Health inspection·August 14, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview and record review, the facility failed to provide services that promoted respect and dignity for four of four sampled residents (Resident 1, 2, 3, and 4) when direct care staff did not respond and help residents dependent on staff with their requests for assistance. These failures resulted in residents feeling afraid to ask for assistance, uncomfortable, and unwanted. Findings: 1. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/12/25 and medical record, indicated Resident 1 was cognitively intact with no memory issues. The MDS indicated Resident 1 required assistance with most activities of daily living (ADLs). During an interview on 7/10/25 at 1:50 pm, with Resident 1, when discussed going to the bathroom, Resident 1 stated that she was often afraid to ask for help. Resident 1 stated staff would ignore their call light, walk by or would answer the light and leave without assisting Resident 1. This resulted in episodes of incontinence of urine and feces, which Resident 1 stated was extremely embarrassing, humiliating, and caused burning pain to bottom and peri-area (the region between the anus and the genitals). When discussed how the night shift care was, Resident 1 began to cry stating I feel so alone and afraid. During an interview on 7/16/25 at 10:45 am, Resident 1 stated she was frustrated because there was always new staff and they don't know how to take care of Resident 1's needs, she must continue to tell the nurses what her plan of care is. 2. A review of Resident 2's MDS dated [DATE] indicated Resident 2 was cognitively intact with minimal memory issues. The MDS indicated Resident 2 required assistance from staff for most ADLs. During an interview on 7/16/25 at 11 am, with Resident 2, when discussing call lights on the night shift Resident 2 stated staff just don't come when light is on. Resident 2 stated they see the light but ignore it because I see them walk by. Resident 2 stated the Certified Nurse Assistants (CNAs) will come in eventually, but they do not talk to her which makes Resident 2 feel uncomfortable. Resident 2 stated that she complained to management, but nothing ever changes. During an interview on 7/30/25 at 10:40 am, Resident 2 stated that one CNA was very rude and makes her feel very uncomfortable but cannot remember her name. 3. A review of Resident 3's MDS dated [DATE], indicated Resident 3 was cognitively intact with some memory issues. The MDS indicated Resident 3 required assistance with all ADLs. During an interview on 7/30/25 at 10:50 am, Resident 3 stated that the staff can be rude, and it makes her feel uncomfortable and unwanted. Resident 3 stated she is used to laying in her urine for long periods of time because she waits so long for help to come, especially at night. Resident 3 stated they don't come unless I am throwing up. 4. A review of Resident 4's MDS dated [DATE] indicated Resident 4 as being cognitively intact and required some assistance with ADLs. During an interview on 7/10/25 at 1 pm, Resident 4 stated he has had many issues with the care at this facility and has reported to management many times but feels nothing is being done. Resident 4 explained that his wife had cried and yelled in the night for help and no one came. Resident 4 tearfully stated he prays every night that he and his wife will get help. Resident 4 (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 08/14/2025 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)