Health inspection·April 7, 2022

F 0805 Level of Harm - Minimal harm or potential for actual harm pulmonary (lung) disease, protein-calorie malnutrition, and dysphagia (difficulty swallowing) following a stroke. A review of Resident 37's diet order in the medical record, dated 2/17/2022, read, Regular/Liberalized diet Regular texture, 'cut crust off bread,' extra sauce/gravy with meat textures. Residents Affected - Few A review of Resident 37's lunch meal tray ticket on 4/4/22, indicated Regular Diet and, chopped meat; no bread crust; Extra sauce/gravy. During an interview, on 4/4/22 at 2 pm, Resident 37 stated, The food is way too hard to chew. Sometimes I can't even cut it with a knife. During an additional interview, with Resident 37 in the dining room on 4/6/22 at 11:32 am, he stated the kitchen didn't cut his meat up, but some staff, especially (he motioned toward) the Activities Director (ACTD), would cut it for him. During an interview, with the Activities Director in the dining room on 4/6/22 at 11:40 am, she stated she cut meat for Resident 37 often. Sometimes the meat comes cut. Sometimes he will get a whole piece of chicken. He needs it cut up small. He had a stroke, so sometimes there is a little bit of a swallowing issue. A review of Resident 20's medical record indicated a diagnosis of left side loss of strength and paralysis following a stroke. A review of Resident 20's physician ordered diet in the medical record, read, Regular/ Liberalized diet Regular texture, cut up meat except for when served with burgers. A review of Resident 20's lunch meal tray ticket on 4/4/22, indicated Regular Diet and, Cut meat except for burgers. During an observation, and concurrent interview, on 4/6/22 at 9:50 am, Resident 20 was unable to use her left arm. She stated the kitchen cut her meat because it took a long time for her to eat if the meat was not cut smaller. She stated her meat came in different sizes all the time, but nursing would cut it up more if she asked them. Resident 20 stated that she needed it, cut real small - almost mushy. She thought maybe ¼-inch to ½- inch size pieces would be good. During an interview, with the Speech Therapist (ST) on 4/6/22 at 11:15 am, she stated if she saw, Chopped Meat, on tray tickets she would expect chopped, size would be one-inch pieces. During an interview, with the Registered Dietitian (RD) on 4/6/22 at 1:32 pm, she was asked what size meat should be when the tray ticket read, Chopped Meat. The RD stated, We don't have a chopped diet, and they didn't have a chopped diet in their diet manual. During an interview, with the Dietary Manager (DM) on 4/06/22 at 3:15 pm, she stated staff were trained in texture modified diets. She stated there was no chopped diet in the facility's diet manual, and she would leave it to the staff's discretion what size to chop the food. The facility's diet manual, dated 2019, titled Diet and Nutrition Care Manual, Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet, was reviewed, and indicated this diet is used for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few individuals with mild oral and or pharyngeal phase dysphagia (difficulty swallowing). Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew and swallow. Food should be prepared according to individual tolerance to the food. To achieve optimal intake, diets should be planned with the individual's preferences and cultural norms in mind. The protein foods section of the document indicated Chopped or Ground as tolerated, but did not provide a definition of size for chopped food. A review of the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines, dated January 2019, indicated that Level 6 Soft and Bite-Sized: ability to chew bite-sized pieces, so they are safe to swallow is required. Bite-sized pieces should be no bigger than 1.5 cm x 1.5 cm (approximately ¾ inch x ¾ inch) in size. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate resident food allergies, intolerance's and preferences for three of 15 sampled residents (Residents 45, 37, and 207). This failure had the potential to result in decreased nutrition intake, decline in health, and decreased quality of life. Findings: During an observation, of lunch tray line on 4/4/22 at 11:50 am, [NAME] A asked the Registered Dietitian (RD), The no dairy resident can have the mashed potatoes? The RD answered, Yes. A review of Resident 45's breakfast and lunch tray tickets on 4/4/22, indicated that she was on a regular diet and allergic to strawberries, dairy/milk/lactose. Cheese is OK. During an observation, and concurrent interview, with [NAME] A on 4/4/22 at 12:45 pm, he stated they use potato pearls for mashed potatoes, and showed the package. The package stated, Contains: Milk. A review of Resident 37's medical record indicated that he was re-admitted to the facility on [DATE], (initial admission date 4/24/19) with diagnoses including chronic obstructive pulmonary (lung) disease, protein-calorie malnutrition, and dysphagia (difficulty swallowing) following a stroke. During an observation in the kitchen, on 4/4/22 at 3:10 