Willow Pass Healthcare Center
Inspection Findings
F-Tag F0584
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 and interview, the facility had one shared bathroom for male and female residents (Residents 1 and 2).This failure resulted in Resident 1 feeling unsafe and made Residents 1 and 2 feeling they lacked privacy. 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 REDACTED], 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
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
WILLOW PASS HEALTHCARE CENTER in CONCORD, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.