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 (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 07/30/2025 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)