Other·June 1, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED STANDARD SURVEY for Entity Reported Incident Number CA00527304. Inspection was limited to the Abbreviated Standard Survey and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyor #21936 Health Facilities Evaluator Supervisor Deficiency Identified for Entity Reported Incident CA00527304 - F226 Notice of Intent to Issue a Citation was issued to the Administrator on 3/21/17

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 05/23/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 1 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on observation, interview, record and document review, the facility failed to implement their abuse policies and procedures for reporting, investigation, protection of residents during an investigation and careplanning when Resident 1 made an allegation of sexual abuse. In addition, the facility failed to develop a policy for specific procedures for reporting and management of residents related to allegations of sexual assault. These failures had the potential that investigations of allegations of abuse would not be conducted timely and placed Resident 1 and other residents at risk for abuse. Findings: On 3/21/17, the Department received a report from the facility's Business Operations Manager (BOM), dated 3/20/17, which documented Resident 1 reported to a nurse on Sunday (3/19/17) that she was raped by three men the previous night (3/18/17). The facility submitted an attached Investigation Summary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 2 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Report, dated 3/20/17, which documented Resident 1 reported to Licensed Staff A on 3/19/17 that she was raped by four men on 3/18/17. The report noted Licensed Nurse A did not see any signs of abuse, made a note in the chart and reported to the BOM, who was identified as the abuse coordinator. Review of Resident 1's Admission Record, printed by the facility on 3/21/17, documented Resident 1 was admitted to the facility on 3/1/14 with diagnosis that included major recurrent depressive disorder, severe with psychotic symptoms. During an interview on 3/21/17 at 11:40 a.m., the BOM stated Resident 1's story changed multiple times. The BOM stated Licensed Staff A called him Sunday afternoon (3/19/17) and informed him that the Resident reported five guys raped her. Licensed Staff A had reported the resident's account of events were not consistent. The BOM stated he asked Licensed Staff A about the "viability" of the story and Licensed Staff A informed him she did not think it was a credible allegation and thought maybe the resident was hallucinating due to a urinary tract infection or recent medication change. The BOM stated he informed Licensed Staff A to "keep him in the loop" and stated that was the end of the investigation for that day until the next day, Monday (3/20/17). When asked if the Resident 1 had received an examination or assessment after the allegation of rape / assault was made or if police were notified that day, the BOM stated he did not believe the resident received a full exam. The BOM stated it was not until the next day, 3/20/17, that police and the resident's physician were notified of the allegation as part of "due diligence." The BOM stated he instructed staff not to interview the resident until after the police had interviewed her. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 3 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The BOM stated after police interviewed Resident 1 on 3/20/17 that was the first time he had heard descriptions of the accused. He stated the resident identified a white male with curly hair named [X] who served food. The BOM stated no one at the facility met that description or name. The BOM stated Resident 1 also identified two other males. The BOM stated CNA D and CNA E worked on 3/18/17 and potentially met the resident's description. The BOM stated CNA D was orienting with CNA C on 3/18/17 but had not provided care and CNA E had worked at the facility for a long time. He stated Resident 1 stated she had never seen the men before. The BOM stated he had not yet interviewed the CNAs who were on duty the evening of 3/18/17. He stated CNA C and CNA E did not work Sunday (3/19/17) or Monday (3/20/17). He stated CNA D did work on Sunday (3/19/17) but was still in orientation. The BOM stated the action plan was only female CNAs would be assigned to work with Resident 1. The Administrator stated he had not suspended any staff from providing care to other residents pending completion of the investigation because he did not feel any staff were a threat and stated the police had indicated the allegation was not substantiated. The BOM confirmed he had not yet completed his investigation or completed interviews of staff who were on duty the night of the alleged event. During an interview and concurrent record review on 3/21/17 at 12:25 p.m., the Acting Director of Nurses (DON) provided Resident 1's care plan dated 3/21/17 which documented Resident 1 was resistive to care related to anxiety and Resident 1 would yell at staff and make accusations of sexual abuse when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 4 