Inspection·August 15, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm 1. A review of Resident 9's admission Record, indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including dementia (a syndrome that causes a decline in cognitive abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), bipolar disorder (a mental health condition that affects a person's mood, energy, thoughts, and ability to focus), and mood disorder. Residents Affected - Few A review of Resident 9's Order Listing Report, dated 8/13/24, indicated Resident 9 was receiving 50 milligrams (a unit of measure) of quetiapine (an antipsychotic medication used for bipolar disorder and depression) for mood disorder and staff were to monitor Resident 9's psychotic behaviors manifested by mood swings and angry outbursts and record any episodes of resisting care as evidenced by refusing activities of daily living (ADLs). A review of Resident 9's MDS, dated [DATE], indicated Resident 9 had no behavioral symptoms and did not reject care such as ADLs. A review of Resident 9's Interdisciplinary [IDT] Notes, dated 11/10/23, indicated Resident 9 was on quetiapine for mood disorder due to known physiological condition manifested by attempts to hit staff and had 27 behavioral episodes in 9/23 and 80 episodes in 10/23. A review of Resident 9's Medication Administration Records [MARs], dated 4/24 and 5/24, indicated Resident 9 had 125 episodes of resisting care as evidenced by refusing ADLs in 4/24 and 51 episodes between 5/1/24 and 5/9/24. A review of Resident 9's Care Plan, dated 8/12/24, indicated Resident 9 had episodes of behavior disturbance manifested by verbal abuse towards staff/others, disruptive behavior manifested by attempts to hit staff, angry verbal outbursts, and resistance to care. During an interview on 8/13/24 at 2:58 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated Resident 9 often had behaviors when the certified nursing assistants changed his briefs or showered him. LN 1 further stated if Resident 9 got really mad then he might run or try to hit the CNAs or other residents. During an interview on 8/13/24 at 3:04 p.m. with Director of Social Services (DSS), DSS stated Resident 9 had behaviors as indicated in his MAR and the social services assistant should have checked the MAR. DSS further stated Resident 9's MDS assessment was inaccurate. During an interview on 8/13/24 at 3:13 p.m. with MDS Coordinator (MDSC), MDSC stated Resident 9's MDS assessment was inaccurate which could have impacted his plan of care. During an interview on 8/13/24 at 3:24 p.m. with Director of Nursing (DON), DON stated Resident 9's MDS was inaccurate because he had behaviors and episodes of resistance to care. DON further stated the inaccurate MDS could have impacted Resident 9's plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 2 of 18 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 08/15/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** According to an admission Record for Resident 82 he was admitted to the facility in late June 2024 with diagnoses including dementia (loss of cognitive functioning to an extent that it interferes with a person's daily life and activities) with agitation. During observation rounds on 8/13/24 at 9:28 a.m., Resident 82 was observed inside his room able to get up on his own, ambulate without using equipment and was wearing a wander guard bracelet to his right ankle. A review of Resident 82's Order Summary Report, dated 6/21/24, indicated an order for a wander guard to be worn due to elopement risk. Review of Resident 82's Care Plans revealed there was no care plan in place that addressed Resident 82's use of a wander guard. In a concurrent interview and record review on 8/14/24 at 1:47 p.m. with the Director of Nursing (DON) Resident 82's care plan was reviewed, and the DON confirmed that there was no care plan developed for the use of a wander guard. DON stated it should have been added to Resident 82's care plan from the time it was ordered. A review of the facility's policy titled, Comprehensive Person-Centered Care Plans, dated 12/16, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for two of 19 sampled residents (Resident 14 and Resident 82), when: 1. Resident 14's care plan did not address the moisture associated skin damage (MASD) care and interventions; and, 2. Resident 82's use of a wander guard (a technology that helps keep wanderers safe while allowing to maintain dignity and quality of life) was not included in his plan of care. These failures decreased the facility's potential to address the residents' individualized and specific needs. Findings: 1. A review of an admission record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including joint contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and muscle wasting and atrophy (loss of muscle tissue). A review of Resident 14's Shower Sheet, dated 2/2/24, indicated Resident 14 had a redness over her right gluteal area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 3 of 18 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 08/15/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm A review of Resident 14's Minimum Data Set (MDS; an assessment tool), dated 1/24/24, indicated Resident 14 had MASD. A review of Resident 14's Nurses Weekly Progress Notes, dated 2/2/24 and 2/9/24, indicated Resident 14 developed MASD. Residents Affected - Few During a concurrent interview and record review on 8/15/24 at 9:25 a.m. with Director of Nursing (DON), Resident 14's care plan was reviewed. DON confirmed there was no care plan for Resident 14's MASD. DON stated nurses should have created a care plan for MASD so they can implement the interventions such as applying barrier cream; otherwise without the care plan they might be unable to identify and prevent further skin break down for Resident 14. