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WILLOW PASS HEALTHCARE CENTER Inspection Report, Violations & Safety Grade (CONCORD, California)

3318 WILLOW PASS ROAD, CONCORD, California 94519

Phone: 9256899222

CMS Overall:3/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

78.4

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Contra Costa

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall3/5

Health2/5

Staffing4/5

Quality5/5

Nurse Staffing Check

Metric	This Facility	California Avg	Difference
RN Hours per Resident per Day	0.61	0.68	-0.06
Total Nurse Hours per Resident per Day	3.94	4.54	-0.60
CMS Staffing Rating	4/5	3.3/5	-
Nursing Staff Turnover	44.9%	36.6%	-

Health Citation History

49 health citations on record

Date	Category	Description	Severity
2026-03-26	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2026-03-26	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2026-03-13	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from the wrongful use of the resident's belongings or money.	D – Moderate Harm Potential
2026-03-13	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2026-03-13	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2025-09-07	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2024-07-09	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2024-04-25	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2024-04-25	Environmental Deficiencies	Provide a bathroom in or located near each resident’s room.	D – Moderate Harm Potential
2024-04-11	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	G – Actual Harm
2024-02-21	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	D – Moderate Harm Potential
2022-10-14	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2022-10-14	Resident Rights Deficiencies	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.	E – Moderate Harm Potential
2022-10-14	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2022-10-14	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2022-10-14	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	E – Moderate Harm Potential
2022-10-14	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2022-10-14	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2022-10-14	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2022-10-14	Resident Rights Deficiencies	Allow residents to self-administer drugs if determined clinically appropriate.	D – Moderate Harm Potential
2022-10-14	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2022-10-14	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	D – Moderate Harm Potential
2022-10-14	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2022-10-14	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2022-10-14	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential
2022-10-14	Pharmacy Service Deficiencies	Ensure each resident’s drug regimen must be free from unnecessary drugs.	D – Moderate Harm Potential
2022-10-14	Quality of Life and Care Deficiencies	Provide routine and 24-hour emergency dental care for each resident.	D – Moderate Harm Potential
2022-10-14	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2022-10-14	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	C – Minimal Harm Potential
2022-10-14	Environmental Deficiencies	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	B – Minimal Harm Potential
2020-02-07	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2020-02-07	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2020-02-07	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	E – Moderate Harm Potential
2020-02-07	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	E – Moderate Harm Potential
2020-02-07	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	E – Moderate Harm Potential
2020-02-07	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2020-02-07	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2020-02-07	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2020-02-07	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2020-02-07	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2020-02-07	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2020-02-07	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2020-02-07	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	D – Moderate Harm Potential
2020-02-07	Environmental Deficiencies	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	B – Minimal Harm Potential
2019-01-09	Resident Assessment and Care Planning Deficiencies	Assure that each resident’s assessment is updated at least once every 3 months.	E – Moderate Harm Potential
2019-01-09	Quality of Life and Care Deficiencies	Provide medically-related social services to help each resident achieve the highest possible quality of life.	E – Moderate Harm Potential
2019-01-09	Resident Assessment and Care Planning Deficiencies	Assess the resident when there is a significant change in condition	D – Moderate Harm Potential
2019-01-09	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2019-01-09	Environmental Deficiencies	Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.	B – Minimal Harm Potential

Fire Safety Citation History

48 fire safety citations on record

Date	Category	Description	Severity
2022-10-14	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2022-10-14	Egress Deficiencies	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	E – Moderate Harm Potential
2022-10-14	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2022-10-14	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2022-10-14	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2022-10-14	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2022-10-14	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2022-10-14	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential
2022-10-14	Emergency Preparedness Deficiencies	Provide primary/alternate means for communication.	D – Moderate Harm Potential
2022-10-14	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	D – Moderate Harm Potential
2022-10-14	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	D – Moderate Harm Potential
2022-10-14	Smoke Deficiencies	Properly select, install, inspect, or maintain portable fire extinguishes.	D – Moderate Harm Potential
2022-10-14	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	D – Moderate Harm Potential
2022-10-14	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	D – Moderate Harm Potential
2022-10-14	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the use of electrical equipment.	D – Moderate Harm Potential
2020-02-07	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	E – Moderate Harm Potential
2020-02-07	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2020-02-07	Miscellaneous Deficiencies	Provide a written emergency evacuation plan.	E – Moderate Harm Potential
2020-02-07	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	E – Moderate Harm Potential
2020-02-07	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2020-02-07	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	E – Moderate Harm Potential
2020-02-07	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential
2020-02-07	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	E – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Conduct risk assessment and an All-Hazards approach.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Address subsistence needs for staff and patients.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Establish procedures for tracking staff and patients during an emergency.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Establish policies and procedures including evacuation.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Establish policies and procedures for medical documentation.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Establish roles under a Waiver declared by secretary.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	List the names and contact information of those in the facility.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Provide emergency officials' contact information.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Provide primary/alternate means for communication.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Provide family notifications of emergency plan.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Conduct testing and exercise requirements.	D – Moderate Harm Potential
2020-02-07	Emergency Preparedness Deficiencies	Implement emergency and standby power systems.	D – Moderate Harm Potential
2020-02-07	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	D – Moderate Harm Potential
2020-02-07	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	D – Moderate Harm Potential
2020-02-07	Smoke Deficiencies	Provide properly protected cooking facilities.	D – Moderate Harm Potential
2020-02-07	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	D – Moderate Harm Potential
2020-02-07	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	D – Moderate Harm Potential
2020-02-07	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	D – Moderate Harm Potential
2019-01-09	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2019-01-09	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	F – Moderate Harm Potential
2019-01-09	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	D – Moderate Harm Potential
2019-01-09	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	D – Moderate Harm Potential
2019-01-09	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	D – Moderate Harm Potential
2019-01-09	Miscellaneous Deficiencies	Provide a written emergency evacuation plan.	D – Moderate Harm Potential
2019-01-09	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	D – Moderate Harm Potential

Total Penalties & Fines

$45,702

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2024-04-11	Fine	$45,702	-
2024-04-11	Payment Denial	-	27 days starting 2024-05-03

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