F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse
for one of three sampled residents (Resident 1) when Resident 2 hit the leg and grabbed the arm of
Resident 1.
This failure resulted in an injury to Resident 1 ' s left arm.
Findings:
Resident 1 was admitted to the facility late 2023 with diagnoses which included heart failure and anxiety
disorder.
During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 11/27/24, the MDS
indicated a Brief Interview for Mental Status (BIMS, a standardized test that screens for cognitive
impairment) score of 14/15, which showed intact cognition.
Resident 2 was admitted to the facility late 2024 with diagnoses which included stroke, depression, and
communication difficulty caused by a cognitive impairment .
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated a BIMS score of 6/15, which
showed severe cognitive impairment.
During a review of Resident 1 ' s SBAR [Situation, Background, Appearance, Review and Notify]
Communication Form, dated 12/15/24 at 9p.m., the SBAR indicated, [Resident 1] with an altercation with
another resident .[Resident 1] with an abrasion to left lower arm.
During a review of Resident 2 ' s SBAR Communication Form, dated 12/15/24 at 9p.m., the SBAR
indicated, [Resident 2] was observed striking [Resident 1] on his arm and legs.
During a review of Resident 1 ' s Progress Notes [PN] Type: IDT [Interdisciplinary Team], dated 12/16/24 at
10:30 a.m., the PN noted indicated, On 12/15/24 at [8 p.m.] , staff heard resident yelling out, when staff
went into the room, [Resident 2] was observed striking [Resident 1] on his arms and legs .Abrasion noted
to left forearm .
During a review of Resident 1 ' s Order Summary Report [OSR], order date 12/17/24, the OSR indicated,
Monitor abrasion to left forearm for s/s [signs and symptoms] of infection .
(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
12/30/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 12/30/24 at 10:52 a.m. with Resident 1 in his bedroom, Resident 1 was asked about
the incident with Resident 2. Resident 1 stated, My bruise is gone now .He [Resident 2] came into my room
and wouldn ' t leave .He was yelling at me .he came over to my bed and grabbed my arm and jerked me up
out of the bed .The nurses came in .He grabbed my left wrist, it was bruised up, he punched me in the leg
in front of the nurses .My arm was sore .
Residents Affected - Few
During a phone interview on 12/30/24 at 11:59 a.m. with Licensed Nurse (LN1), LN1 stated, .I heard a
patient yelling for help. [Resident 2] was in [Resident 1 ' s] room and he [Resident 2] was leaning over the
bed. [Resident 1] was in bed and said [Resident 2] hit him. I saw [Resident 2] slap [Resident 1 ' s] legs and
he was acting like he was going to hit him. He [Resident 2] was extremely hard to re-direct. We separated
them. [Resident 2] kept lunging at [Resident 1] .We assessed [Resident 1]; he had redness on his arm .
During an interview on 12/30/24 at 1:03 p.m. with the Director of Nursing (DON), the DON stated,
Residents have the right to be free from any form of abuse.
During a review of the facility ' s policy and procedure (P&P) titled, Resident-to-Resident Altercation, dated
11/22, the P&P indicated, .Resident-to-Resident physical altercations that must be reported include, any
willful action that results in physical injury .Willful actions include .Hitting, Slapping .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056098
If continuation sheet
Page 2 of 2