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 4 of 18 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 08/15/2024 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise care plan interventions in a timely manner following a change in condition for one of 19 sampled residents (Resident 14), when Resident 14 developed moisture associated skin damage (MASD) and a right hip pressure ulcer (skin and tissue injury). This failure decreased the facility's potential to provide Resident 14 with a person-centered care plan and evaluate its effectiveness. Findings: A review of an admission record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including joint contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and muscle wasting and atrophy (loss of muscle tissue). A review of Resident 14's Nurses Weekly Progress Notes, dated 2/2/24 and 2/9/24, indicated Resident 14 developed MASD. A review of Resident 14's Situation, Background, Assessment, and Recommendation [SBAR] Communication Form, dated 2/28/24, indicated a deterioration in Resident 14's right hip skin tear with dark maroon/red discoloration to surrounding skin, some non-blanchable (does not fade when pressed) areas, and red/brown colored wound bed. A review of Resident 14's Weekly Pressure Ulcer Observation Tool, dated 3/7/24, indicated Resident 14 developed an unstageable pressure ulcer on her right hip. A review of Resident 14's Care Plan, dated 8/13/24, indicated Resident 14 was at risk for impaired skin integrity related to thin fragile skin, impaired mobility, and joint contractures.The care plan was last revised on 11/21/23. During an interview on 8/15/24 at 9:25 a.m. with Director of Nursing (DON), DON confirmed Resident 14's care plan was not revised and stated it should have been updated and revised quarterly and as needed to personalize the interventions when there were changes in care. DON further stated nurses might not implement the new interventions if the care plan was not revised. A review of the facility's policy titled, Comprehensive Person-Centered Care Plans, dated 12/16, indicated The Interdisciplinary Team must review and update the care plan: When there has been a significant change in the resident's condition; When the desired outcome is not met; At least quarterly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 5 of 18 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 08/15/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 identify and assess the skin condition for one of 19 sampled residents (Resident 14), when the licensed nurses did not assess or inaccurately assessed Resident 14's skin condition before she developed a right hip pressure ulcer (skin and tissue injury). Residents Affected - Few This failure decreased the facility's potential to prevent Resident 14's development of pressure ulcer. Findings: A review of an admission record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including joint contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and muscle wasting and atrophy (loss of muscle tissue). A review of Resident 14's Minimum Data Set (MDS; an assessment tool), dated 1/24/24, indicated Resident 14 had no pressure ulcers/injuries. MDS further indicated Resident 14 had a skin tear and moisture associated skin damage (MASD). A review of Resident 14's Shower Sheet, dated 2/2/24, indicated Resident 14 had a skin tear and redness over her right gluteus (buttock). A review of Resident 14's Nurses Weekly Progress Notes, dated 2/2/24 and 2/9/24, indicated Resident 14 developed MASD. A review of Resident 14's Shower Sheet, dated 2/16/24, indicated Resident 14 had an open area and redness over her right gluteus. A review of Resident 14's Nurses Weekly Progress Notes, dated 2/16/24, indicated Resident 14's skin was not clear and intact. The notes further indicated Resident 14 had a skin tear and left great toe sore. A review of Resident 14's Shower Sheet, dated 2/23/24, indicated Resident 14 had a skin tear and redness over her right gluteus. A review of Resident 14's Nurses Weekly Progress Notes, dated 2/23/24, indicated Resident 14's skin was clear and intact. A review of Resident 14's Situation, Background, Assessment, and Recommendation [SBAR] Communication Form, dated 2/28/24, indicated a deterioration in Resident 14's right hip skin tear with dark maroon/red discoloration to surrounding skin, some non-blanchable (does not fade when pressed) areas, and red/brown colored wound bed. A review of Resident 14's Nurses Weekly Progress Notes, dated 3/1/24, indicated Resident 14's skin was not assessed. A review of Resident 14's Weekly Pressure Ulcer Observation Tool, dated 3/7/24, indicated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 6 of 18 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 08/15/2024 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 0686 14 developed an unstageable pressure ulcer on her right hip. