Willow Pass Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one (Resident 1) of the six sampled residents from verbal abuse. Certified Nursing Assistant 1 (CNA 1) used profanity (irrelevant language and behavior that shows disrespect, used to express anger and frustration), raised his voice, yelled/shouted at Resident 1, when Resident 1 asked CNA 1's help for Resident 2 when Resident 2 was crying out for help in the TV dining area (a common area used for dining and to watch television). This failure resulted in Resident 1 crying and becoming visibly upset after the incident. During a record review of Resident 1's admission record, dated 2/10/26, the record indicated Resident 1 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to remove Certified Nursing Assistant (CNA 1) from resident care areas for over three hours, after he had an altercation with Resident 1. CNA 1 used profanity (irrelevant language and behavior that shows disrespect, used to express anger and frustration), raised his voice, yelled/shouted at Resident 1 in front of other residents when Resident 1 asked CNA 1's help for Resident 2 when Resident 2 was crying out for help in the TV dining area (a common area used for dining and to watch television). CNA 1 continued to provide direct care to his nine (9) other assigned residents until end of his shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent exploitation (taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion) of one of three sampled residents (Resident 3), when Certified Nursing Assistant (CNA) 1, received a new pair of shoes bought by Resident 3 for CNA 1's personal use. This failure had the potential to cause Resident 3 to be taken advantage of resources, manipulation and abuse. During a review of Resident 3's admission Record (AR), printed 3/11/26, the AR indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included pain in the right knee. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its Care Planning-IDT Care Planning Conference, policy and procedure when: Interdisciplinary Team (IDT-a professional discipline that works together to provide the greatest benefit to the resident which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically and appropriate and person-centered) did not develop a care plan that addressed Resident 1's refusal to shower for over a month with appropriate interventions. IDT did not develop a care plan that addressed Resident 1's discharge plan upon admission to the facility. This failure placed Resident 1 at risk for poor hygiene, body odor, transmission of diseases and misunderstanding with discharge process. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), was provided services to maintain grooming and personal hygiene when: Certified Nursing Assistants (CNAs) did not shave Resident 2's facial hair with showers as scheduled. This failure placed residents at risk for poor hygiene, body odor, infection, and transmission of diseases. During a review of Resident 2's admission Record (AR), printed 3/11/26, the AR indicated, Resident 2, was admitted to the facility on [DATE] with diagnoses that included hip fracture. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents' (Resident 1 and Resident 3) rooms were maintained in a comfortable and safe temperature level when Resident 1 and 3's room air temperature was at 84 degrees Fahrenheit during a heat wave. This failure had the potential to cause overheating in residents and discomfort during severe hot weather.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of one sampled resident (Resident 1) a functioning toilet that can be accessed quickly, when Resident 1 needed to use the toilet, but her bathroom was Out-of-Order and she did not have a bedside commode. This failure potentially resulted in Resident 1 sustaining a fall while looking for an alternate bathroom, resulting in left hip fracture (broken bone), pain, and transfer to Acute Care Hospital (ACH 1) for follow up care. (Cross reference F689)

