Inspection·July 11, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess one resident (Resident 1) of five sampled residents, when the Minimum Data Set (MDS; an assessment tool) did not accurately reflect Resident 1 ' s nutritional status. Residents Affected - Few This failure decreased the facility ' s potential to identify residents' care needs. Findings: A review of an admission record indicated Resident 1 was re-admitted to the facility in April 2023 with diagnoses including dementia (loss of cognitive functioning, thinking, remembering, and reasoning) and dysphagia (swallowing difficulty). During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 had no weight loss of 5% (percent) or more in the last month or 10% or more in the last six months. A review of a document titled, Weights and Vitals Summary, indicated Resident 1 ' s weight was 176 pounds (a unit of weight measure) on 1/4/23 and 142 pounds on 5/5/23 (a loss of 34 pounds in the last four months). A review of Resident 1 ' s interdisciplinary team (IDT) note titled, RD [Registered Dietician] Weight Review, dated 3/31/23, indicated Resident 1 had a weight loss of six pounds in the last month and 26 pounds in the last three months. RD note further indicated Resident 1 had significant weight loss and inadequate oral intake. During an interview on 7/11/23 at 3:49 p.m. with the RD, RD stated in the last six months, Resident 1 had more than 30 pounds weight loss and that's significant. During an interview on 7/11/23 at 3:05 p.m. with MDS Coordinator (MDSC), MDSC stated, she would have checked Resident 1 ' s weight log and dietary notes to decide whether Resident 1 lost weight or not prior MDS documentation. MDSC stated she noticed a decline in Resident 1 ' s weight after she reviewed the weight log and IDT note, dated 3/31/23, and would have documented there was weight loss. MDSC further stated Resident 1 ' s MDS documentation was inaccurate and the documentation needs to be accurate, because the resident ' s care plan relies on MDS documentation and MDS helps in tracking the resident ' s progress and care. During an interview on 7/11/23 at 3:34 p.m. with Registered Nurse Clinical Resource (RNCR), RNCR stated, she reviewed Resident 1 ' s weight log and MDS and noticed a trend of weight loss of more than (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 056098 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056098 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cottonwood Healthcare Center 625 Cottonwood Street Woodland, CA 95695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)