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/15/24 at 9:12 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated Resident 14 had a stage three pressure ulcer on her right hip and stage two pressure ulcer on her left heel and gluteus. Residents Affected - Few During an interview on 8/15/24 at 9:25 a.m. with Director of Nursing (DON), DON confirmed Resident 14's nursing skin assessment on 2/24 was inaccurate. DON stated the nurses should have done a head to toe assessment to Resident 14's skin and if they were unsure about their assessment then they could have asked for supervisory consultation. The DON further stated having inaccurate skin assessment could have led the facility to miss the early identification of Resident 14's pressure ulcers and delayed the implementation of care/prevention interventions. A review of the facility's policy titled, Change in a Resident's Condition or Status, dated 5/17, indicated .the nurse will make detailed observations and gather relevant and pertinent information for the provider .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 7 of 18 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 08/15/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to provide respiratory care services according to professional standards of quality for one of 19 sampled residents (Resident 244) when Resident 244's administered oxygen was not consistent with physician's order. Residents Affected - Few This failure decreased the facility's potential to safely follow the physician's order when providing respiratory services and increased the resident's risk of developing lung problems. Findings: A review of Resident 244's admission Record indicated she was admitted in late July 2024 with diagnoses including heart failure. During the initial screen and interview on 8/12/24 at 9:33 a.m., Resident 244 was observed in bed breathing oxygen via nasal cannula (a device that delivers oxygen through a tube into your nose). The oxygen was connected to a concentrator which was set at 5L/min (liters per minute, unit of measurement). Resident 244 verbalized that it felt like the oxygen she was getting from the concentrator was too much. A review of Resident 244's Order Summary Report, dated 7/31/24, indicated Resident 244 had an order to use oxygen continuously via nasal cannula at 2L/min. A review of Resident 244's care plan, dated 8/1/24, indicated an intervention for oxygen to be administered to Resident 244 as ordered to decrease the risk of cardiac distress due to heart failure. During a concurrent observation, interview, and record review on 8/12/24 at 10 a.m., with Licensed Nurse 7 (LN 7), LN 7 verified that Resident 244 was using oxygen via NC, and it was set at 5L/min. LN 7 reviewed Resident 244's physician orders and then stated Resident 244 should only be given oxygen at 2L/min as ordered. During an interview on 8/14/24 at 1:47 p.m. with the Director of Nursing (DON) the DON stated it was her expectation for the staff to always follow the physician's order to properly care for the residents. A review of the facility's Policy and Procedure titled Medication and Treatment Orders revised 7/2016 it indicated Orders for medication and treatments will be consistent with principles of safe and effective order writing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 8 of 18 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 08/15/2024 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to complete the annual performance evaluations for three of seven sampled certified nursing assistants (CNAs; CNA 1, CNA 2, and CNA 3). Residents Affected - Few This failure increased the residents' potential to receive poor quality of care from CNAs. Findings: A review of an undated document titled, Employee Data Base-Certified Nurse Assistant, indicated the following: 1. CNA 1's date of hire (DOH) was 5/15/07, and last performance evaluation (PE) was completed on 7/13/22; 2. CNA 2's DOH was 5/9/23, and had no PE; and, 3. CNA 3's DOH was 4/24/17, and last PE was completed on 5/28/23. During an interview on 8/14/24 at 12:25 p.m. with Director of Staff Development (DSD), DSD confirmed CNA 1, CNA 2, and CNA 3's PEs were due and stated it should have been completed annually. During an interview on 8/14/24 at 12:59 p.m. with Director of Nursing (DON), DON stated the CNAs' PEs should have been completed annually to receive positive and negative feedback about the care provided by staff. DON further stated PEs are used to identify areas for improvement of residents' care and make sure CNAs are up to date and on track. A review of the facility's policy titled, Performance Evaluations, dated 6/10, indicated The job performance of each employee shall be reviewed and evaluated at least annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 9 of 18 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 08/15/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility failed to act on the Consultant Pharmacist's Medication Regimen Review (MRR) recommendation for one of 19 sampled residents (Resident 24) when the physician did not address Resident 24's MRR recommendation related to the use of risperidone tablet (an antipsychotic medication, that affects brain activities associated with mental processes and behavior). This failure had the potential to increase Resident 24's risk for the continued use of an antipsychotic medication without adequate indication that could cause adverse consequences. Findings: A review of Resident 24's admission Record indicated she was originally admitted in October 2022 with diagnoses including schizophrenia. Resident 24 receives psychological services through the Yolo County Mental Health. A review of an Order Summary Report of Resident 24 revealed an order, dated 8/8/24, for an antipsychotic medication risperidone tablet 1 milligram (mg, unit of measurement) given at bedtime for adjustment disorder (excessive reactions