pm, Resident 37 came to the kitchen door and stated to Dietary Aide E (DA E) You sent me chocolate. Don't send me chocolate. DA E stated, That was me, and apologized. She opened a can of butterscotch pudding and sent it to him. A review of resident breakfast and lunch tray tickets dated 4/4/22, listed Resident 37's Dislikes: chocolate IC, chocolate pudding. A review of snack labels dated 4/4/22, and 4/5/22, indicated that Resident 37 was to receive butterscotch pudding at 2 pm both dates. The labels did not show the, no chocolate, preference. A review of Resident 207's medical record showed Resident 207 was admitted to the facility on [DATE], with diagnoses that included diabetes, and dysphagia. The most recent Minimum Data Set (MDS, a standardized resident assessment) indicated Resident 207 was cognitively intact (ability to think and reason). During a concurrent observation, and interview, with Resident 207 in her room on 4/4/22 at 9:30 am,, Resident 207 stated, I tell them every time they serve biscuits and gravy for breakfast, that I do not like it. But they just keep giving it to me. I have asked them many times if I can get something different, however they keep bringing it. Resident 207's breakfast tray was plated with biscuits and gravy, that was not touched. During a concurrent interview, and record review, with the Registered Dietitian (RD) on 4/6/22 at 11:30 pm, Resident 207's Food Preferences Interview, (FPI, a tool used to identify a resident's food (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few likes and dislikes), dated 3/16/22, was reviewed. The FPI did not indicate Resident 207 disliked biscuits and gravy. During an interview with the RD on 4/6/22 at 1:32 pm she stated: The Dietary Manager (DM) saw residents and obtained their food likes and dislikes. There was a menu substitution log where menu changes were documented related to food supply and to general resident preferences (e.g., residents who disliked green beans were served carrots). Food allergies and intolerance were listed on the tray ticket. When asked about Resident 45 being given mashed potatoes containing milk when the tray ticket said Allergy to dairy/milk/lactose, she stated the resident was lactose intolerant but could tolerate some milk. The DM, and Dietary Manager in Training (DMIT) wrote resident preference information on paper documents (stored in DM office), and entered preferences into the diet office software program. During an interview, with the DM on 4/6/22 at 3:15 pm, she stated nursing told them about new admissions at the Stand Up huddle each morning and provided pink slips regarding diet orders, allergies, etc. When asked why data from resident interviews was stored in her office, and not in the medical record, the DM replied she and the DMIT currently didn't have access to the electronic medical record to enter any notes regarding resident preferences, or other information obtained during their interviews with residents. She stated normally they wrote a short progress note in the medical record after visiting residents, but they were no longer able to do that. During an observation, and concurrent record review, in the kitchen on 4/4/22 at 9:24 am, a document titled, Resident Allergies and Dislikes Report, was posted on the refrigerator for staff reference and showed it was printed on 2/13/22. It listed the names, room numbers, diet orders, allergies and dislikes for the 60 residents residing in the facility on the print date. Further review, showed food preference information for Resident 37 (admitted [DATE]) and Resident 207 (admitted [DATE]), were not included on that report because they were admitted after it was printed. A review of the Resident Allergies and Dislikes Report, printed per request on 4/4/22, indicated 13 of 62 residents residing in the facility on 4/4/22, were not listed on the 2/13/22 version, of the report posted in the kitchen, and there was no reliable system in place to ensure timely printing of this report occurred to assist staff in honoring resident food preference and allergies. During an interview, with the Dietary Manager (DM) on 4/4/22 at 9:25 am, she was asked about the Resident Allergies and Dislikes Report, posted on the refrigerator and dated 2/13/22. She stated there was one resident with a strawberry allergy, and maybe another one but she couldn't remember. But it's on the tray tickets. She stated staff who had been there awhile knew resident allergies and preferences, and if there was a new cook, the Dietary Aide checked the tray tickets, would tell the cook, and alternate choices would be served. While food dislikes and allergies did print on tray tickets, they didn't all print on snack labels as shown with Resident 37 and his dislike of chocolate. The facility's policy titled, Dining and Food Preferences, revised 9/17, was reviewed, and indicated that individual dining, food and beverage preferences are identified for all residents/patients. Residents or resident representative are interviewed within 48-hours of admission. The Food Preference Interview will be entered into the medical record. The Dining Services Director, RDN or qualified designee, will enter information pertinent to the individual meal plan into the plan of care. