Other·October 20, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00526036. Representing the Department of Public Health: HFEN, 36524 HFEN, 38528 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F225 SS=E INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 10/20/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HNBB11 Facility ID: CA030000008 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056098 (X3) DATE SURVEY COMPLETED 09/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COTTONWOOD HEALTHCARE CENTER 625 Cottonwood Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or misappropriation of resident property. (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HNBB11 Facility ID: CA030000008 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056098 (X3) DATE SURVEY COMPLETED 09/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COTTONWOOD HEALTHCARE CENTER 625 Cottonwood Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interviews, record and facility policy review, the facility failed to identify, investigate, and report an allegation of abuse for one of six sampled residents (Resident 1) when there was no documented evidence the alleged incident had been identified, investigated, and reported to the Department. This failure increased the potential for further abuse to Resident 1. Findings: Resident 1 is a long term resident of the facility with multiple diagnoses including depression and cerebral palsy (neurological condition that involves poor coordination and muscle weakness). According to the most recent quarterly Minimum Data Set (MDS, an assessment tool), Resident 1 scored 15 out of 15 in a Brief Interview for Mental Status indicating she was cognitively intact. During an interview on 3/24/17 at 11:20 a.m., Resident 1 verbalized Certified Nurse Assistant 1 (CNA 1) was "scrubbing hard" while washing her perineal area after an incontinence episode. Resident 1 was tearful and stated she asked CNA 1 to stop but CNA 1 did not stop. Resident 1 further stated she reported the incident to management in early February. Resident 1 confirmed CNA 1 was still assigned to her. During a concurrent interview and record review on 3/24/17 at 2:35 p.m., Social Services Assistant (SSA) stated she heard a grievance from Resident 1 getting a bad treatment from CNA 1. SSA further stated Social Services Director was aware. There was no documented FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HNBB11 Facility ID: CA030000008 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056098 (X3) DATE SURVEY COMPLETED 09/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COTTONWOOD HEALTHCARE CENTER 625 Cottonwood Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE evidence of the report and investigation. During an interview on 3/24/17 at 2:40 p.m., Staffing Coordinator stated CNAs are assigned to the same residents even if there is a resident complaint regarding the CNA. She further stated "I can't do anything about it." She verified CNA 1 was still assigned to Resident 1 as of 3/24/17. During an interview on 4/6/17 at 10:20 a.m., CNA 1 stated Resident 1 "did not like the way I take care of her". It started between October and November of 2016. CNA 1 further stated she reported the incident to management and was told she will be reassigned to a different resident but was still assigned to Resident 1 until a few days ago. Review of the CNA assignment sheets for February and March revealed CNA 1 was still assigned to Resident 1 as of 3/29/17. During an interview on 3/24/17 at 2:55 p.m., the Administrator indicated he was aware of the incident. The Administrator further stated the allegation should have been investigated and reported to the Department. A review of the facility's policy titled, "Elder/Dependent Adult Abuse" revised 06/21/2013, indicated, "The facility will fully protect the rights of each resident from...any form of mistreatment, or any other treatment that would result in physical harm, pain or mental suffering...The facility will enforce a policy of non-tolerance of any form of behavior that might be construed as abuse by any individual... each employee is a mandated reporter...to immediately report any actual/known, alleged, suspected incident of ... abuse... immediately or as soon as possible but not to exceed 24 hours after the discovery of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HNBB11 Facility ID: CA030000008 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056098 (X3) DATE SURVEY COMPLETED 09/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE COTTONWOOD HEALTHCARE CENTER 625 Cottonwood Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the incident..." During an interview on 4/6/17 at 10 a.m., the Director of Nursing (DON) stated she had spoken to Resident 1 and CNA 1 regarding the allegation about a month ago. The DON validated there was no documented evidence of the investigation. She stated, "we should have reported it" to the Department. The DON further stated CNA 1 was still assigned to Resident 1 until after the Department came and investigated the incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HNBB11 Facility ID: CA030000008 If continuation sheet 5 of 5