Average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willows Post Acute during CMS and state inspections, most recent first.
A resident with multiple medical conditions but no documented cognitive, mood, or behavior problems was asked by the BOM and SSA to transfer her funds into a resident fund management service account and explicitly declined, stating she wished to manage her own bank account. Despite facility policy requiring a signed delegation before opening such an account, the BOM later signed an authorization agreement to transfer the resident's funds without the resident's signature. The resident reported that she had not agreed to facility management of her funds and was very angry and upset about losing control of her money.
Multiple residents who required staff assistance for ADLs reported that staff frequently ignored call lights, failed to provide timely help, and behaved in a rude or uncommunicative manner. These actions led to residents experiencing incontinence, embarrassment, and emotional distress. Despite complaints to management and staff awareness of problematic behavior by a CNA, residents perceived that their concerns were not addressed.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with a history of cerebrovascular disease and diabetes did not receive adequate nail care, as required by the facility's policy. Despite documentation of personal hygiene being provided, observations showed the resident's nails were soiled. Staff interviews revealed a lack of adherence to the expected nail care routine, highlighting a deficiency in the facility's care practices.
The facility failed to maintain kitchen equipment in accordance with professional standards, as evidenced by a slimy substance in the icemaker, improper drainage from the dishwasher, and a missing kick plate on an oven/stove unit. These issues were identified during a review of the facility's policies and through direct observations and interviews with staff.
The facility failed to maintain a sanitary, comfortable, and homelike environment, with worn-off varnish on wooden handrails and scratched or disrepaired wall paint in several rooms. The Environmental Services Director acknowledged the difficulty in maintaining infection control on these surfaces, and the Director of Maintenance confirmed the disrepair of walls and curtains.
The facility failed to maintain proper grooming and personal hygiene for three residents. One resident had an unkempt beard and dirty nails, while two others had matted hair. Despite their needs and preferences, the staff did not provide the necessary care, and there was a lack of proper documentation and communication.
A resident with diabetes and hypertension experienced a six-month delay in receiving cataract treatment due to inadequate follow-up by social services. The delay was acknowledged by the DON, who noted that social services responsibilities had been inconsistently managed.
A resident with chronic pain and dental issues experienced ongoing discomfort due to the facility's failure to document pain location consistently and administer a prescribed dental rinse. The resident reported daily tooth pain and felt neglected by the facility staff, who did not follow the care plan or place the necessary medication orders.
The facility failed to arrange dental and vision services for a resident with multiple health issues, leading to the resident feeling neglected and like giving up on addressing his problems. Despite having no cognitive impairment, the resident's dental and vision needs were not followed up on, and social services were inconsistent in the previous three months.
The facility failed to ensure accurate labeling of medications for two residents. One resident's clonidine label was incomplete, lacking instructions to hold the medication for a low heart rate, while another resident's Visine eye drops were labeled with only initials, risking confusion and cross-contamination.
The facility failed to ensure timely dental services for a resident experiencing tooth pain. Despite multiple complaints and a documented need for dental treatment, no appointment was made, leading to continued pain and frustration for the resident. The process for dental service authorization was delayed, and the responsibility for coordinating care had been inconsistently managed.
The facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and maintain a full-time Registered Dietitian (RD). Records showed inconsistent RD coverage, issues with labeling, maintenance, and the absence of a written policy to honor resident preferences. Further inspection revealed a lack of Quality Assurance (QA) processes, outdated skill checks for food service workers, and improper food storage practices.
The facility failed to consistently incorporate resident dietary preferences, leading to dissatisfaction with food quality and availability. Residents reported receiving disliked food items, limited snack options, and a lack of fresh fruit. The facility also did not have a Dining Committee and had an inadequate food supply based on licensed bed capacity.
The facility failed to implement an effective infection prevention and control program. Medical supplies and equipment in the medication room were found dirty, a resident was allowed to wash soiled laundry in a shared bathroom, and a CNA did not perform hand hygiene between assisting two residents, increasing the risk of cross-contamination.
The facility failed to ensure safe medication administration for four residents. An LVN did not check expiration dates before administering medications, another LVN did not confirm resident identities before giving medications, and a resident received the wrong eye drops. The DON confirmed these lapses in protocol.
