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 Page 1 of 2 555151 555151 08/14/2025 Willows Post Acute 320 North Crawford Street Willows, CA 95988

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated he hates when the staff gossip around him during care, stated he feels unwanted because of this. During a concurrent interview and record review on 7/10/25 at 11:30 am, with Director of Staff Services (DSD), Complain/Grievance report dated 6/16/25 was reviewed. The report indicated a resident filed a formal complaint with management for not receiving proper care one night in the facility. The report indicated one CNA was responsible for helping the residents and CNA received a corrective action notice (write up). During an interview with Licensed Vocational Nurse (LVN) A on 7/16/25 at 1 pm, stated she was aware of several residents complaining about one specific CNA. LVN A stated she now requests to not work with this CNA when they are scheduled together because she does not feel like she is a good team player and does not take good care of the residents. LVN A stated she has seen this CNA slam things on the desk when she gets upset and has witnessed her speak down to residents and other staff members. LVN A stated she has reported this behavior to management many times, but nothing seems to change. During an interview on 7/30/25 at 1:30 pm, with Director of Nursing (DON), he stated that he had not heard of any grievances from the residents about the CNA's or about staffing. DON stated he has heard of no issues with staffing to his knowledge. DON stated that he is aware of one CNA with behavior issues documented and they are following human resources policies for the process of termination of employment. DON stated residents should feel safe and comfortable while at this facility and not scared and afraid. 555151 Page 2 of 2