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerance, and preferences. While this policy describes a system for how resident individual food preferences, allergies and intolerance were accommodated, it did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 accurately reflect the day-to-day practice of the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to protect food and equipment from potential cross contamination when: Residents Affected - Some 1. Staff did not consistently wear or change aprons when moving from dirty to clean tasks. 2. The ice machine was not clean. These failures had the potential to result in foodborne illness from cross contamination between staff clothing, food, and equipment during food preparation, meal service and dish washing processes, and between the ice machine and ice used in food production and served to residents. Findings: 1. A review of the FDA Food Code 2017, 2-304.11 indicated that food employees shall wear clean outer clothing to prevent contamination of food, equipment, utensils, linens, and single-service and single-use articles. A review of the FDA Food Code 2017, Annex 3, 2-304.11 indicated that dirty clothing may harbor diseases that are transmissible through food. Food employees who inadvertently touch their dirty clothing may contaminate their hands. This could result in contamination of the food being prepared. Food may also be contaminated through direct contact with dirty clothing. During an observation, on 4/4/22 at 11:50 am, Dietary Aide B (DA B) wore a white cloth apron but [NAME] A, Dietary Aide C (DA C), and the Dietary Manager in Training (DMIT) did not wear aprons to protect food, equipment, and their clothing from potential cross-contamination while serving food and assembling resident meal trays during lunch tray line. During an observation, on 4/5/22 between 8:55 am and 9:45 am, [NAME] A poured a red sauce over the Chicken Enchilada Casserole and wore no apron to protect his clothing from contamination by food splatter. DA B wore a white cloth apron as she worked the clean side of the dish machine. The apron had a large black spot resembling felt pen ink below the pen pocket. DA C and DMIT did not wear aprons to protect their clothing from potential cross-contamination while putting away the truck delivery boxes. Dietary Aide D (DA D) wore a long sleeved, black, quilted coat with a plastic apron over the front as she worked the dirty side of the dish room area. [NAME] A wore no apron as he cleaned the food production counter. During an observation, on 4/5/22 between 10:45 am and 11:45 am, DA D wore her black coat and no apron as she pureed pineapple in the food production area. DA B continued to wear the apron with the black spot as she carried a tub of trash to a garbage can in the back hall, worked the dirty side of the dish machine, then put away clean dishes, cleaned the clean side of dish machine, and then went to help with cold food assembly for lunch tray line. At 11:25 am, DA B received soiled dishes from nursing at the door and carried them with her hands to the dirty side of the dish machine. She washed her hands and then received additional soiled dishes from nursing and carried them with her hands to the dirty side of the dish machine. She washed her hands, continued to wear the same apron, and proceeded to assist with assembly of cold foods on lunch tray line. DA B did not change into a clean apron to protect against cross contamination as she moved between these multiple clean and dirty tasks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm During an observation, and concurrent interview, with DA B on 4/6/22 at 10:05 am, she wore a different white cloth apron with a large light brown stain resembling a coffee stain. DA B stated she wore two aprons each day, one from 5:00 am to 9:00 am, and then she changed it. She stated she wore an apron to protect her clothes (from being soiled by food and splash). She was not observed to change her apron at any time during her shift on 4/5/22, and she did not change her apron between dirty and clean tasks. Residents Affected - Some During an interview, with the Dietary Manager in Training (DMIT) on 4/6/22 at 10:18 am, she stated they had plastic aprons that were mainly for staff working the dirty side of the dish area. She stated staff should change their apron when they go from a dirty task to other (clean) tasks, and they should wash their hands. The DMIT stated she believed apron use was a preference, and added if production staff wore aprons, they'd have to change them every time they went to the refrigerator. During an interview, with the DM on 4/6/22 at 3:15 pm, she stated staff wore coats/ outerwear in the kitchen because, Sometimes it's just cold and they wear a jacket. Since everyone didn't have a corporate-supplied jacket, they wore their own coats when it was cold. The DM confirmed the jackets that the staff wore in