Willow Pass Healthcare Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from verbal abuse when a CNA used profanity, raised his voice, and yelled at the resident in the TV dining area after the resident requested help for another resident who was crying out. The involved resident had an admission date of 2/10/26 and an MDS dated 3/6/26 showing intact cognition, clear communication, and full understanding, with a BIMS score of 15/15. On Super Bowl Sunday, while in the TV dining room, the resident observed another resident crying out for help and called out to a CNA for assistance. The resident reported that the CNA responded in a rude tone, saying, “We got a problem?” in a loud and angry manner, and that other staff had to remove the CNA from the room. The resident stated that the CNA’s tone was “pissed and loud,” that people should not talk to residents that way, and that the CNA should have been fired. In interviews, the CNA acknowledged that he had previously been counseled about professionalism and his loud voice, and admitted that during the 2/8/26 incident he raised his voice at the resident instead of “swallowing his pride.” The DSD confirmed that the CNA had a loud voice that some residents did not like and that loud talking by direct care staff could make residents feel hurt or scared, and stated the CNA had been spoken to before about his loud voice. Another resident described the CNA as sometimes “obnoxious.” The Social Services Director reported hearing a commotion, then observing the CNA and the resident yelling and shouting at each other and exchanging profanities, with the CNA appearing “hot headed,” and documented the verbal altercation in the progress notes. A witness statement and interview from another CNA indicated she heard loud screaming, was told the CNA was “fighting with a resident,” and then saw both the CNA and the resident arguing, with the resident crying and visibly upset afterward. A nurse’s progress note documented that the resident perceived the CNA’s tone as rude and loud and stated, “That’s not the way they can talk to me.” The facility’s abuse prevention policy stated that each resident has the right to be free from verbal, sexual, physical, and mental abuse and must not be subjected to abuse by anyone, including facility staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to remove a CNA from resident care areas after he engaged in a verbal altercation with a resident. On the date of the incident, Resident 1, who had an intact mental status with a BIMS score of 15 and was able to clearly express ideas and understand others, was in the TV dining room when another resident (Resident 2) began crying out for help. Resident 1 asked CNA 1, who was sitting in the room, to help Resident 2. According to Resident 1, CNA 1 responded in a rude tone, asking, “We got a problem?” and used a loud, angry tone. Social Services Director 1 reported hearing a commotion and, upon entering the TV room, observed Resident 1 and CNA 1 yelling and shouting at each other and exchanging profanities, with CNA 1 described as hot headed. SSD 1 documented in the progress notes that Resident 1 had a verbal altercation with CNA 1, and she noted that Resident 1 was trembling from anger after the incident. CNA 1 acknowledged that he raised his voice at Resident 1 during the incident and stated he had previously been counseled about being professional and lowering his voice with residents. The DON confirmed that CNA 1 had a generally loud voice and had been told in the past to treat residents with respect. Despite the altercation occurring around midday, staffing records and the CNA’s timecard showed that CNA 1 continued working his full shift from approximately 7:00 a.m. to 3:30 p.m., providing direct care to nine assigned residents for more than three hours after the incident. The Administrator, who served as the Abuse Coordinator, stated that if the incident occurred around noon, CNA 1 should have been sent home immediately and suspended during the investigation, and that the facility’s abuse prevention policy required immediate removal of an employee suspected of abuse from the care or vicinity of the resident. The failure to remove CNA 1 from resident care areas after the altercation constituted the cited deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent financial exploitation of a resident when a CNA accepted a new pair of shoes that the resident purchased for the CNA’s personal use. The resident had been admitted with a diagnosis that included right knee pain, and the MDS assessment showed a BIMS score of 15, indicating intact cognitive status with the ability to recall the correct year, month, and day of the week. According to the CNA, the resident noticed the CNA’s swollen feet, inquired about the condition, and was told the CNA had arthritis. The resident then bought a new pair of shoes and gave them to the CNA, who accepted them and later gave the resident twenty dollars for the shoes. During an interview, the CNA stated she did not see anything wrong with accepting the shoes from the resident. The Administrator and DON reported they were not aware that the CNA had received shoes purchased by the resident and stated the facility did not expect the CNA to receive shoes from the resident for personal use. Review of the facility’s Abuse Prevention policy, dated 9/1/2008, indicated that abuse, neglect, abandonment, isolation, and financial abuse would not be tolerated at any time. Despite this policy, the CNA’s acceptance of the shoes constituted exploitation, as the resident’s belongings or money were used for the CNA’s personal gain.