to stress that involves negative thoughts, strong emotions, and changes in behavior) with mixed anxiety and depressed mood. A review of the facility's Consultant Pharmacist's (CP) MRR dated 6/25/24 indicated that the CP reviewed Resident 24's medication orders and found irregularity in the use of risperidone because it was indicated for anxiety and depression. CP recommended for the physician to re-evaluate current regimen and/or update the order with the appropriate indication to help the facility stay in compliance with regulations. In an interview on 8/14/24 at 1:02 p.m., with the facility's CP, the CP acknowledged that Resident 24 had an order for risperidone 1 mg to be given at bedtime with an indication for anxiety and depression, CP stated that she submitted an MRR recommendation to the facility to review Resident 24's current use of risperidone. CP also added that she wrote a note reminding the physician of Resident 24 being given an antipsychotic medication without proper diagnosis to support its use. CP confirmed that there's no evidence of any documentation written by the physician stating the reason for Resident 24's continued use of risperidone. In an interview on 8/14/24 at 1:47 p.m., with the Director of Nursing (DON) the DON confirmed that the facility received the MRR recommendation from the CP regarding Resident 24's risperidone order without proper indication for use. DON stated the physician through the nurse practitioner was informed of the CP recommendation. The DON further added both disagreed with the recommendation but did not document the reason. DON acknowledged that the risperidone was still given continuously as ordered but should have been revised or updated with the right indication according to the regulations. A review of the facility's Policy and Procedure (P&P) titled Consultant Pharmacist Reportsdated 6/2021 the P&P stipulated The consultant pharmacist performs a comprehensive Medication Regimen Review (MRR) at least monthly. The MRR includes evaluating the resident's response to the medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimize adverse consequences related to medication therapy .The findings are phoned, faxed, or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 10 of 18 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 08/15/2024 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 0756 Level of Harm - Minimal harm or potential for actual harm emailed to the Director of Nursing or designee .Recommendations are acted upon and documented by the facility staff and or the prescriber .If the attending physician does not concur, or the attending physician refuses to document an explanation for disagreeing, the Director of Nursing or designee contacts the Medical Director. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 11 of 18 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 08/15/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview, and record review the facility failed to ensure one of 19 sampled residents (Resident 24) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when Resident 24 was ordered an anti-psychotic medication without an adequate indication. This failure placed the resident at risk for unnecessary psychotropic medication use. Findings: A review of Resident 24's admission Record indicated she was originally admitted in October 2022 with diagnoses including schizophrenia. A review of an Order Summary Report of Resident 24 revealed an order dated 8/8/24 for an antipsychotic medication risperidone tablet 1 milligram (mg, unit of measurement) given at bedtime indicated for adjustment disorder (excessive reaction to stress that involves negative thoughts, strong emotions, and changes in behavior) with mixed anxiety and depressed mood. A review of the facility's Consultant Pharmacist's (CP) Medication Regimen Review, dated 6/25/24, indicated that the CP reviewed Resident 24's medication orders and found irregularity in the use of risperidone because it was indicated for anxiety and depression. CP recommended for the physician to re-evaluate current regimen and/or update the order with the appropriate indication to help the facility stay in compliance with regulations. In an interview on 8/14/24 at 1:47 p.m., with the Director of Nursing (DON) the DON confirmed that the facility received the MRR recommendation from the CP regarding Resident 24's risperidone order without proper indication for use. DON stated the physician through the nurse practitioner was informed of the CP recommendation. The DON further added both disagreed with the recommendation but did not document the reason. DON acknowledged that the risperidone was still given continuously as ordered but should have been revised or updated with the right indication according to the regulations. A review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use dated 10/2017 the P&P indicated The use of an antipsychotic must meet the criteria and applicable requirements listed: Enduring Psychiatric Conditions .Not due to environmental stressors e.g. alteration in the resident's customary location or daily routine, unfamiliar care provider .Not due to psychological stressors or anxiety or fear . