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F0550
E

Failure to Ensure Resident Dignity and Timely Assistance

Willows, California Survey Completed on 08-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Direct care staff failed to respond to and assist residents who were dependent on staff for activities of daily living (ADLs), resulting in multiple residents feeling afraid, uncomfortable, and unwanted. Residents reported that staff ignored call lights, walked by without assisting, or answered call lights but left without providing help. This led to episodes of incontinence, embarrassment, humiliation, and physical discomfort for residents. Several residents expressed fear of asking for help, frustration with frequent staff turnover, and the need to repeatedly explain their care needs to new staff. Residents also described staff as being rude, uncommunicative, and engaging in inappropriate behavior such as gossiping during care. Interviews and record reviews indicated that residents had reported these issues to management multiple times, but perceived that no changes were made. One resident described a specific incident where his wife cried and yelled for help at night without receiving assistance. Staff interviews corroborated concerns about a particular CNA's behavior, including rudeness and lack of teamwork, with reports made to management but no apparent resolution. The DON stated he was unaware of grievances or staffing issues, though documentation showed at least one CNA had received corrective action for care deficiencies.

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