Willow Pass Healthcare Center

In the surveyor’s words

From the most serious findings on record at Willow Pass Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 25, 2024

  Based on observation, interview and record review, the facility failed to supervise one of three residents (Resident 1) with a history of falls when, Resident 1 was not supervised and assisted to the bathroom. This failure resulted in Resident 1 sustaining a left hip fracture (broken bone), experiencing pain, and transferring to Acute Care Hospital 1 (ACH 1) for follow up care. Findings: During a record review of Resident 1's Admission Record, printed on 4/25/24, the record indicated Resident 1 was admitted to the facility on [DATE], with dementia (memory loss), muscle weakness, abnormalities of gait (a person's manner of walking) and mobility, and abnormal posture. […]

• Actual harm, isolatedF600Apr 11, 2024

  Based on observation, interview and record review, the facility failed to protect one (Resident 1) of three sampled residents' right to be free from verbal and physical abuse when, Resident 2 yelled and punched Resident 1 in the face. Resident 1 sustained skin tear with flap (a traumatic wound that is caused by direct contact between the skin and another object) during an altercation in the courtyard. This failure resulted in Resident 1's increased anger and fear for his safety at the facility from Resident 2. Findings: Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care), dated 3/26/24, indicated. Resident 1 had clear speech, able to express his ideas and wants, made self-understood and understood others. […]

• Actual harm, isolatedF686Apr 5, 2022

  Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment and services consistent with professional standards of practice to promote healing of a pressure ulcer (otherwise known as bed sore, a skin injury that result from unrelieved pressure on a body part, usually on a bony prominence like the tailbone, buttocks and hips) and prevent new pressure ulcers from developing when: -the facility staff did not continuously provide assessment, monitoring and physician ordered treatment to an existing Stage II (partial thickness skin loss that involves the deeper layers of the skin, may appear as a shallow crater) pressure ulcer on the coccyx (tailbone). […]

• No harm, potential for more than minimal, widespreadF880Oct 14, 2022

  Based on record review and interview, the facility failed to follow infection control policies and procedures when: 1. staff did not answer COVID-19 screening questions before entering the facility; 2. Resident 14 and Resident 54's nasal cannula and bilevel positive airway pressure (BiPAP, a machine used to deliver pressured air to lungs) mask were not bagged and touching the floor; 3. Resident 54's BiPAP mask had brown matter sticking to the mask; and 4. staff did not clean the morphine sulfate (MS- medication to relieve moderate to severe pain) solution re-usable syringe for Resident 377 after use. This deficient practice had the potential to spread infection. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF925Oct 13, 2022

  Based on observation, interview, and record review, the facility failed to ensure a pest free environment when rat and rat droppings were seen in the patio and inside the facility. This failure had the potential to cause health hazard to residents. During an interview on 7/21/22, at 11:14 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she saw newborn rat under the vending machine in the patio where the residents were smoking. CNA 1 stated she sometimes sees a rat running in the hallway when they are passing the breakfast tray. During an interview on 7/21/22, at 12:25 p.m., with Resident 1, Resident 1 stated saw big black rats in the patio by the activity room. […]