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 12 of 18 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 08/15/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly for census of 87 when: 1. Two bottles of sodium chloride (a solution used to dilute medications) were found expired in the automatic dispensing system inside the medication room of station 1 and 2; and, 2. Multiple medications were found at the bottom of medication carts behind the medication drawers in medication carts 3 and 5. These failures had the potential for medication misuse, ineffectiveness, diversion, and missed dosages. Findings: 1. During a concurrent observation and interview on 8/14/24 at 12:05 p.m. with Licensed Nurse (LN) 4 in the medication room of station 1 and 2, an automatic dispensing system unit was inspected. Two bottles of sodium chloride each of 10 milliliters (a unit of measure) were expired on 8/1/2024. The LN 4 verified the expiration date. 2. During a concurrent observation and interview on 8/15/24 at 11:03 a.m. with LN 3 on station 1 and 2, medication cart 3 was inspected. One bubble pack of medications and a vial full of liquid medication in a plastic bag were found behind the bottom drawer of the medication cart 3. The LN 3 verified and stated residents might have missed a scheduled dose of these medications. During a concurrent observation and interview on 8/15/24 at 11:07 a.m. with LN 3 on station 3 and 4, medication cart 5 was inspected. Two bubble packs of medications were found behind the bottom drawer of the medication cart 5. The LN 3 verified and stated this might have caused misuse of medications. During an interview on 8/15/24 at 2:57 p.m. with the Director of Nursing (DON), the DON stated this might have caused residents missing dosages and misuse of medications. The DON also stated pharmacy staff should have checked automatic dispensing system for any expired medications and replaced them. During the review of facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2007, the P&P indicated, .The nursing staff shall be responsible for maintaining medication storage . The facility shall not use .outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy . Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 13 of 18 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 08/15/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and facility policy review, the facility failed to ensure the competency of food and nutrition services for a census of 87 when: Residents Affected - Some 1. Dietary Staff 2 (DS 2) did not know the chlorine sanitizing concentration when performing the three compartments of manual dish washing; 2. Dietary [NAME] 1 (DC 1) did not follow standardized recipes when cooking green beans; and, 3. DC 2 did not follow the recipes when making pureed bread. These failures had the potential to cause contamination of food resulting in food borne illness and provide food for residents which did not meet the nutrients according to the planned recipes resulting related medical issues. Findings: 1. During an interview on 8/14/24 at 8:26 a.m. with DS 2, DS 2 confirmed he did not know the chemical concentration for sanitizing dishes when manual dish washing. A review of the facility's policy titled, 3 Compartment Procedure for Manual Dish Washing, stipulated, The third compartment is for sanitizing. Test the concentration with appropriate test drip, which is dipped in the sanitizer solution 10 seconds before reading. Record on log. Must read 200 [part per million, a unit of measurement]. 2. A review of the Menu titled, Week 3 Regular, dated 9/8/24, stipulated, the lunch menu on Wednesday, 9/14/24 was lasagna, seasoned green beans, garlic bread stick, gelatin jewels with topping, and whole milk. During an observation on 8/14/24 at 8:58 a.m. in the kitchen with Dietary [NAME] 1 (DC 1), DC 1 put frozen green beans on a pan and into the steamer to cook for 15 minutes. During an observation of the pureeing process on 8/14/24 at 11:12 a.m. with DC 1, DC 1 poured eight scoops of four ounces (32 oz, a unit of measurement) green beans into the blender to puree. DC 1 did not add any seasonings of salt, pepper, or butter into the blender with the green beans. During a tray line observation on 8/14/24 at 12:50 p.m., there were not enough green beans so DC 1 needed to make more. DC 1 put some frozen green beans into the steamer. After cooking the green beans, DC 1 added three scoops of melted butter into the green beans. There was no salt and pepper seasoning added to the green beans. A review of an undated recipe titled, Seas [NAME] Beans, indicated the ingredients to use included green beans, salt, black pepper, and margarine. During a concurrent observation of the tray line and interview on 8/14/24 at 1:12 p.m. with Dietary Manager 1 (DM 1) and DC 1, both the DM 1 and DC 1 confirmed dietary staff should have used the recipe when cooking pureed green beans and bread. DC 1 confirmed he did not add salt, pepper, and butter (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 14 of 18 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 08/15/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to the cooked green beans when pureeing it. DC 1 confirmed they did not use salt and pepper in the second batch of cooked green beans. DC 1 stated the green beans without seasoning would not have any flavoring. 3. During an interview on 8/14/24 at 4:35 p.m. with DC 2 and DM 1, DC 2 confirmed he used three cups (a unit of measurement) of hot water, ¼ cup of butter, and 16 oz or two cups of breadcrumbs to make six servings of the pureed bread. DM 1 confirmed DC 2 did not use the correct measurement of all the ingredients when making pureed bread and should have followed the recipe instructions. DM 1 stated there was no policy to follow recipe. A review of an undated recipe titled, P Bread (H) indicated, the recipe to use were ¾ cup of puree bread mix, 1 and 1/8 cup of warm water, and ¼ cup of canola oil for six servings of pureed bread. