Other·April 10, 2019

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 standard survey for investigation of complaint #CA00612246. Representing the Department of Public Health: HFEN, 32525 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 03/18/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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 long-term care facilities) in accordance with State law through established procedures. 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: JHBC11 Facility ID: CA030000008 If continuation sheet 1 of 7 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 02/20/2019 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 §483.12(c)(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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report and investigate an incident of elopement for 1 of 6 sampled residents (Resident 1) to the authorities as required by State law. This failure had the potential for the further elopement attempts and increased the potential for harm to Resident 1. Findings: According to the 'Record of Admission' the facility admitted Resident 1 less than a year ago with multiple diagnoses which included dementia. A significant change in status assessment dated 9/5/18 indicated Resident 1 had short-term and long-term memory problems. A report received by the Department on 11/16/18 indicated Resident 1 had been seen by a neighbor, crawling on the ground outside of the facility on 11/13/18 and when the staff had been notified they had stated, "Well she does that all the time." Resident 1's clinical record was reviewed as follows: An elopement risk assessment dated 8/29/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JHBC11 Facility ID: CA030000008 If continuation sheet 2 of 7 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 02/20/2019 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 indicated she was confused, disoriented, had language barrier, had a history of wandering to the front lobby and leaving facility without supervision. An elopement risk care plan 2/21/18 and revised 6/29/18 indicated she had episodes of trying to leave the facility and sometimes removed the alarm device placed on her (alarm devices are usually placed an arm or ankle and triggers the alarm at the exit doors to notify staff an attempt to leave the facility). A physician order dated 8/29/18 indicated, "Wanderguard [alarm device] on right must be worn at all times for elopement risk. Monitor site Qshift [every shift]." During an interview with the Administrator on 12/3/18 at 12:45 p.m., she stated Resident 1 had eloped on 11/13/18 after dinner and was brought back to the facility by a neighbor around 8-8:10 p.m. The Administrator further stated Resident 1 often exited the facility through the lobby doors but she had never gone beyond the facility's premises. The Administrator stated Resident 1 was not wearing an alarmed device when she eloped on 11/13/18. A review of the facility's 'Wandering, Unsafe Resident' policy, dated 8/2014, indicated, "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." The policy failed to direct staff on the reporting requirements. A review of the facility's 'Unusual Occurrence' policy dated 3/23/15 indicated, "The facility shall notify the Department of Health Services, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JHBC11 Facility ID: CA030000008 If continuation sheet 3 of 7 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 02/20/2019 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 Licensing and Certification, the local health officer(s) by telephone, of unusual occurrences within twenty-four (24) hours of the occurrence (confirmed in writing or by fax)." The policy did not list elopement as an unusual occurrence. During a follow up interview with the Administrator on 12/3/18 at 2:46 p.m., she stated she should have reported Resident 1's elopement incident to the authorities.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/18/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure safety for 1 of 6 sampled residents (Resident 1) when she eloped from the facility and was found by a neighbor near the facility, crawling on the concrete ground. This failure resulted in Resident 1 sustaining a head injury and was sent to the emergency room. Additionally, this failure placed the Resident 1 at high risk of being hit by vehicles on the busy street next to the facility had she attempted to cross the road. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JHBC11 Facility ID: CA030000008 If continuation sheet 4 of 7 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 02/20/2019 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 According to the "Record of Admission" the facility admitted Resident 1 less than a year ago with multiple diagnoses which included dementia. A significant change in status assessment dated 9/5/18 indicated Resident 1 had short-term and long-term memory problems. A report received by the Department on 11/16/18 indicated Resident 1 had been seen crawling on the ground outside of the facility on 11/13/18 and when the staff had been notified they had stated, "Well she does that all the time." Resident 1's clinical record was reviewed as follows: An elopement risk assessment dated 8/29/18 indicated she was confused, disoriented, had a language barrier, wandered to the front lobby and had a history of leaving the facility without supervision. An elopement risk care plan 2/21/18 and revised 6/29/18 indicated she had episodes of trying to leave the facility and sometimes removed the alarming device placed on her (alarm devices are usually placed on arms or ankles. The exit doors alarm to notify staff of an attempt to leave the facility). A physician order dated 8/29/18 indicated, "Wanderguard [alarm device] on right must be worn at all times for elopement risk. Monitor site Qshift [every shift]." A nurses' progress note dated 11/14/18 and timed at 12:05 a.m., indicated, "Resident had an unwitnessed fall this evening around 2000 [8 p.m.]...cna [Certified Nursing Assistant] wheeled resident to the nurses station with skin tear on her forehead and a knot r/t [related to] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JHBC11 Facility ID: CA030000008 If continuation sheet 5 of 7 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 02/20/2019 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 fall. Per cna family saw her fall outside the facility...Resident was grimacing when first aid was applied pointing to her head...Resident was transported to [name of hospital] for further assessment." The hospital emergency department discharge instructions dated 11/13/18 indicated the diagnoses Resident 1 was treated for was, "Closed head injury; fall from ground level; Scalp abrasion; Scalp contusion (another name for a bruise). During an observation of the neighborhood on 12/3/18 at 12:45 p.m., accompanied by the Administrator, where Resident 1 was found by a neighbor, houses were noted and loose concrete on the ground where she was found 'crawling.' A few vehicles were noted parked on the premises and moving traffic was noted on the busy street in front of the facility. During a concurrent interview with the Administrator on 12/3/18 at 12:45 p.m., she validated the observation and stated Resident 1 had eloped on 11/13/18 after dinner and was brought back to the facility by a neighbor around 8-8:10 p.m. The Administrator further stated Resident 1 often exited the facility through the lobby doors but she had never gone beyond the facility's premises. The Administrator stated Resident 1 did not have an alarmed device when she eloped on 11/13/18 as Resident 1 had removed it. An interview conducted with Licensed Nurse 1 (LN 1) on 12/3/18 at 1:45 p.m., she stated Resident 1 was at high risk for elopement and had recently eloped, fell and sustained head injury and a skin tear when she was found in the neighborhood. LN 1 stated Resident 1 wanders and goes to the lobby near the exit door. LN 1 stated Resident 1 eloped many FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JHBC11 Facility ID: CA030000008 If continuation sheet 6 of 7 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 02/20/2019 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 times outside to the parking lot and the ankle bracelet alarmed and staff will bring her back. During an interview with a Certified Nursing Assistant 2 (CNA 2) on 12/3/18 at 2:16 p.m., she stated Resident 1 exited the door to the front lobby multiple times and she usually slept on the couch at the front lobby. A review of the facility's 'Wandering, Unsafe Resident' policy dated 8/2014 indicated, "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement." The policy did not include staff supervision as part of the preventative elopement measures. During a follow up interview with the Administrator on 12/3/18 at 2:46 p.m., she stated the staff were not aware Resident 1 had eloped. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JHBC11 Facility ID: CA030000008 If continuation sheet 7 of 7