Health inspection·October 1, 2024

F 0880 should be kept in closed and put away after use. Level of Harm - Minimal harm or potential for actual harm 2.During a concurrent observation and interview on 10/1/24 at 3:12 p.m., with HS in Station 2 shower area, the men ' s and women ' s shower drains had dark and grey colored hair in them. [NAME] colored track marks were in on the tile in the middle of the shower area. HS stated the brown tracks in the middle of the tile shower floor was feces and should have been cleaned up by staff. HS stated the janitor ' s is supposed to clean the showers before resident ' s shower in the morning and the afternoon. HS stated the janitor is also supposed to clean the shower areas after afternoon showers. HS stated the facility janitors and housekeepers are assigned to clean every day and she would not consider the shower areas clean. HS stated nursing staff should notify if housekeeping if they suspect any bodily fluids present, like feces. HS stated staff should clean and feces as best they can, then call housekeeping to disinfect the area. HS stated she had not received a notification of feces in the shower areas for today (10/1/24). Residents Affected - Some 3. During a concurrent observation and interview on 10/1/24 at 3:25 p.m., with HS in Station 3 shower area, the men ' s and women ' s shower drains had dark and grey hair and plastic and paper debris in it. HS stated staff are assigned cleaning duties daily. HS stated none of the shower areas observed in Station 1, 2, and 3 were up to her infection control standards expectations and staff had been trained to higher standards. HS stated there is a potential for germs to spread throughout the facility with the current conditions of shower areas. During an interview on 10/1/24 at 3:30 p.m., with HS, the HS stated all housekeeping staff had recently been trained in September 2023 in infection control. HS stated staff know what the expected standards are for clean shower areas. During an interview on 10/1/24 at 3:40 p.m. with the Janitor (JAN), the JAN stated janitors are in charge of cleaning showers every morning after showers and in the evenings after evening showers. JAN stated showers in Station 3 do not look clean. JAN stated Station 3 shower area have clogged hair and paper in the drains. JAN stated when there are bodily fluids present a certified nursing assistant should call janitors in order to sanitize. JAN stated he just arrived at 2 p.m. and has not received a call. 4. During an interview on 10/1/24 at 5:02 p.m. with Certified Nursing Assistant (CNA) 2, the CNA 2 stated the shower in room [ROOM NUMBER] was dirty. CNA 2 stated room [ROOM NUMBER] shower had built up from shampoo and loose hair. CNA 2 stated the toilet chair commode has rust stains and paint peeling and has the potential to cause injury on a resident ' s exposed areas. CNA 2 stated when equipment is in the condition she would reports to maintenance and nursing to alert them of the condition. CNA 2 stated she had reported the commode yet. During an interview on 10/1/24 at 5:17 p.m. with the Administrator (ADM), the ADM stated Housekeeping Supervisor is the individual who checks off work being completed and goes through facility to validate concerns when they are brought up. ADM stated usually showers are cleaned by 11 a.m. ADM stated when there is feces, shower should be disinfected and cleaned prior to use. He stated all staff should be communicating issues with housekeeping if found and the expectations are that staff should have notified someone to clean up the feces. ADM stated he would consider the shower areas clean today (10/1/24) . ADM stated it creates a risk for cross contamination and potential infection control issues. During a concurrent observation and interview on 10/1/24 at 5:32 p.m., with the Director of Nurses (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555652 If continuation sheet Page 2 of 3 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 555652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Creek Healthcare Center 650 W. Alluvial Clovis, CA 93611 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (DON) and Administrator (ADM), in room [ROOM NUMBER] a toilet commode was observed to have rust on it. The ADM stated the toilet commode had rust on the chair, and peeling paint and rust could potentially injure a resident. The DON stated rust can cause injury to residents using chair, it should be addressed with nursing or maintenance staff immediately. DON stated the shower had visible hair stuck in the drains and should have been cleaned with daily cleanings. The ADM and DON validated the ceiling vent had debris in it. The ADM stated dirt accumulation was more then one day, it could have been days or weeks of accumulation. The ADM stated room [ROOM NUMBER] bathroom was not cleaned to facility standards. ADM stated this should have been cleaned as part of the deep cleaning. The ADM stated deep cleaning is done once a month but also if observed to be dirty should have been cleaned. During an interview on 10/9/24 at 8:30a.m., with the Infection Preventionist (IP), the IP stated, housekeeping/janitors are supposed to clean showers daily and as needed if soiled. The IP stated drains are included in cleaning. The IP stated if fecal matter is present staff should have notified housekeeping staff in order to sanitize bathroom prior next use of shower area. The IP stated the plunger found in the shower room should not have been left on the floor uncovered. The IP stated plunger should be in the housekeeping closet. The IP stated bodily fluids should be cleaned up and disinfected by housekeeping staff. The IP stated showers for today (10/1/24) were not clean. The IP stated when staff do not clean the shower areas there is a potential risk for bacteria to and fungus to grow and risk of cross contamination for residents that use the use the shower areas. During an interview on 10/9/24 a.m., with the Director of Nursing (DON), the DON stated, the showers were not cleaned to facility standards. The DON stated the shower areas and room [ROOM NUMBER] appropriate for residents to use. The DON stated showers, plungers and soiled locations areas did not follow the policy for maintaining a clean and sanitary environment and placed residents at risk for cross contamination and harboring bacteria. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection Residents ' Rooms dated, August 2013, the P&P indicated, Environmental surfaces will be disinfected (or cleaned) on a regular basis daily and when surfaces are visibly soiled .Clean spills of blood or body fluids as outline in the established procedures .Clean all high touch use items with disinfectant solution . During a review of the facility's P&P titled, Cleaning Spills or Splashes of Blood or Body Fluids dated, February 2023, the P&P indicated, .Whoever spills or splashes blood or body fluids, or witnesses splattered or spilled blood anywhere in the facility, shall notify environmental services that a spill or splash of blood or body fluids has occurred and shall provide pertinent information including amount and area in which the incident occurred .An appropriate trained and authorized individual shall clean and disinfect any surfaces or equipment contaminated with spills or splashes of blood or body fluids as soon as practical to prevent exposure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555652 If continuation sheet Page 3 of 3