Unauthorized Transfer of Resident Funds to Managed Account
Penalty
Summary
The facility violated a resident's right to manage her own financial affairs by arranging for her pension checks to be deposited into a resident fund management service account without her written authorization. The facility's Resident Trust Account Policy, dated 1/1/2023, required that no account be opened until a Delegation of Responsibility for the Management of Personal Funds was signed by the resident or their representative. The resident, who had diagnoses including diabetes, peripheral vascular disease, osteoporosis, hypertension, delusional disorder, and cognitive/communication deficits, had an MDS dated 10/9/25 indicating no memory, recall, thinking, reasoning, mood, or behavior problems. On 12/6/23, a Business Office Activity Note documented that the Business Office Manager (BOM) and Social Service Assistant (SSA) approached the resident and asked her to have her funds transferred into a resident fund management service bank account, and the resident declined, stating she wanted to continue managing her own bank account. Despite this refusal, an Authorization Agreement to Handle Resident Funds showed that on 6/5/25 the BOM signed the authorization to have the resident's funds transferred into the resident fund management service account, without the resident's signature. In an interview on 10/17/25, the resident stated she understood the facility believed she was not competent but asserted that she was competent, wanted to manage her own bank account, had not agreed to the facility managing her funds, and was very angry and upset over no longer having control of her money.
Failure to Ensure Resident Dignity and Timely Assistance
Penalty
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.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #119, who was admitted with a medical history of cerebrovascular disease, weakness, and type 2 diabetes mellitus. The resident's care plan indicated a need for assistance with activities of daily living (ADLs) due to a self-care performance deficit. Despite documentation showing that personal hygiene and bed baths were provided on specific dates, observations revealed that the resident's fingernails were soiled on multiple occasions. Interviews with staff, including a CNA and an LVN, confirmed that nail care was expected to be part of the ADL routine, yet the resident's nails remained dirty. The facility's policy on nail care, revised in 2018, required daily cleaning and regular trimming to prevent infections. However, the CNA responsible for the resident admitted to checking the resident's nails daily but did not ensure they were clean. The LVN and Interim Director of Nursing also acknowledged the expectation for nail care but were unsure of the documentation process. The Interim Administrator confirmed that nail care should be performed during showers, baths, and as needed, yet the resident's nails were not maintained according to these standards.
Failure to Maintain Kitchen Equipment in Accordance with Professional Standards
Penalty
Summary
The facility failed to maintain kitchen equipment in accordance with professional standards for food service safety. A slimy, brown-pink substance was found inside the holding tray of the facility's icemaker, despite the Director of Maintenance (DM) stating that the icemaker had been sanitized recently. Additionally, dirty dishwasher water from the dishwasher's air gap was splashing onto floor tiles next to the drain, which was confirmed by the Registered Dietitian (RD A) during an observation. The DM was unaware of this issue and only fixed the air gap after it was pointed out during the survey. Furthermore, a kick plate at the bottom of an oven/stove unit was missing, exposing wires and other internal parts, which was acknowledged by RD A, who stated that Maintenance was aware of the issue and had ordered the part. These deficiencies were identified during a review of the facility's Infection Prevention and Control Program (IPCP) and Sanitation policy, as well as through direct observations and interviews with staff. The presence of the slimy substance in the icemaker, the improper drainage of the dishwasher, and the missing kick plate all indicate lapses in the facility's adherence to its own policies and professional standards for maintaining a safe and sanitary kitchen environment. These failures created safety issues for staff and had the potential to cause avoidable food- or waterborne illness for all 68 facility residents.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary, comfortable, and homelike environment, as evidenced by worn-off varnish on wooden handrails in Unit 1 and scratched or disrepaired wall paint in several rooms. Specifically, the varnish on the handrails between Rooms 27-34 and the hallway between Station 1 nurses' desk and the patio was worn off, making it difficult to maintain infection control on these porous surfaces. The Environmental Services Director acknowledged that the increased frequency of cleaning during the COVID pandemic contributed to the deterioration of the varnish. Additionally, the wall paint in Rooms 6, 10, 30, and 37 was scratched or in disrepair, and curtains were missing in one of the rooms, further compromising the homelike environment for residents. During an observational tour, it was noted that there were no curtains in one of the rooms, and a significant portion of paint was peeled off the wall, revealing the drywall. The Director of Maintenance confirmed that the walls and curtains in the affected rooms were in disrepair and that the handrails were in the process of being revarnished. These deficiencies violated the residents' rights to a clean, comfortable, and homelike environment, diminishing their quality of life and increasing the potential risk for infection from exposure to uncleanable surfaces.
