The Vardell Report.Willow Pass Healthcare Center

Across 10 inspections from January 2019 to March 2026, state surveyors documented 49 findings at Willow Pass Healthcare Center; 49 have a recorded correction; CMS lists 2 enforcement actions in the window.

Inspections

10

2019–2026, complaint and standard

Findings

49

Deficiencies cited by state inspectors

Corrected

49

Of 49 findings, with a recorded correction date

Penalties

2

1 fine; payment not published, 1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Mar 262026

   Complaint investigation

   2 findings

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Apr 14, 2026
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 14, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Mar 132026

   Complaint investigation

   3 findings

   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Apr 13, 2026
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 13, 2026
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 13, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Sep 72025

   Complaint investigation

   1 finding

   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Dec 29, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Jul 92024

   Complaint investigation

   1 finding

   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Aug 9, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Apr 252024

   Complaint investigation

   2 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 30, 2024
   • F918Provide a bathroom in or located near each resident’s room.Level DNo actual harm, potential for moreCorrected Apr 30, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Apr 112024

   Complaint investigation

   1 finding

   • F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected May 30, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Feb 212024

   Complaint investigation

   1 finding

   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Mar 15, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Oct 142022

   Standard health inspection

   19 findings

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Dec 1, 2022
   • F584Honor 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.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Dec 1, 2022
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F693Ensure 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.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Dec 1, 2022
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level CPotential for minimal harmCorrected Dec 1, 2022
   • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Dec 1, 2022

   Enforcement Action

   Civil money penalty, $45,702 imposed April 11, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 14, 2022, the nearest before the penalty date.

   Enforcement Action

   Denial of payment imposed April 11, 2024. Status: Closed, May 30, 2024. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 14, 2022, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

9. Feb 72020

   Standard health inspection

   14 findings

   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Mar 27, 2020
   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Mar 27, 2020
   • F558Reasonably accommodate the needs and preferences of each resident.Level ENo actual harm, potential for moreCorrected Mar 27, 2020
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Mar 27, 2020
   • F583Keep residents' personal and medical records private and confidential.Level ENo actual harm, potential for moreCorrected Mar 27, 2020
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Mar 27, 2020
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Mar 27, 2020
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
   • F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
   • F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Mar 27, 2020
   • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Mar 27, 2020

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

10. Jan 92019

    Standard health inspection

    5 findings

    • F638Assure that each resident’s assessment is updated at least once every 3 months.Level ENo actual harm, potential for moreCorrected Feb 9, 2019
    • F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Level ENo actual harm, potential for moreCorrected Feb 9, 2019
    • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Feb 9, 2019
    • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Feb 9, 2019
    • F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.Level BPotential for minimal harmCorrected Feb 9, 2019

    Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   A Clean, Homelike Setting, Cited in Three Inspections

   Inspectors cited F584 in October 2022, July 2024 and September 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F584 across all 10 inspections, oldest to newest
2. 2

   Help With Daily Living, Cited in Three Inspections

   Inspectors cited F677 in February 2020, October 2022 and March 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F677 across all 10 inspections, oldest to newest
3. 3

   Citation F912, Cited in Three Inspections

   Inspectors cited F912 in January 2019, February 2020 and October 2022. The agency describes it this way: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. None rose above level B (potential for minimal harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F912 across all 10 inspections, oldest to newest
4. 4

   Citation F583, Cited in Two Inspections

   Inspectors cited F583 in February 2020 and February 2024. The agency describes it this way: Keep residents' personal and medical records private and confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F583 across all 10 inspections, oldest to newest
5. 5

   Protection From Abuse and Neglect, Cited in Two Inspections

   Inspectors cited F600 in April 2024 and March 2026. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F600 across all 10 inspections, oldest to newest
6. 6

   The First 48 Hours, Cited in Two Inspections

   Inspectors cited F655 in January 2019 and October 2022. This citation covers the baseline care plan for a new resident’s immediate needs, due within 48 hours of admission. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F655 across all 10 inspections, oldest to newest
7. 7

   Care Plans, Cited in Two Inspections

   Inspectors cited F656 in February 2020 and March 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F656 across all 10 inspections, oldest to newest
8. 8

   Respiratory Care, Cited in Two Inspections

   Inspectors cited F695 in February 2020 and October 2022. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F695 across all 10 inspections, oldest to newest
9. 9

   Pharmacy Services, Cited in Two Inspections

   Inspectors cited F755 in February 2020 and October 2022. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   19202224242424252626F755 across all 10 inspections, oldest to newest
10. 10

    Medication Labeling and Storage, Cited in Two Inspections

    Inspectors cited F761 in February 2020 and October 2022. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19202224242424252626F761 across all 10 inspections, oldest to newest
11. 11

    Kitchen and Food Safety, Cited in Two Inspections

    Inspectors cited F812 in February 2020 and October 2022. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19202224242424252626F812 across all 10 inspections, oldest to newest
12. 12

    Infection Control, Cited in Two Inspections

    Inspectors cited F880 in February 2020 and October 2022. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    19202224242424252626F880 across all 10 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in three inspections, most seriously at level E.

2. 02

   How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?

   Help With Daily Living: cited in three inspections, most seriously at level E.

3. 03

   What changed after F912 was cited, and how do you check it now?

   Citation F912: cited in three inspections, most seriously at level B.

4. 04

   What changed after F583 was cited, and how do you check it now?

   Citation F583: cited in two inspections, most seriously at level E.

5. 05

   What happened after the abuse or neglect citation, and what changed in training or supervision?

   Protection From Abuse and Neglect: cited in two inspections, most seriously at level G.

6. 06

   What happens in the first 48 hours after admission, and who writes the first care plan?

   The First 48 Hours: cited in two inspections, most seriously at level D.

7. 07

   How is a care plan written and reviewed here, and how do families take part in it?

   Care Plans: cited in two inspections, most seriously at level D.

8. 08

   Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?

   Respiratory Care: cited in two inspections, most seriously at level E.

9. 09

   How often does the consultant pharmacist review each resident’s medications?

   Pharmacy Services: cited in two inspections, most seriously at level E.

10. 10

    How are medications stored and secured, and who checks the medication carts?

    Medication Labeling and Storage: cited in two inspections, most seriously at level E.

11. 11

    May we see the kitchen, and what do your own sanitation checks look like week to week?

    Kitchen and Food Safety: cited in two inspections, most seriously at level E.

12. 12

    Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

    Infection Control: cited in two inspections, most seriously at level F.

13. 13

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

14. 14

    What led to the 2024 fine, and has it been paid?

    A $45,702 civil money penalty was imposed April 11, 2024. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jan 9, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Feb 7, 2020 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Oct 14, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Feb 21, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Apr 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Apr 25, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Jul 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Sep 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Mar 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  California state survey agency

  Inspection Mar 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 055241

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.