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in care planning related to a cognitively intact resident admitted with malignant neoplasm of the skin. The resident’s Minimum Data Set (MDS) showed a BIMS score of 15, indicating intact mental status, with clear speech and ability to understand and be understood. The resident reported during interview that he had not showered for some time and that he sometimes refused showers. Review of the shower record from 2/10/26 to 3/11/26 showed the resident had not received a shower for more than a month, despite being scheduled for showers twice weekly. The ADL care plan did not address the resident’s ongoing refusal to shower, and the DON acknowledged that the facility’s expectation was that the care plan be updated with the refusal and appropriate interventions. This was inconsistent with the facility’s “Shower for Residents” policy, which required that continual refusal to shower/bathe trigger social services involvement and care plan interventions to remedy the situation. Surveyors also found that the Interdisciplinary Team (IDT) did not develop a care plan addressing the resident’s discharge plan upon admission. Although the MDS indicated no discharge plan, care plan conference documentation on multiple dates reflected that the resident had discharge potential. The DON was unable to provide a discharge care plan for the resident and stated that discharge planning was addressed during care conferences rather than through a written care plan initiated on admission. Additionally, care plan conference records showed that the resident’s family member was not invited to participate, and the DON confirmed that the family member was not consistently invited. These findings were not in accordance with the facility’s Care Planning policy, which required that all resident care needs be identified through continuous assessments and care planned with measurable objectives and adequate interventions, and with the facility’s Care Planning-IDT process that included the resident and family/representative whenever possible.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that a resident who was cognitively impaired and dependent on staff for toileting, hygiene, and bathing was not provided grooming services to maintain personal hygiene. The resident had been admitted with a hip fracture and had a BIMS score of 03, indicating impaired mental status and inability to recall the correct year, month, and day of the week. The resident’s MDS documented that she required maximal assistance with showering/bathing and assistance of two or more helpers with toileting and hygiene. During observation, the resident was seen sitting in a wheelchair next to her bed with visible facial hair around her chin. The resident stated she had previously asked staff for a shave and that she wanted to be shaved. CNA 1 reported that residents’ facial hair was supposed to be shaved during scheduled showers but could not explain why this resident had not been shaved. Review of the resident’s Shower Day Skin Inspection forms on multiple dates showed that the resident had facial hair documented on each occasion, indicating the condition was ongoing. The DON stated that the facility’s expectation was that CNAs offer shaving with scheduled showers after obtaining consent, and that refusals should be reported to the charge nurse and documented. The facility’s shower policy required showers at least twice weekly, documentation of showers on the ADL flow sheet, and involvement of nursing and social services if residents continually refused bathing, with care plan interventions to address the situation. Despite these expectations and policies, the resident’s facial hair remained unshaven over multiple shower days.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, private, and homelike environment for two residents by assigning them to rooms that shared a single bathroom without a lock, resulting in both male and female residents having to share the same bathroom. During observation and interviews, a female resident expressed feeling unsafe due to sharing the bathroom with a male resident and noted the absence of a lock on the bathroom door. The male resident also reported discomfort with the arrangement and stated that there should be a lock for privacy. Both residents were cognitively able to express their needs and concerns, and their Minimum Data Set (MDS) assessments indicated they required only minimal assistance with toileting and ambulation. The shared bathroom was located between the two residents' rooms, and the lack of a lock required the male resident to signal when the bathroom was in use to avoid accidental entry. The Director of Nursing acknowledged that female and male residents should not be sharing bathrooms and recognized the lack of privacy as a risk, further stating that a bathroom lock was necessary to prevent abuse. The facility's policy emphasized providing person-centered care that respects residents' comfort, independence, and personal preferences, which was not upheld in this situation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 25 requirements. During a record review and interview with the Maintenance Director, it was found that the facility could not provide records of quarterly sprinkler inspections and testing for the first, second, and fourth quarters of the year. Only the third quarter inspection record was available. The Maintenance Director stated that the inspections and testing are performed in-house and that no external vendor had been used for these services. This deficiency affected all 77 residents across three smoke compartments. The lack of required documentation for quarterly inspections and testing was identified during the survey, and the absence of these records could result in a malfunctioning fire sprinkler system in the event of a fire. The findings were based solely on the review of records and staff interview, with no mention of any specific incidents involving residents at the time of the deficiency.