Failure to Maintain Resident Grooming and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary care to maintain good grooming and personal hygiene for three residents. Resident 6 had an unkempt beard and mustache, with long and dirty nails. Despite expressing his desire to be shaved and have his nails cut, these needs were not addressed. The CNA responsible for Resident 6's care did not inquire about his grooming preferences, and there was no care plan indicating his preference to be clean-shaven. The Director of Staff Development confirmed the lack of documentation and care planning for Resident 6's grooming needs. Resident 56, who was on comfort care and required full assistance with personal hygiene, was observed with matted and unkempt hair. Despite documentation indicating that personal care was provided earlier in the day, her hair remained unbrushed. Similarly, Resident 22, who was on hospice care and required full assistance with personal hygiene, was also observed with matted hair. The Licensed Vocational Nurse confirmed that both residents' hair needed attention, but these grooming needs were not met. The facility's policy on Activities of Daily Living (ADLs) indicated that residents unable to carry out ADLs independently should receive necessary services to maintain grooming and personal hygiene. However, the observations and interviews revealed that the facility staff did not adhere to this policy, resulting in unmet grooming needs for Residents 6, 22, and 56. The lack of proper documentation and communication among staff contributed to these deficiencies.
Failure to Ensure Timely Vision Services
Penalty
Summary
The facility failed to ensure timely vision services for a resident, resulting in continued vision issues and feelings of frustration. Resident 416, who has diagnoses including diabetes and hypertension, was admitted over a year ago and had a cataract in his left eye that required treatment. Despite an ophthalmology consultation recommending cataract treatment for quality of life enhancement, no appointment was made for six months. The delay in referral was confirmed during an interview with the Director of Nursing (DON), who acknowledged that social services should have followed up on the issue. The deficiency was further highlighted by the fact that the social services responsibilities had been inconsistently managed. The Administrator had delegated social services work to the desk nurse and MDS nurse three months prior, but the follow-up on the ophthalmology consultation was still delayed. The facility's job description for the Social Worker clearly states that they are responsible for coordinating social services activities and obtaining resources to meet residents' needs, which was not adequately done in this case.
Failure to Document Pain Location and Administer Dental Prescription
Penalty
Summary
The facility failed to consistently document the location of pain for Resident 416, who had a history of chronic pain, COPD, diabetes, and dysphagia. Over a four-month period, the facility missed 52 out of 70 opportunities to document the location of the resident's pain while administering pain medications. This lack of documentation prevented the facility from recognizing and addressing the resident's dental pain in a timely manner. Additionally, the facility failed to administer a prescribed dental rinse, Chlorhexidine, which was ordered to help manage the resident's oral health issues. The order for Chlorhexidine was not placed in June or July of 2023, despite being indicated in the resident's hygiene notes. The resident reported experiencing daily tooth pain, which varied in intensity, and expressed frustration over the lack of dental care provided by the facility. Interviews with the resident and facility staff, including the Director of Nursing (DON), confirmed these deficiencies. The DON acknowledged that the location of the resident's pain was not consistently documented and that the Chlorhexidine order was never placed. The resident's care plan indicated a risk for oral health problems and required staff to assess for signs of pain and report them to the medical doctor, but these steps were not followed. The resident felt that his complaints about tooth pain were not being heard by the facility staff, leading to ongoing discomfort and a sense of neglect.
