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Health Inspection Summary

Cottonwood Healthcare Center

625 Cottonwood Street

Woodland, CA 95695

(530) 662-9193

Deficiency Category	Inspection Date: 8/15/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 7/15/21 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 3/22/19 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	0	0
Quality of Life and Care Deficiencies	3	3	2
Infection Control Deficiencies	2	2	1
Resident Assessment and Care Planning Deficiencies	4	2	4
Nursing and Physician Services Deficiencies	1	1	0
Resident Rights Deficiencies	2	2	3
Nutrition and Dietary Deficiencies	2	2	0
Pharmacy Service Deficiencies	3	4	5
Environmental Deficiencies	1	1	0
Administration Deficiencies	1	0	1

Detailed result for inspection on 8/15/24

Date of last standard health inspection:	8/15/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	2/20/25Read the full report (PDF) 12/30/24Read the full report (PDF) 11/25/24Read the full report (PDF) 4/25/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	19
Average number of Health Deficiencies in California:	16.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/30/24	1/15/25	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	2/20/25	3/12/25	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	2/20/25	3/12/25	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Observe each nurse aide's job performance and give regular training.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	4/25/24	5/10/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	11/25/24	12/13/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
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.	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Make sure that a working call system is available in each resident's bathroom and bathing area.	2/20/25	3/12/25	2 - Minimal harm or potential for actual harm	Few

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	8/15/24	9/4/24	2 - Minimal harm or potential for actual harm	Some

Detailed result for inspection on 7/15/21

Date of last standard health inspection:	7/15/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	7/12/23Read the full report (PDF) 7/11/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	17
Average number of Health Deficiencies in California:	17.3
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide activities to meet all resident's needs.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	7/12/23	7/12/23	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	7/11/23	8/11/23	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	7/11/23	8/11/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Some

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Many
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.	7/12/23	7/12/23	2 - Minimal harm or potential for actual harm	Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Few
Ensure medication error rates are not 5 percent or greater.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep all essential equipment working safely.	7/15/21	8/20/21	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 3/22/19

Date of last standard health inspection:	3/22/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	3/13/23Read the full report (PDF) 10/14/22Read the full report (PDF) 8/15/22Read the full report (PDF) 8/10/22Read the full report (PDF) 7/28/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	16
Average number of Health Deficiencies in California:	15.3
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate foot care.	3/13/23	4/10/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	7/28/22	8/16/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	10/14/22	11/4/22	2 - Minimal harm or potential for actual harm	Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	10/14/22	11/4/22	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	8/15/22	8/26/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.	8/10/22	8/22/22	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Few
Ensure that residents are free from significant medication errors.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Few
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.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Some
Ensure medication error rates are not 5 percent or greater.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.	3/22/19	5/15/19	2 - Minimal harm or potential for actual harm	Some

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/30/24	1/15/25	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	2/20/25	3/12/25	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	2/20/25	3/12/25	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	4/25/24	5/10/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	11/25/24	12/13/24	2 - Minimal harm or potential for actual harm	Few
Make sure that a working call system is available in each resident's bathroom and bathing area.	2/20/25	3/12/25	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	7/12/23	7/12/23	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	7/11/23	8/11/23	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	7/11/23	8/11/23	2 - Minimal harm or potential for actual harm	Few
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.	7/12/23	7/12/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate foot care.	3/13/23	4/10/23	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	7/28/22	8/16/22	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	10/14/22	11/4/22	2 - Minimal harm or potential for actual harm	Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	10/14/22	11/4/22	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	8/15/22	8/26/22	2 - Minimal harm or potential for actual harm	Few
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.	8/10/22	8/22/22	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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