Plan Of Correction

Corrective Action Facility renewed the contract with the sprinkler company. Moving forward, the facility will make sure that sprinkler inspections are done by a professional company on a quarterly basis. Maintenance director will make sure that there will be no quarterly missing inspections. He will make sure that it is done by a contracted professional vendor. Identify other residents. All other residents have the potential to be affected by this deficient practice, so the facility will ensure that fire sprinklers are inspected on a quarterly basis by a professional vendor. Maintenance director and administrator made a walk-through and made sure that this deficiency is not affecting any other areas of the facility. Systemic Changes As a systemic change, the facility will add a quarterly sprinkler inspection into the safety committee action list. Team members will monitor and also check the maintenance records for compliance. Any discrepancy will be brought to the maintenance director and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction was completed on 04/18/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain portable fire extinguishers in accordance with NFPA 10 standards, as evidenced by observations during a facility tour. Specifically, fire extinguishers were found to be obstructed in two separate locations. In the kitchen, a K fire extinguisher was blocked by a metal cart approximately three feet high and one inch away from the extinguisher. The Maintenance Director stated that the cart was placed there temporarily during dishwashing activities. In another instance, a fire extinguisher next to Room 133 was obstructed by a four-foot-high medical cart, which was about three inches away from the extinguisher. The Maintenance Director explained that the cart was being used to charge a computer. These obstructions affected 54 of 77 residents in two of three smoke compartments. The facility conducts fire extinguisher inspections in-house and has not had a vendor perform inspections or testing. The observed obstructions could result in a delay in accessing a fire extinguisher in the event of a fire, as the extinguishers were not readily accessible or visible as required by NFPA 10.

Plan Of Correction

Corrective Action Maintenance director immediately removed the obstruction (metal cart) in front of the fire extinguisher. The Dietary manager will do an in-service to the kitchen team regarding the importance of keeping the fire extinguister area clean and easily accessible. Maintenance director pulled the med cart away from the fire extinguisher immediately. DSD will in-service the nursing team regarding the importance of keeping the fire extinguishers area clear and accessible all the time. Identify Other Residents Facility will ensure that no other residents are affected by this deficient practice by ensuring that fire extinguishers in the facility are not obstructed by anything. K 353 Maintenance director in conjunction with dietary manager periodically checks the fire extinguisher in the kitchen to ensure that it is not obstructed by any equipment. Maintenance director will make sure that this deficiency is not affected in any other area by checking all other fire extinguishers at the facility. Systemic changes As a systemic change, safety committee members check the fire extinguishers at the facility randomly to ensure that there are no impediments in front of any fire extinguishers. Monitoring Process Administrator and maintenance supervisor will monitor for compliance on a quarterly basis. QA Process This plan of correction is integrated into the facility's monthly QA process. POC will review for the completeness and effectiveness. Completion Date This plan of correction will be completed on 04/18/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors found that the facility failed to maintain required inspection and maintenance records for its kitchen cooking equipment. During a tour and record review, it was observed that the facility could not provide annual inspection records for the kitchen equipment, and the Maintenance Director confirmed that there was no annual inspection plan in place. The Maintenance Director stated that equipment was only checked by a vendor when it broke down, rather than being inspected regularly as required. Additionally, the facility was unable to provide one of two required semiannual maintenance records for the kitchen suppression system and one of two required semiannual kitchen hood-exhaust cleaning records. Although one record for each was provided, the other records were not located, and the facility did not submit the missing documentation by the deadline given by surveyors. These deficiencies affected 17 of 77 residents in one of three smoke compartments.