Failure to Arrange Dental and Vision Services
Penalty
Summary
The facility failed to ensure that social services arranged for dental and vision services for Resident 416, who had been admitted with multiple diagnoses including Chronic Pain, Chronic Obstructive Pulmonary Disease, Diabetes, and Dysphagia. Despite having no cognitive impairment, as indicated by a BIMS score of 14, Resident 416 reported feeling neglected regarding his dental and vision needs. He had a cataract in his left eye and required dental work, but no appointments had been made for these issues, leading him to feel like giving up on getting his problems addressed. The records showed that dental x-rays were completed on 11/30/23, but no follow-up was done, and a vision exam on 8/25/23 was not followed up until 2/27/24, which was a significant delay. The facility's Director of Nursing confirmed that social services were inconsistent in the previous three months and that the responsibility had been delegated to the desk nurse and MDS nurse, who were also training a new social services person since December 2023. The facility's job description for the Social Worker, dated October 2020, states that the Social Worker is responsible for assisting in obtaining resources from community social, health, and welfare agencies to meet the needs of the resident and coordinating social services activities with other members of the interdisciplinary team. However, the facility did not adhere to these responsibilities, resulting in Resident 416's dental and vision needs being neglected. The Director of Nursing acknowledged that social services should have followed up on the dental and vision services as per their policy and procedure, but this was not done, leading to the deficiency identified in the report.
Medication Labeling Deficiencies
Penalty
Summary
The facility failed to ensure accurate labeling of medications for two residents. For Resident 44, who was admitted with essential primary hypertension and a history of myocardial infarction, the label for clonidine was incomplete. During a medication pass observation, the Licensed Vocational Nurse (LVN) noted a blood pressure reading of 138/78 and a heart rate of 52 for Resident 44 and decided to hold the clonidine because the heart rate was less than 60. However, the medication label only instructed to hold the medication for a systolic blood pressure under 100, with no instruction regarding the heart rate. This discrepancy between the medication label and the medication administration record (MAR) could lead to inappropriate administration of the medication, potentially causing a dangerously low heart rate. The Director of Nurses (DON) confirmed that the MAR should always match the medication label exactly to prevent such errors. For Resident 38, who was admitted with diagnoses including diabetes mellitus and heart failure, an opened container of Visine dry eye drops was found labeled with only the resident's first and last initials. The eye drops were taken from general stock and not properly labeled with the resident's full name. This labeling practice could lead to confusion about the intended recipient and potential cross-contamination. The DON acknowledged that using only initials on medications could result in the medications being given to the wrong residents with similar initials.
Failure to Ensure Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for Resident 416, who had been experiencing tooth pain. Resident 416, admitted with diagnoses including Chronic Pain, COPD, Diabetes, and Dysphagia, had a BIMS score indicating no cognitive impairment. Despite his complaints of tooth pain and the need for dental treatment, no appointment had been made for him. Hygiene notes from 6/9/23 indicated that Resident 416 could benefit from oral appliances due to multiple broken or rotting teeth, and he was prescribed a Chlorhexidine dental rinse. However, during interviews in April 2024, Resident 416 reported daily tooth pain and expressed frustration over the lack of dental care, stating that he felt like giving up on getting his teeth treated. The Minimum Data Set/Social Services Nurse (MDS/SS B) confirmed that the dental service process could take 6-8 weeks, but it had been 16 weeks since Resident 416's last dental exam on 11/30/23. The Director of Nursing (DON) confirmed that Social Services was responsible for coordinating dental care and should have followed up on Resident 416's dental consultation. The DON also mentioned that the Administrator had delegated social services work to the desk nurse and MDS nurse three months prior, due to inconsistencies in Social Services. Despite these changes, no further dental records were available after 11/30/23, and Resident 416 continued to experience unresolved dental pain.
Failure to Ensure Competency in Dietary Services
Penalty
Summary
The facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and maintain a full-time Registered Dietitian (RD). The review of records indicated that the facility did not have consistent full-time RD coverage for 20 out of 26 weeks, with hours ranging from 16 to 36 hours per week. Additionally, the facility's Sanitation and Food Safety Checklist revealed that the Dietary Manager was not consistently present, and there were no RD approval signatures on menu substitutions records for over a month. Observations during a kitchen audit found issues with labeling, maintenance, and the absence of a written policy to honor resident preferences safely. Further inspection revealed that the facility lacked a Quality Assurance (QA) process to ensure residents were consuming physician-ordered nutritional supplements and did not have a Dining Committee that met quarterly. The menu was not followed as posted, and the cool-down log was not used accurately. Skill checks for food service workers were not up to date, and there was an inadequate supply of food based on licensed bed capacity. During an interview, the Administrator confirmed the facility did not have a qualified DSS and a full-time RD, and observations in the kitchen showed improper food storage practices.