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 15 of 18 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 08/15/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food in a sanitary manner for a census of 87 when: Residents Affected - Some 1. Seven snack cookie bags and seasoning bottles were stored past their expiration date and several food items were opened and not dated with their open date in the dry storage; and, 2. Staff did not check and document the ammonia log when performing test strips for one shift on 8/11/24. These failures had the potential to result in foodborne illnesses. Findings: 1. During a concurrent observation and interview on 8/12/24 at 8:21 a.m. in the kitchen with Dietary Manager 1 (DM 1), there were: -Seven bags of cookies with expiration date 8/11/24; -One pound (lb., a unit of measurement) seasoning bottle with expiration date 8/4/24; -An opened salad oil with no labeling; -An opened one lb and 12 ounces (oz., a unit of measurement) quick creamy wheat without its use-by-date; and, -An opened one lb corn starch without an open date and labeling. The DM 1 confirmed food items should have labeling with open date, use-by-date, and expiration date. The DM 1 confirmed staff should have discarded the expired food items. A review of the facility's policy titled, Sanitation and Infection Control, dated 2023, indicated, All open food items will have an open date and use-by-date manufacturer's guidelines. 2. During a concurrent interview on 8/12/24 at 8:27 a.m. with DM 1 and record review of the Quaternary Ammonium Log, the DM 1 confirmed there was missing documentation for testing the concentration of the ammonium in the quatemary sanitizer for one shift. DM 1 stated there is no policy for ammonium concentration upon request. A review of the facility's document titled, Quaternary Ammonium Log, dated 8/2024, indicated the instruction to, Test the concentration of the ammonium in the quaternary sanitizer using the proper strips. At least once per shift, record concentration reading of the quaternary chemical you are using. There is no documentation of the ammonium concentration for one shift on 8/11/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 16 of 18 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 08/15/2024 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee met at least quarterly with the required members for a census of 87, when the QAA committee did not meet in the first quarter of 2024, and the Medical Director (MD) and Director of Nursing (DON) did not attend two meetings. Residents Affected - Some This failure had the potential to negatively impact the quality of resident care. Findings: A record review of the document titled, Class Attendance Roster, dated 11/16/23, indicated a Quality Assurance and Performance Improvement (QAPI) meeting was held on 10/2023. The document further indicated that the DON and MD did not attend this meeting. A record review of a document titled, Quality Assurance [QA] Meeting, dated 4/2024, indicated a QAA meeting was held 4/2024. A review of a document titled, QA Meeting, dated 8/13/24, indicated a QAA meeting was held 8/13/24. The document further indicated that the MD did not attend this meeting. During an interview with the Administrator (ADM) on 8/15/24 at 12:35 p.m., ADM confirmed the QAA committee was not held at least quarterly over the past year, and stated it should have been held at least quarterly. The ADM also confirmed that the DON and MD were not regularly attending the meetings, and stated they should have attended the meetings. ADM further stated because of lack of regularly scheduled QAA meetings, the feedback from the DON and MD would not be presented in a meeting in a timely manner and therefore priorities would drop off. ADM also stated the QAA needed the MD for clinical feedback and direction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 17 of 18 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 08/15/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow infection control practices for a census of 87 when Dietary Staff 1 (DS 1) did not change gloves and perform hand hygiene after cleaning and disinfecting the kitchen cart and touched clean kitchen items. Residents Affected - Few This failure had the potential to spread infection in the facility. Findings: During an observation on 8/13/24 at 8:36 a.m. with DS 1, DS 1 had gloved hands and was on the clean side (the side that handles only cleaned kitchen items) of the dishwasher machine. DS 1 then used the same gloved hands, got a rag from the red bucket (the disinfecting water mixture), and wiped down the soiled kitchen cart. With the same gloves, DS 1 took the clean cooler and went to the ice machine to fill it up with some ice. DS 1 continued with dishwashing on the clean side of the dishwasher. There was no change of gloves or hand hygiene performed between these kitchen tasks. During an interview on 8/13/24 at 8:46 a.m. with Dietary Manager 1 (DM 1), DM 1 confirmed staff should have removed their gloves and washed their hands after cleaning and disinfecting the carts. A review of the facility's policy titled, Glove Use Policy, dated 2020, stipulated, When gloves need to be changed: before beginning a different task. The policy further indicated, As soon as [the gloves] become soiled such as when doing housekeeping duties-including . cleaning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056098 If continuation sheet Page 18 of 18