the kitchen were what staff also wore for everyday activities in their lives outside the facility. She stated it was not necessarily a cross contamination issue because it was the same as how staff wore their own clothes to work. If staff jackets were filthy, they couldn't wear them. The DM agreed most people didn't wash their jackets as often as they washed their clothes, so could potentially pose a higher risk for cross-contamination. The DM stated the department had plastic aprons and staff had a choice to wear them (or not). She stated staff should wear a plastic apron when working the dirty side of the dish area. They should take it off when they leave the dirty side. She further stated if staff clothes were clean, an apron was not an issue since their policy said clean attire and did not say staff had to wear aprons. Yet observations showed staff did not wear aprons to protect their clothing from potential cross contamination when performing dirty activities such as taking out the trash, putting away corrugated boxes of food from deliveries or carrying soiled dishes. Staff did not consistently change potentially soiled aprons before engaging in food preparation activities, or resident meal tray assembly. The facility's policy titled, Staff Attire, revised 9/17, was reviewed, and indicated that all employees should wear approved attire for the performance of their duties. All staff members will wear clean approved attire, including appropriate footwear for safety, daily. The policy did not suggest or require any use of aprons or changing out soiled aprons to decrease the risks of cross contamination in the dish room or any area in the kitchen. While both the DM and the DMIT stated aprons should be worn by staff working the dirty side of the dish area and that aprons should be changed before leaving the dish area, this potential source of preventable cross contamination was not included in the policy. 2. During an observation, and concurrent interview, and record review, with the Maintenance Director (MAINT) on 4/6/22 at 10:05 am, the ice machine was not clean. There was an accumulation of a black substance resembling mold in two interior locations. The MAINT stated he cleaned the ice machine monthly using the manufacturer's cleaning and descaling products. The Ice Machine Cleaning Log posted near the machine showed it was last cleaned 3/29/22. MAINT stated he cleaned and sanitized the bin using the descaler and sanitizer; he put in the Clear 1 Descaler and ran it for 45-minutes. Then he put in 7-ounces Scotsman Cleaner for 45-minutes. A review of the manufacturer's instructions titled, Scotsman Ice Systems, C0530D through C1030D Remote Condenser Models - User Manual: Cleaning, Sanitation and Maintenance, pages 19-20, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete December 2014, directed use of larger amounts of cleaner and descaler than was described by the MAINT. It directed use of 10 to 12 ounces of Scotsman Clear 1 ice machine scale remover to be poured into the reservoir. It directed mixing a cleaning solution of 1 ounce ice machine scale remover with 12 ounces of water to flush out the curtain in the ice machine and clean the removable parts. Step 14 directed creating a solution of sanitizer mixing 8 ounces NuCalgon IMS II, and 5 gallons of 105-115-degree Fahrenheit water to create a 200 ppm (parts per million) active quaternary solution (sanitizer) used to wash sensors, curtain, water distributor, freezing compartment and evaporator cover. Cleaning the ice storage bin included use of 7 ounces Scotsman Clear 1 ice machine scale remover to 84 ounces potable water to wash all interior surfaces of the bin, followed by thoroughly washing all interior surfaces of the ice storage bin. Event ID: Facility ID: 555151 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) system when: 1. The committee did not ensure that the nursing staff accurately recorded percentages of meals eaten for two of 15 sampled residents (Residents 36, and 43), and 2. The committee did not monitor the effectiveness of their plan to detect weight variances for two of 15 sampled residents (Residents 43, and 208). This failure had the potential to lead to undetected weight loss which could have threatened the residents' health and well-being leading to negative clinical outcomes. Findings: The facility's policy titled, 2022 QAPI Plan for [NAME] Post Acute, was reviewed, and indicated a list of guiding principles for this facility. These included: identifying areas of improvement; identifying system gaps and breakdowns; performing root cause analysis; and either enhancing existing systems or developing new ones to improve their quality of care and quality of life for the residents. The facility would have put in place systems to monitor care and services, drawing data from multiple sources. The governing body was ultimately responsible for overseeing the QAPI committee. The owner/president had direct oversight responsibility for all functions of the QAPI committee, and reported directly to the governing body. The QAPI committee, which included the medical director, was ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. 