Health inspection·July 30, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to contact and consult with the Responsible Party (RP) and the family for Resident 1, a Native American individual with a diagnosis of unspecified dementia (where cognitive decline is present, but the specific type of dementia cannot be identified), regarding cultural practices related to hair. This failure resulted in Resident 1 given a haircut, which was against her family's cultural preferences. During a record review of facility policy titled Brushing and Combing Hair dated 2001 MED-PASS, indicated staff were to review resident's care plan to assess for any special needs of the resident prior to the haircut.During a record review of Resident 1's admission record, indicated that she was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, cerebral infarction (where a part of the brain is damaged or died due to a lack of blood supply), and encounter for palliative care (focuses on improving the quality of life for individuals facing serious illnesses by managing symptoms, relieving suffering, and providing emotional and spiritual support).During a record review of document titled Nursing Documentation Evaluation dated [DATE] 6:30 pm, indicated no documentation of cultural preferences. Document further indicated resident responds to name and understand simple commands.During a record review of document titled, Minimum Data Set (MDS - a resident assessment tool) Section C, dated [DATE] at 3:38 pm, indicated Resident 1 was assessed by facility MDS nurse to have a Brief Interview for Mental Status (BIMS) score of 5 (0 to 7 points suggests severe cognitive impairment).During an interview with RP on [DATE] at 8:15 am, RP expressed that cutting hair holds significant cultural importance in their heritage and that Resident 1 would have not have consented to this action. During an interview with Licensed Vocational Nurse (LN) A on [DATE] at 9:13 am, LN A stated Resident 1 could make wants and needs known such as I'm cold, I'm thirsty, but Resident 1 would answer 'yes' to almost anything. LN A stated Resident 1 was generally confused, and she did not believe Resident 1 would be able to make the decision for herself for a haircut.During an interview with MDS nurse on [DATE] at 9:26 am, MDS stated residents that wanted a haircut and had mental capacity (the ability to make their own decisions) received a haircut. MDS stated the facility's expectation was to call RPs for residents who did not have mental capacity and needed a haircut. MDS stated a BIMS score of 5 was not considered mental capacity, but it's on the line. MDS stated Resident 1 could answer simple yes or no questions. During an interview with Social Services (SS) on [DATE] at 9:56 am, SS stated she believed Resident 1 could make her wants and needs known. The SS stated she completed admission assessment with Resident 1 and determined Resident 1 did not have mental capacity. The SS stated Resident 1 could make her needs known for items like water or a blanket. SS stated a BIMS score of 5 is not considered mental capacity. SS stated Resident 1 would not be able to answer if she wanted a haircut. SS stated she found out Resident 1 was in the dining room on [DATE] when COS arrived. SS stated COS did not have any residents who wanted their haircut and asked the entire room Does anyone want a Page 1 of 2 555151 555151 07/30/2025 Willows Post Acute 320 North Crawford Street Willows, CA 95988

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few haircut? SS stated Activity Assistant (AA - helps plan, organize, and facilitate recreational and social activities) turned to Resident 1 and asked her, and this was when Resident 1 said yes. SS stated Activities Director (AD) completed an in-service with the AA staff.During an interview with facility cosmetologist (COS - a professional who is licensed to perform cosmetic treatments on hair, skin, and nails) on [DATE] at 10:39 am, COS stated she arrived at the facility on [DATE] and realized there were no residents who wanted a haircut. COS stated she asked everyone if anyone wanted a haircut. COS stated AA asked Resident 1 who said yes, and COS wheeled her into the facility salon. COS stated Resident 1's hair was one simple braid, not in her face or anything. COS stated she trimmed Resident 1's hair from her lower back to her mid back, approximately six inches.During an interview with AD on [DATE] at 10:54 am, AD stated AA staff expectation was to not get involved with asking residents if they wanted a haircut. AD stated AA staff did not have access to the residents' charts and should notify nursing staff if a resident requested a haircut. AD stated she completed an in-service on AA job description with AA staff after the incident. AD confirmed AA staff were not trained to understand medical diagnoses, mental capacity, etc. AD stated AA staff expectation was to involve nursing staff for anything other than activities.During an interview with Director of Nursing (DON) on [DATE] at 11:25 pm, DON stated AA staff were allowed to ask residents if they wanted a haircut, regardless of mental capacity. DON verified facility haircut policy stated to verify if residents did not have any special needs prior to a haircut. DON confirmed AA staff did not have access to residents' charts. DON confirmed AA staff were not medically trained and did not have access to care plans for residents. DON confirmed a BIMS score of 5 did not confirm mental capacity. DON confirmed that AA staff would refer residents to nursing staff if they wanted a haircut. DON confirmed family should have been contacted prior to Resident 1 given a haircut, especially with Resident's 1 diagnosis of dementia. 555151 Page 2 of 2