Plan Of Correction

Corrective Actions Facility will make sure that all cooking equipment is maintained as required. Facility contacted the company to come for the semi-annual kitchen suppression system service and semi-annual kitchen hood cleaning system. Facility will contact a qualified company to inspect the kitchen equipment annually. Maintenance director will make sure that he is organized and keeping all maintenance records for kitchen equipment regularly and ready for an inspection. Identify other residents. Other residents may have the potential to be affected by this deficient practice, so maintenance supervisor along with dietary supervisor will make sure that all kitchen equipment is serviced, and preventive maintenance is done regularly. Administrator and maintenance director will walk through in the building to ensure that this deficient practice is not affecting any other areas. Systemic Changes As a result of systemic change, the maintenance director, dietary manager, and administrator will meet monthly to ensure that there is no kitchen equipment inspection due at that time. Facility will keep a special binder to keep all the maintenance records for the kitchen equipment. Monitoring Process Maintenance supervisor will monitor for compliance on a monthly basis. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction completed on 04/18/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete fire drill records, as evidenced by the absence of documentation for fire drills conducted during the AM shift in the fourth quarter of 2024. During a record review and interview, the Administrator was unable to provide the required fire drill records and could not locate them in the designated binders. The facility was given an opportunity to submit the missing records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. Additionally, the facility did not maintain electrical equipment in accordance with regulatory requirements. Observations revealed the use of extension cords and daisy-chained power strips in several areas, including the Main Entrance, Kaiser Room, and Dietary Supervisor's Office. Specifically, extension cords were used to power a wander guard detector and a portable air conditioning unit, while a power strip was found powering another power strip for computers and monitors. The Maintenance Director confirmed these setups were due to insufficient outlets and the need to power specific equipment.

Plan Of Correction

Systemic Changes As a new system, the safety committee monthly meeting will review the documentation to ensure the plan of correction is sustained and completed. Any discrepancy will be addressed to the maintenance supervisor and administrator immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025. Corrective Action Maintenance director removed the yellow extension cord at the main entrance. Wander guard system is directly connected to the main power. Facility immediately removed the power strip from the kaiser room. The maintenance director will make sure that all electrical equipment is connected directly to the power outlet in the wall. Maintenance director and dietary manager removed the extension cord from the dietary manager's office and the portable air conditioner connected directly to the wall outlet. Identify other residents Maintenance director will do walk through the facility to make sure that this deficiency is not repeating in any other rooms. Any similar violations will be corrected immediately. Safety committee members will assist the maintenance director to identify any similar violations at the facility. Systemic Changes As a systemic change, the DSD and maintenance director will conduct an in-service to housekeeping and maintenance staff to re-educate them about the importance of not having any extension cords in the rooms & hallway. Housekeeping will assist and report to the maintenance director if they see any similar violations anywhere in the facility, and maintenance will correct it immediately. Monitoring Process Maintenance supervisor will monitor for compliance monthly. Administrator will oversee the process with the help of the safety committee members. QA Process This plan of correction is integrated into the monthly QA committee for its effectiveness and completeness. Completion Date This plan of correction will be completed on 04/18/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete fire drill records as required by NFPA 101. During a record review and interview with the Administrator, it was found that fire drill documentation for the AM shift during the fourth quarter of 2024 (October, November, December) was missing. The Administrator was unable to provide these records when requested and stated that it was unusual for them not to be in the binders. The facility was given an opportunity to submit the missing fire drill records by email, but no records were received by the specified deadline. This deficiency affected all 77 residents across three smoke compartments. No additional information about the medical history or condition of the residents at the time of the deficiency was provided in the report.