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote one of three sampled residents (Resident 1) right to privacy when the licensed social worker (SW) discussed Resident 1 ' s personal care with Resident 1 ' s family without Resident 1 ' s consent. This failure resulted in Resident 1 feeling emotional distress.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and sanitary environment to three of three sampled residents (Resident 14, 54, and 6) when 1. Resident 14 and Resident 54's standing/ table fans had visible dust, dirt and debris; and 2. Resident 6 had rodent droppings next to her beds for three days. These failures placed Residents 6, 14, 54 at risk for infection and loss of a homelike environment due to unclean and unsanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Activities of Daily Living (activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) care for one of one sampled resident (Resident 14) who required extensive assistance when Resident 14's scheduled showers and bed baths were missed. This failure placed Resident 14 at risk for infection and skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policies and procedures for oxygen administration for two (Resident 14 and Resident 68) of four sampled residents receiving oxygen therapy when there was no sign outside of Resident 14 and Resident 68's room stating Oxygen in Use and when Resident 68 was receiving oxygen therapy without a doctors order. These deficient practices may result in placing all individuals in the facility at risk of potential harm in the event smoke or fire in the vicinity of the oxygen container and ineffective oxygen therapy for Resident 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled (those with high potential for abuse or addiction) and non-controlled medications when: 1. Random controlled medication use audits for five out of 5 residents (Residents 8, 14, 29, 45 and 63) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents; 2. An emergency kit (e-kit, a kit containing medications and supplies for immediate use during a medical emergency) containing oral medications had medication removed without the required documentation of the removal in accordance with the facility policy and procedures (P&P); and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 31.03% error rate when nine medication errors out of 29 opportunities were observed during a medication pass for four of eight residents (Residents 4, 22, 53 and 63). These failures resulted in medications not given in accordance with the prescriber's orders and may affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: -Thirteen expired medications were not available for resident use; -Three medications were labeled properly with a pharmacy label to ensure it was used for the right resident; -Two multi-dose injectable insulin (medication to lower blood sugar level) products were dated with an open and discard date, to ensure they were not used beyond the discard date; -One medication had a legible expiration date; and -Six medications with discontinued physician's orders were removed from facility stock. The deficient practices had the potential for residents to receive the wrong medication or medications that were unsafe or with reduced potency from being used past their discard date.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Expired food items were found in the dry storage room; 2. Multiple dry food items did not have a use by date or open date on them; 3. Food was left uncovered and unlabeled and undated in freezer; 4. Ice machine was not clean with brown residue; 5. Expired test strips were used for testing the sanitizer strength used to sanitize food contact surfaces; 6. A box of popcorn was leaking in the dry storage area; 7. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for 3-part compartment sink; 8. Kitchen vents were dirty with black and brown residue; 9. Kitchen counters over the cooking range were dusty with black/brown residue; 10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure self-administered medications kept at bedside for one of 18 sampled residents (Resident 4) were reviewed and approved by the physician. This failure had the potential for unsafe medication use, exposure to unwanted side effects and duplication of therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess one of one sampled resident (Resident 38) for oral/dental status on one annual and two quarterly Minimum Data Set (MDS - an assessment used to guide care) assessments when Resident 38's MDS assessment was coded No to Broken or loosely fitting partial or full dentures and Resident 38 was not able to wear dentures. This failure resulted in an inaccurate reflection of Resident 38's oral/dental status and not triggering the facility to develop and implement a care plan for Resident 38's ill-fitting dentures for nine consecutive months.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR) assessment for one of three sampled residents (Resident 8) when the PASARR did not to reflect Resident 8's diagnosis of Anxiety (emotion we feel when we experience fear, nervousness, or a sense that something bad will happen), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and use of psychotropic medication (any medication capable of affecting the mind, emotions, and behavior). This failure placed Resident 8 at risk to not receive care and services appropriate to her needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and provide a written summary of a baseline care plan to one of one sampled resident (Resident 14) when Resident 14's baseline care plan was not developed within 48 hours of admission to the facility. This failure placed Resident 14 at risk of not receiving person-centered care and facility staff to be unaware of Resident 14's needs.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for one (Resident 126) of two residents receiving enteral feeding (a way of delivering nutrition directly to your stomach or small intestine) when staff did not label and date Resident 126's enteral bottle and tubing. This deficient practice may result in a risk for contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate renal (kidney) dialysis (therapy used to remove waste and extra chemicals and fluid from your blood) documentation and dialysis food preferences were provided for one of one sampled resident (Resident 65) with end stage renal disease (kidneys are no longer able to work as they should to your body's needs) when 1. Resident 65's renal dialysis access site was documented on the incorrect arm; 2. Resident 65 was not provided snacks during dialysis days; and 3. Resident 65 was not assessed before and after dialysis for various dates. This failure resulted in Resident 65's inaccurate pre- and post-dialysis assessments, Resident 65 feeling very hungry after dialysis, and the potential for unmet needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of three residents (Resident 32) receiving anticoagulation medication (medication to thin blood) was free from unnecessary medication when staff did not monitor the side effects of Resident 32's use of eliquis (medication used to thin blood). This failure had the potential to result in side effects of the medication to go unnoticed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dental services were provided for one of one sampled resident (Resident 38) when Resident 38's upper and lower dentures were loosely fitted, needed realignment and Resident 38 was not able to wear dentures for nine consecutive months. This failure resulted in Resident 38 to not receive timely dental care, be able to wear lower dentures, and develop oral sores on the roof of their mouth. (Cross-reference F 641)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 38)'s medical record reflected accurate meal intake when Resident 38's meal intake was documented but was not served breakfast and lunch. This failure resulted in an inaccurate reflection of Resident 38's meal intake.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Quality Assessment and Performance Improvement (QAPI) plan included a pest control plan, when the facility had rats in the facility for three months. This failure had the potential for rats to continue to be present in the facility and to spread bacteria and/or disease.

Inspectors wroteBased on observation and interview, the facility had 21 resident rooms (room numbers 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) with a total of 65 beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of resident belongings.

