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. (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 07/09/2024 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)