Inspection·April 25, 2024

F 0550 the same information. Level of Harm - Minimal harm or potential for actual harm During a review of Licensed Vocational Nurse Student 2's (LVN Student 2) statement, dated 4/15/24, the statement indicated Resident 1's call light was on, and they (LVN Student 1 and LVN Student 2) went to Resident 1's room. Resident 1 stated he needed help getting up to the bathroom. They transferred Resident 1 to his wheelchair and rolled him into the bathroom. Resident 1 grabbed the pole to pull himself up, but was unable to do it. LVN Student 1 told LVN Student 2 to grab a nurse/CNA. The medication nurse helped them transfer Resident 1 to the toilet. The medication nurse left the room due to it would take Resident 1 awhile to finish using the bathroom. Before LVN Student 2 and LVN Student 1 left the room, LVN Student 2 told Resident 1 to call if he needed anything. Per LVN Student 2's statement, a few seconds later Resident 1's call light was on. Her and LVN Student 1 went back into Resident 1's room. Resident 1 was finished using the bathroom. They were going to clean Resident 1 up when CNA 1 came in and was going to assist them. CNA 1 told Resident 1 to stand up, wiped him, and then told him to pull up his brief by himself. Resident 1 looked like he was struggling. He had one hand holding the pole and the other hand on the sink. LVN Student 2 stated to CNA 1 that she could help him pull up his brief. CNA 1 responded that he can do it himself. Resident 1 was struggling to pull up his brief but the CNA did not want me to help him. Instead, she was yelling at him and stomping the ground to pull up his brief. He only did it half way and the CNA just put him on the wheelchair. I saw there was feces on the seat, and I said I can help clean that up. She said no and told us to leave. LVN Student 1 and LVN Student 2 left the room. Residents Affected - Few During a review of LVN Student 1's statement, dated 4/15/24, the statement indicated LVN Student 1 and LVN Student 2 saw Resident 1's call light was on, and they went to Resident 1's room. Resident 1 stated he needed to use the bathroom. They transferred Resident 1 to his wheelchair and took him to the bathroom. When Resident 1 stood up they noticed his leg was shaking, so they helped him sit back in his wheelchair. Per LVN Student 1's statement she went to get help and had the medication nurse help them get Resident 1 onto the toilet and the nurse then left the room. CNA 1 then came into the room and told Resident 1 to get up but his legs were shaking. CNA 1 cleaned the resident up and told Resident 1 to pull up his brief but Resident 1 couldn't, then CNA 1 yelled at him to pull up his brief. Resident 1 tried to pull up his brief, but he couldn't and then sat back in his wheelchair. Resident 1's brief was half way pulled up. They asked CNA 1 if she wanted them to help clean the bathroom. CNA 1 stated no and told them they could leave. During an interview on 4/24/24 at 10:33 a.m. with Resident 1, via an interpreter, Resident 1 stated this was the first time CNA 1 had provided care for him. Resident 1 stated after going to the bathroom he need help wiping himself and pulling up his brief. CNA 1 told him he could do it, but resident kept saying he couldn't. Resident 1 stated he got tired and sat back down in the wheelchair with his brief still by this knees. He also stated he got wheelchair dirty from not being cleaned up. Resident 1 stated they left him in his wheelchair with his brief and pants still down. Resident 1 stated, the two other people, along with CNA 1 left him. Resident 1 was asked how this made him feel. Resident 1 stated he felt sad. During an interview on 4/24/24 at 11:47 a.m. with the DON, the DON stated they substantiated the allegation. The DON stated CNA 1 never gave a statement and her last day of work at the facility was on 4/15/24. During a review of the facility's policy and procedure titled, Resident Rights, revised 08/2002, indicated, Facility staff shall treat all residents with kindness, respect, and dignity .These rights (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 2 of 3 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 04/25/2024 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)

F 0550 include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 3 of 3