Complaint Investigation

Willow Pass Healthcare Center

September 7, 2025 · Concord, CA · 3318 Willow Pass Road

Citations 1

CMS Rating 3/5

Beds 81

Provider ID 055241

Healthcare Facility

Willow Pass Healthcare Center

Concord, CA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

WILLOW PASS HEALTHCARE CENTER in CONCORD, CA — inspection on September 7, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0584

Resident Rights Deficiencies

Potential for More Than Minimal Harm

During a concurrent observation and interview on 8/8/2025 at 12:31 p.m., with Resident 1 (female) in the resident's room, Resident 1 stated she felt unsafe because she was sharing the bathroom with Resident 2 (male) and further stated there was no bathroom lock. On observation, Resident 1's room was situated beside a room for male residents and there was one shared bathroom inside the two rooms with no locks in the doors. Resident 1 further stated that Resident 2 had to raise his arm outside of the bathroom door so that she knew that Resident 2 was using the bathroom.

Stated she was not sure if it was okay for female residents to share bathrooms with male residents.

During a review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool) dated 6/5/25, indicated Resident 1 was able to make herself understood by others and was able to understand others.

The MDS also indicated Resident 1 only needed set up and clean up assistance in toileting and only needed supervision from the staff when walking a distance of 150 feet.

During an interview on 8/8/25 at 12:40 p.m., with Resident 2, the resident stated he shared the bathroom with Resident 1 and stated that there should be a lock for privacy.

Stated it was uncomfortable for him to share his bathroom with a female.

During a review of Resident 2's MDS, dated [DATE], it indicated Resident 2 usually made himself understood by others and was usually able to understand others.

The MDS also indicated Resident only needed supervision from the staff in toileting and when walking a distance of 150 feet.

During an interview on 8/8/25 at 1:00 p.m., with the Director of Nursing (DON), the DON acknowledged that female residents should not be sharing bathrooms with male residents.

Stated the risk was lack of privacy for the residents.

Further stated there should be a bathroom lock to prevent abuse.

During a review of the facility's policy and procedure (P&P) titled, quality of life-Homelike Environment, revised February 2021, the P&P indicated, .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.

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

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Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CONCORD, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WILLOW PASS HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.