F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, interview, and facility policy review, the facility failed to provide nail
care for 1 (Resident #119) of 2 residents reviewed for activities of daily living (ADLs).
Residents Affected - Few
Findings included:
A facility policy titled, Fingernails/Toenails, Care of, revised 02/2018, revealed, The purposes of this
procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The policy revealed,
General Guidelines 1. Nail care includes daily cleaning and regular trimming.
An admission Record revealed that the facility admitted Resident #119 on 03/27/2025. According to the
admission Record, the resident had a medical history that included diagnoses of unspecified
cerebrovascular disease, weakness, and type 2 diabetes mellitus without complications.
Resident #119's Care Plan Report, included a focus area initiated 03/28/2025, that indicated the resident
had an ADL self-care performance deficit due to a cerebrovascular accident (CVA). Interventions (initiated
03/28/2025) directed staff to praise all efforts at self-care, promote dignity by ensuring privacy, and provide
supportive care and assistance with mobility as needed.
A Nursing Documentation Evaluation, dated 03/27/2025, revealed the section titled, Physical functional
assessment/physical assist [assistance], indicated that the resident required extensive assistance of one
person for bathing and person for hygiene.
Resident #119's Documentation Survey Report, for March 2025, revealed staff had documented that
personal hygiene was provided during the day shift on 03/28/2025, 03/29/2025, and 03/30/2025, and during
the night shift on 03/27/2025 and 03/30/2025. The Documentation Survey Report revealed staff had
documented that a bed bath was provided during the day shift on 03/28/2025, 03/29/2025, and 03/30/2025,
and during the night shift on 03/30/3035.
During an observation on 03/31/2025 at 10:55 AM, Resident #119's fingernails on the first three fingers of
their right hand were soiled.
During an observation on 04/01/2025 at 9:05 AM, Resident #119 was lying in bed. Resident #119's
fingernails on the first three fingers of their right hand were heavily soiled. During a concurrent interview,
Resident #119 stated that they did not know how long they had been in the facility and did not know if they
had been given a shower or bath.
During an interview on 04/01/2025 at 12:10 PM, Certified Nursing Assistant (CNA) #3 stated that
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
555151
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
04/03/2025
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
residents were to get ADL care daily. CNA #3 stated that residents had assigned shower days and in
between shower days, staff were to give bed baths. CNA #3 stated that when they provided showers to the
residents, they cleaned the residents' nails. She stated that she checked the resident's nails daily, and if
needed clipped their nails once a week, but cleaned the nails whenever it was needed. CNA #3 stated she
had worked with Resident #119 for the past three days. She stated that she was to do nail care for Resident
#119 if the resident's nails were long or if their nails were dirty. She stated that she had checked Resident
#119's nails daily for the past three days.
During an interview on 04/01/2025 at 12:32 PM, Licensed Vocational Nurse (LVN) #4 stated Resident #119
was a part of her assignment for the day. LVN #4 stated that all staff were to provide ADL care. She stated
that each resident was to have assigned shower days, and in between the shower days each resident was
to get peri-care or ADL care as needed. LVN #4 stated that the CNAs were to check the resident's nails
once a week on shower days, and as a nurse she was to check the resident's nails once weekly. She stated
that she was unsure as to where the CNAs documented nail care. LVN #4 stated that she was not aware of
any reason why nail care would not be provided to Resident #119. During a concurrent observation of
Resident #119's fingernails, LVN #4 confirmed that Resident #119 had dirty fingernails. She stated that her
expectation was that staff clean the resident's nails when needed.
During an interview on 04/03/2025 at 10:26 AM, the Interim Director of Nursing (DON) stated that the
CNAs were to get a list of residents who needed nail care, and the expectation was that nails were to be
cleaned during care, and if the resident was diabetic the nurses were to do the nailcare.
During an interview on 04/03/2025 at 10:42 AM, the Interim Administrator stated that CNAs were
responsible for ensuring ADLs were completed for residents as needed. She stated that nail care was to be
performed while showering and bathing the resident and as needed. She stated that her definition of as
needed meant that any time the resident's hands were soiled, they were to be cleaned. The Interim
Administrator stated that his expectation was that Resident #119's nails should have been cleaned.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555151
If continuation sheet
Page 2 of 2