Plan Of Correction

Corrective Action Facility will ensure that fire drills are conducted each quarter each shift. The Director of Staff Development and Maintenance Supervisor is on board with the new plans. Facility already contacted the vendor and explained to them the importance of fire drills in each quarter. Facility got the copies of the missing fire drills conducted from the vendor. Please see attached. Facility will make sure that disaster drill is not mingled with the quarterly fire drills. Identify Other Residents Facility will ensure that other residents in the facility are not affected by this deficiency. As a new plan, there will be a new schedule for the fire drills for the whole year to make sure each quarter, each shift are covered, and with the new documentation sheet, it will be clearly documented. Disaster drills will be separated from the fire drill.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a comfortable and safe temperature level in the rooms of two residents during a heat wave, with room temperatures recorded at 84 degrees Fahrenheit. Resident 1, who has chronic obstructive pulmonary disease and intact mental status, reported discomfort due to the heat despite using a fan. Similarly, Resident 3, who has dementia and impaired mental status, also expressed discomfort with the room temperature. Both residents experienced fluctuating room temperatures, with no cool air flow from the vents, indicating a malfunctioning air conditioning system. The Maintenance Supervisor (MS) and Administrator acknowledged the issue, noting that the air conditioning unit had been faulty for weeks and repairs were ongoing. However, they were unable to provide records of air filter replacements or preventative maintenance for the air conditioning units. The facility's policy requires maintenance services to ensure all equipment is operable and safe, but the lack of documentation and unresolved air conditioning issues suggest a failure to adhere to these standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately supervise a resident with a history of falls, resulting in the resident sustaining a left hip fracture. The resident, who was admitted with dementia, muscle weakness, and mobility issues, required supervision during activities of daily living. Despite these needs, the resident was left unsupervised and attempted to use a bathroom that was out of order, leading to a fall in the hallway. The resident's care plan indicated a high risk for falls, and staff were instructed to anticipate and meet the resident's needs promptly, which was not adhered to in this instance. On the day of the incident, a Certified Nursing Assistant observed the resident walking in the hallway without a walker and expressed a need to use the bathroom. The CNA's back was turned when the resident fell, indicating a lack of supervision. Subsequently, the resident was found in distress with a deformed left hip and severe pain, necessitating emergency medical attention and transfer to an acute care hospital. The resident underwent surgery for a hip fracture, highlighting the facility's failure to provide adequate supervision and prevent accidents for a high-risk resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a functioning toilet for a resident, leading to a potential fall incident. The resident, who was admitted with dementia, muscle weakness, and mobility issues, had a bathroom that was out of order. The resident's Annual Minimum Data Set (MDS) assessment indicated occasional bladder incontinence and a moderately impaired mental status. On the day of the incident, the resident attempted to find an alternate bathroom due to the nonfunctional toilet in her room, which resulted in a fall in the hallway. The Certified Nursing Assistant (CNA) observed the resident walking in the hall without a walker and expressed the need for a bathroom. The CNA confirmed the bathroom was out of order and noted the absence of a bedside commode. While the CNA was looking for an alternate bathroom, the resident fell. The Maintenance Supervisor later confirmed the bathroom issue was not logged, and the Director of Nursing stated that a bedside commode should have been provided, and staff should have been more attentive to the resident's needs.

Penalty

Inspection fine: $45,70227 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from verbal and physical abuse when another resident yelled and punched him in the face, resulting in a skin tear. The incident occurred in the courtyard, where there was no staff presence to intervene. The injured resident expressed increased anger and fear for his safety following the altercation. The facility's records indicated that the injured resident had no history of physical or verbal behavioral symptoms, while the aggressor had a documented history of behavioral problems, including previous altercations with other residents. During the incident, the aggressor became angry after being called a derogatory name by the injured resident and responded by hitting him. The facility's interdisciplinary team notes and interviews with staff confirmed that the altercation was not witnessed by staff, and the injured resident's care plan was not updated to address the incident or the injury sustained. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of staff oversight in the courtyard and the failure to revise the care plan to address the resident's injury and safety concerns.