Inspectors wrote5. During a concurrent observation and interview on 2/3/20, at 12:38 p.m., with CNA 2 at Station 1, CNA 2 was seen removing a dirty meal tray from a resident's room and placing it inside a meal conveyor cart with the clean meal trays that were being served to residents in their rooms. CNA 2 stated, It is an infection and contamination issue. 6. During a concurrent observation and interview on 2/4/20, at 1:42 p.m., with the Dietary Supervisor (DS), of the ice machine located at Station 1, the ice machine had a pinkish, blackish substance inside the ice bin. The DS stated, This is dirty, I will tell the administrator. During an interview on 2/4/20 at 1:44 p.m., with the Administrator (ADM) and the Maintenance Supervisor (MS), MS stated he cleaned the ice machine monthly and the manufacturer's representative came every six months for maintenance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the privacy and dignity of two of 22 sampled residents (Residents 45 and 71) was protected when urinary drainage bags were left uncovered and visible to other residents, as well as visitors. This failure had the potential to negatively affect the emotional well-being of the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two sampled residents (Resident 11 and 36) with limited range of motion were able to notify staff they required assistance when the call lights for Residents 11 and 36 were not within reach. This failure had the potential for both residents to have unmet physical, medical, and psychological needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond in a timely manner to concerns brought up by Resident Council members (Residents 8, 16, 21, 42, 47, 64, 71, and 74). This failure resulted in residents' concerns not being addressed or followed up on.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care with dignity for one of one sampled residents (Resident 5) when Certified Nurse Assistant 7 (CNA 7) did not cover Resident 5 completely when transporting him down the hall after showering. This failure resulted in Resident 5 feeling embarrassed that his back-side was exposed for everyone to see.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label medications when: 1. Six of 30 house supply medications did not have the date they were opened written on the bottles; and 2. One of one intravenous (IV, given in a vein) antibiotic that had been mixed in a bag of normal saline (a combination of salt and water) did not have an expiration date written on the bag. This failure had the potential to result in residents receiving old or expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when: 1. The Dietary Supervisor's (DS) hair was not totally covered by her hairnet while she was in the food preparation area. 2. There were two 3-gallon containers of sherbet in the freezer that had been opened and were not completely covered. 3. There was one 4-ounce (oz, a unit of measurement) tub of cream cheese in the walk-in refrigerator that had the aluminum seal pulled opened with no 'opened on' date recorded and had fluid build up on the surface of the cream cheese. These deficient practices had the potential to cause food-borne illnesses throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one of 22 sampled residents (Resident 177) when Resident 177's fall care plan did not include nursing interventions. This failure had the potential for Resident 177 to receive inconsistent care and not reach desired outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs), including assistance with personal hygiene (grooming, combing hair, nail care, oral care), to one of 22 sampled residents (Resident 8) when the resident's nail care was neglected. This failure resulted in Resident 8 having long, chipped, fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 54) received care to prevent pressure ulcers (PU, injuries to skin and underlying tissue resulting from prolonged pressure on the skin) when the staff did not identify a newly developed pressure ulcer on his tailbone. This failure resulted in the delay in the initiation of appropriate treatment and could result in worsening of the pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for oxygen (O2) administration for one of four sampled residents (Resident 68), when Resident 68's O2 flow rate was not at the specific ordered rate. This failure had the potential to result in adverse effects for Resident 68 due to O2 toxicity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the correct amount of liquid morphine sulfate (a narcotic medication used to treat moderate to severe pain). This failure resulted in 2 milliliters (ml, a unit of measurement) of liquid morphine sulfate for which the facility could not account.

Inspectors wroteBased on interview and observation, the facility failed to provide functional environment when there was no towel hook in Shower room [ROOM NUMBER]. This failure resulted in residents not having a towel readily available to dry off after showering.

Inspectors wroteBased on observation and interview, the facility had 21 resident rooms (room numbers 100, 102, 104, 106, 108, 110, 112, 114, 116, 118, 120, 122, 124, 126, 128, 130, 132, 134, 136, 138, 140) with a total of 65 beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete quarterly psychosocial assessments on seven (Residents 11, 21, 22, 40, 52, 54, 56) of 38 sampled residents. This failure had the potential to cause residents not to have their medical and/or psychosocial needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide three (Residents 11, 21, 22) of 38 sampled residents with medically-related social services. These failures resulted in Resident 11 not receiving adequate visual aid, Resident 21 not receiving dental services as recommended, and Resident 22 not receiving supportive mental health services. This placed all three residents at risk for not meeting their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to complete an assessment of one (Resident 22) of 38 sampled residents after a significant change in condition occurred. This failure had the potential to result in Resident 22 not receiving the appropriate mental health services.

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan for one (Resident 22) of 38 sampled residents upon admission to the facility. This failure had the potential to result in Resident 22 not receiving the appropriate psychosocial services.

Inspectors wroteBased on observation and interview, the facility had 21 resident rooms (room numbers 100, 102, 104, 106, 108, 110, 112, 114, 116, 118, 120, 122, 124, 126, 128, 130, 132, 134, 136, 138, 140) with a total of 65 beds that provided less than 80 square feet (sq.ft.) per resident who occupied these rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for storage of resident belongings.