1. During a review of the facility's document, titled, Clinical Competency Validation: Feeding the Patient, revised 1/1/14, it indicated a list of critical elements for the staff member who fed residents, which included recording the meal intake. An illustration in the form of a pie chart diagram was provided to help staff determine the percentage of the meal that was eaten. A full plate indicated zero percent eaten; three-quarters of a plate was 25%; one-half a plate was 50%; one-quarter plate was 75%; and an empty plate indicated 100%, of the meal had been eaten by the resident. During a review of a facility's job description, titled, Charge Nurse - LVN (Licensed Vocational Nurse), revised 6/16/17, it indicated a position summary and a list of responsibilities. Under the category of Quality Improvement, the Charge Nurse was to have ensured that the residents' Care Plans were implemented. Resident 36's medical record was reviewed. Resident 36 was admitted on [DATE], with diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affected movement, often including tremors), and dysphagia (difficulty swallowing). The resident was not her own decision maker. A review of Resident 36's meal percentage intake tasks showed that from 3/9/22 to 4/5/22, there should have been a total of 84 food intakes recorded, but only 38 recorded meal intakes were located. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Resident's 43's medical record was reviewed. Resident 43 was admitted on [DATE], with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that were severe enough to interfere with daily life), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic and remembering information), and protein-calorie malnutrition. Resident 43 was not his own decision maker. Residents Affected - Few A review of Resident 43's Care Plan, initiated on 10/9/20, indicated, monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. A review of Resident 43's meal percentage intake tasks showed that from 3/1/22 to 4/5/22, there should have been a total of 108 food intakes recorded, but only 43 records were located. During a concurrent interview, and record review, on 4/6/22, at 9:35 am, the Assistant Director of Nursing (ADON) reviewed Resident 43's Care Plan and meal intake sheets. The ADON stated that the staff should have followed the Care Plan, and recorded all the intake for each meal, and confirmed that the staff needed more education. During an interview, on 4/7/22, at 11:26 am, the ADON, and the Administrator (ADMIN) confirmed that meal percentage calculation were not accurate, and they had been working on improving the documentation of meal intakes since December of 2021. 2. The facility's policy titled, Weight Management, dated 8/25/21, was reviewed, and indicated that its purpose was to obtain a baseline weight, identify significant weight changes, and to determine possible causes of significant weight changes. Staff were to follow acceptable procedure to obtain accurate weights. During an interview, on 4/5/22, at 3:14 pm, the Registered Dietitian (RD) stated that the staff made a mistake with Resident 43's weight, which was listed at 94.2 pounds on 4/4/22. After re-weighing on 4/5/22, Resident 43's wieght was 110 pounds. Resident 208's medical record was reviewed. Resident 208 was admitted to the facility on [DATE], with diagnoses that included diabetes, obesity, muscle weakness, and anxiety. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 3/16/22, indicated Resident 208 was cognitively intact (able to think and reason). During a concurrent interview, and record review, on 4/6/22 at 1:30 pm, with the RD, Resident 208's, Weights and Vitals Summary, (WVS), dated 4/7/22, was reviewed. The WVS indicated, Resident 208's weight on 3/16/22 at 12:20 pm, was 159 pounds, on 3/21/22 at 4:28 pm was 158 pounds, on 3/28/22 at 4:28 pm was 108.8 pounds, on 4/4/22 at 3:10 pm was 101.6 pounds, and on 4/5/22 at 3 pm was 100.6 pounds. The RD stated, I did not know about the weight discrepancy of 58.4 pounds until this morning. During an interview, on 4/7/22, at 9:08 am, the ADON stated that the facility had a weight committee that met once a week. ADON stated that normally the Certified Nursing Assistants (CNAs) checked the weights and would have told the Licensed Nurse (LN) the weight of the resident. The CNAs wouldn't have seen the previous weight of the resident. During an interview, on 4/7/22, at 11:26 am, ADMIN and ADON confirmed that there was not good documentation regarding weight variance. Staff had not given close attention to whether a resident had been weighed in a wheelchair, and then weighed without the wheelchair, for example. These types of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows Post Acute 320 North Crawford Street Willows, CA 95988 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 details would have contributed to inconsistent weights. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555151 If continuation sheet Page 12 of 12