Inspection·November 25, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review, and facility documents review, the facility failed to ensure one of three Residents (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 raised her voice and cussed at Resident 1. This failure resulted in Resident 1 feeling scared. Findings: Resident 1 was admitted to the facility on [DATE]. During a review Resident 1 ' s Quarterly Minimum Data Set (MDS-an assessment tool), dated 10/20/24, described Resident 1 as having clear speech, able to make herself understood and as able to understand others. Resident 1 ' s BIMS (a brief screening that aids in detecting cognitive impairment) score was 15 which indicated she was cognitively intact. The MDS described Resident 1 as having no signs or symptoms of delirium or behavioral symptoms. During a review of Resident 1 ' s Progress Notes, dated 11/18/24 at 10:39 a.m., it Was reported to the DON [Director of Nursing] at 0815 11/18/24, by the resident that on 11/16/24 during lunchtime when the dining room only had a handful of residents that the resident (Resident 1) and C.N.A. (CNA 1) got into a verbal altercation. Resident was talking to another resident and was encouraging her to eat, when the C.N.A. told her to mind her own business and that the resident was fine. [Resident 1] continued to encourage resident in Spanish. [Resident 1] and another resident were at a different table discussing the other resident's upcoming Surgery when the CNA turned around and started to curse at her, [Resident 1] then told her that she was talking to the other resident to give her reassurance for her upcoming surgery, and she wasn't saying anything. CNA was feeding another resident at a different table when event happened. Per resident they argued back in forth for a few minutes when another staff member came in and the CNA left the room. During an interview on 11/25/24 at 9:52 a.m. with Resident 2, she stated the incident it was so upsetting and didn ' t want to be interviewed regarding what she witnessed or heard. Resident 2 stated she gave her statement to [DON]. During a review of the facility ' s interview with Resident 2, dated 11/21/24, regarding the incident on 11/18/24 during the lunch meal. Resident 2 stated, I was having a conversation with [Resident 1] regarding my upcoming surgery. [Resident 1] was trying to reassure me, and I was worried about managing my pain after surgery. We did notice a resident spilling food on herself, and I mentioned that she was dropping food on herself. [Resident 1] went and was trying to help the other resident and came back to our table and started to talk to me. [CNA 1] did start cussing at [Resdient1] and did (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 2 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 11/25/2024 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)