature was at 84 degrees Fahrenheit during a heat wave. This failure had the potential to cause overheating in residents and discomfort during severe hot weather. Findings: During a facility tour on 7/3/24 at 12:06 p.m., with Maintenance Supervisor (MS), the air temperature in Resident 1's room was 84 degrees Fahrenheit. During a review of Resident 1's Minimum Data Set (MDS - Resident assessment and care guide tool), dated 6/11/24, the MDS indicated Resident 1's Basic Interview of Mental Status (BIMS, 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 15 and indicated intact mental status. The MDS indicated Resident 1 was able to recall the correct year, month, and day of the week. The MDS indicated Resident 1 had diagnosis of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). During a concurrent observation and interview on 7/3/24 at 12:06 p.m., Resident 1 laid in bed with loose-fitted clothes, awake and verbally responsive. Resident 1 stated her room was hot and uncomfortable in the afternoon despite the use of fan. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's BIMS, score was 15 and indicated intact mental status. The MDS indicated Resident 2 was able to recall the correct year, month, and day of the week. The MDS indicated Resident 2 had diagnosis of asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe). During an interview on 7/8/24 at 10:40 a.m., Resident 2 stated the facility was hot in the afternoon over the weekend. Resident 2 stated the air condition had been faulty for weeks and not repaired. Resident 2 stated facility does nothing about it. Resident 2 stated sometimes air condition blows cool air sometimes it blows warm air. Page 1 of 2 055241 055241 07/09/2024 Willow Pass Healthcare Center 3318 Willow Pass Road Concord, CA 94519

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a facility tour on 7/9/24 at 10:58 a.m., with MS, the air temperature in Resident 1's room was 84 degrees Fahrenheit. During an interview on 7/9/24 at 10:58 a.m., with Resident 1, Resident 1 stated her room temperature swings from okay to very hot and is not comfortable in the afternoon. Resident 1 stated despite the fan working continuously the room is too warm. Resident 1 stated there was no cool air flow through the vent. Resident stated the air condition had been faulty for some two to three weeks ago. During a facility tour on 7/9/24 at 11:10 a.m., with MS, the air temperature in Resident 3's room was 84 degrees Fahrenheit. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's BIMS score was 08 and indicated impaired mental status. The MDS indicated Resident was unable to recall the correct day of the week but was able to recall the correct week and year. The MDS indicated Resident 3 had diagnosis of Dementia (a group of thinking and social symptoms that interferes with daily functioning). During a concurrent observation and interview on 7/9/24 at 11:10 a.m., Resident 3 was sitting in a wheelchair in the hallway with a portable air condition cooler blowing cool air nearby. Resident 3 stated his room temperature was too warm in the afternoon and made him uncomfortable. During an interview on 7/3/24 at 12:58 p.m., with Administrator (Admin), Director of Nursing (DON) and MS, Admin stated the air condition technician was at the facility to repair the air condition unit. MS stated he checked the air condition unit quarterly and replaced air filters. MS could not provide records of air filter replacements and preventative maintenance records for the facility's air condition units. Admin and MS could not provide preventative maintenance record for the cooling system. Admin stated facility's MS does preventative maintenance of the air conditioning units. During an interview on 7/9/24 at 10:35 a.m., Admin stated the air condition technician made some repair but there were still rooms with air flow problems and not circulating cool air properly. During a review of the facility's policy and procedure (P&P) titled, Maintenance Services, revised December 2004, the P&P indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. During a review of the Air Condition manufacturer manual titled, DIY AC Maintenance indicated; on an average, filters should be replaced every 90 days depending on where you live and how often your air conditioner operates. However, your HVAC contractor can provide the proper filter replacement schedule for your particular air conditioning unit. Reference: https://www.goodmanmfg.com. 055241 Page 2 of 2