Failure to Incorporate Resident Dietary Preferences
Penalty
Summary
The facility failed to consistently incorporate resident preferences in personal dietary choices for 8 of 68 sampled residents. The dietitian or nursing staff were supposed to identify a resident's food preferences within 24 hours after admission and offer a variety of foods at scheduled meals and snacks. However, observations and interviews revealed that residents were receiving food items they disliked, such as pre-made Jell-O that was described as rubbery, and lukewarm hot chocolate. Additionally, residents reported a lack of fresh fruit and snacks, with only canned or prepackaged options available. The facility also did not have a Dining Committee and had an inadequate supply of food based on licensed bed capacity. During interviews, residents expressed dissatisfaction with the food quality and availability. One resident mentioned that snacks were not always available on weekends, and another noted that the facility often ran out of snacks. The nourishment refrigerator was observed to have limited options, and prepackaged dried snacks were not readily available. Additionally, a resident's dietary ticket indicated butter packets, but the tray contained margarine instead. The facility only ordered margarine for resident food trays, although large blocks of butter were available for cooking. The Resident Council Minutes indicated that some residents were receiving dislikes on their meal trays and had not received butter for three weeks. The facility conducted a staff in-service training on meal preferences and the difference between margarine and butter. However, the issues persisted, and the facility's Quality Assessment and Performance Improvement (QAPI) Committee was supposed to review food preferences and meals periodically. Despite these measures, the facility failed to meet the residents' dietary needs and preferences consistently.
Infection Control Deficiencies
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several observations and interviews. In the medication room, medical supplies were found in a dirty condition on the floor, and the sink, soap dispenser, and towel dispenser were also dirty. The Director of Nurses confirmed that the equipment and products were dirty and could cause cross-contamination. This indicates a lapse in maintaining a clean and sanitary environment in critical areas of the facility. Resident 316 was allowed to store and wash her soiled laundry in a shared bathroom, which had the potential to spread infection to Resident 44. Observations revealed that Resident 316 kept her soiled laundry in an open basin on the floor under the sink and washed her clothes in the shared bathroom sink. Interviews with the Environmental Services staff and the Infection Preventionist confirmed that this practice posed a risk of cross-contamination and was against the facility's infection control policies. Certified Nursing Assistant (CNA) E failed to perform hand hygiene between assisting two residents, Resident 15 and Resident 50. CNA E was observed assisting Resident 15 with toileting, including removing soiled briefs and wiping the resident, without performing hand hygiene before moving on to assist Resident 50. The CNA confirmed the lapse in hand hygiene, and the Infection Preventionist acknowledged that proper hand hygiene was not followed, increasing the risk of cross-contamination between residents.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure the safe administration of medications for four residents. Licensed Vocational Nurse (LVN) C did not check the expiration dates on medications administered to Resident 44, who had a history of essential primary hypertension and myocardial infarction. During a medication pass, LVN C administered several medications without verifying their expiration dates, which was confirmed by the Director of Nurses (DON) as a necessary step to prevent ineffective or harmful medication administration. LVN D failed to confirm the identities of Residents 39 and 60 before administering medications. Resident 39, diagnosed with paraplegia, adult failure to thrive, and GERD, received three medications without identity verification. Similarly, Resident 60, diagnosed with diabetes mellitus and fractures of the lumbosacral spine and pelvis, received gabapentin without identity confirmation. The DON acknowledged that proper identification is crucial to ensure medications are given to the correct residents. Additionally, Resident 38, who had diabetes mellitus and heart failure, was given the wrong eye drop medication. A bottle of Visine dry eye drops, pulled from over-the-counter stock, was found labeled with Resident 38's initials, despite the resident having an order for Refresh Tears Ophthalmic solution. The DON confirmed that the incorrect eye drops were administered to Resident 38, highlighting a failure to follow the prescribed medication orders.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Willows
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colusa Medical Center - Snf | 24.6 mi | ★★★★★ | 0 | 0 |
| Chico Terrace Care Center | 24.8 mi | ★★★★★ | 6 | 0 |
| Oakwood Healthcare Center | 24.8 mi | ★★★★★ | 48 | 0 |
| Autumn Creek Post Acute | 24.9 mi | ★★★★★ | 18 | 0 |
| Almond View Care Center | 25.8 mi | ★★★★★ | 0 | 0 |
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