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resisting care. Interventions included only female caregivers with a partner. The Acting DON stated they had conducted an inservice to staff on 3/20/17 related to providing female only caregivers to Resident 1, but a care plan had not been developed until 3/21/17 related to Resident 1's history of making false allegations or the interventions implemented related to allegation of sexual abuse. During an observation on 3/21/17 at 12:30 p.m., Resident 1 was observed in the dining room. Resident 1 propelled herself out of the dining room and announced to staff that she could not wait to go to court for, "what they did." When staff asked Resident what she was referring to, Resident 1 announced she was raped and stated "he is in there now" referring to the dining room. During an interview on 3/21/17 at 1:05 p.m., the BOM stated the staff member identified by Resident 1 in the dining room was CNA C who had just returned to work that day after being off. The BOM stated he had not yet had a chance to interview CNA C prior to starting his shift that day. During a follow up interview at 1:25 p.m., the BOM stated he had just suspended CNA C and CNA C, D and E would be removed from the schedule until completion of the investigation. During an interview, on 3/21/17 at 1:30 p.m., Licensed Staff A stated on the afternoon of 3/19/17, Resident 1 reported to her that four men had raped her the previous night. Licensed Staff A stated she asked the resident for details and the resident stated they "played" with her one after another and then went away. Licensed Staff A stated she asked the resident if she was "ok" and the resident stated no, "four men raped me." Licensed Staff A stated Resident 1 did not provide any descriptions of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 5 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the alleged individuals. Licensed Staff A stated she asked Resident 1 if she had any pain or problem urinating to which the resident denied. Licensed Staff A stated she asked the CNAs if they noticed any bruising on the resident when they changed her. Licensed Staff A stated she did not physically assess or examine the resident herself because the resident was in a chair. She stated if the resident was in bed she may have looked at her if she changed her. Licensed Staff A stated Resident 1 had an increase in her paranoia that day and stated that was a change. Licensed Staff A stated she did not notify the physician of the resident's allegation of rape, nor of her noted changed condition on 3/19/17. She stated the resident's physician came in the next morning and she informed the physician at that time. When asked how she protected the resident and other residents pending completion of the investigation, she stated she instituted female only caregivers for Resident 1. Licensed Staff A stated she documented "something" and passed it on to the oncoming nurse. Concurrent review of a Nursing note, dated 3/19/17 at 3:27 p.m., Licensed Staff A documented Resident 1 was "paranoid, thinks that four men raped her last night." Licensed Staff A documented Resident 1 continued with foul language towards staff and other residents and was not easy to redirect. The resident denied pain when asked and had no reports of discomfort with urination. There was no documentation of notification to the Administrator or abuse coordinator, no notification to the physician and no documentation of complete evaluation of the resident or immediate interventions to protect the resident or other residents during the investigation. Licensed Staff A confirmed that was the only nursing note she wrote that day regarding the incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 6 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Staff A was asked how she ensured staff instituted female only caregivers. She stated she left a poster visible to all at the nursing station and spoke to the CNAs. Licensed Staff A stated she did not document or develop a care plan related to the incident or immediate interventions. Licensed Nurse A stated the facility policy related to allegations of abuse or rape included to notify the Administrator and notify the physician. Licensed Nurse A stated the BOM happened to call her that afternoon of 3/19/17 about another issue and that was when she let him know about Resident 1's allegation as an "FYI". Licensed Staff A stated she did not document that notification and stated she should have. During a telephone interview on 4/3/17 at 10 a.m., CNA F stated she worked on the p.m. shift on 3/18/17 but was not assigned to care for Resident 1. CNA F stated during the early evening (of 3/18/17) CNA E, who was Resident 1's assigned CNA, asked her to assist him with Resident 1's request to go back to bed. CNA F stated Resident 1 began to make racist and vulgar comments to her and the other CNAs in the room (CNA D and CNA E). CNA F stated Resident 1 started calling out that staff were raping her and kept yelling "rape, rape." CNA F stated she just quickly put an incontinent brief on the resident. She stated she had never seen her so upset before and stated another female, CNA G, came into the room later to try to calm Resident 1 down. She stated they decided to just leave the Resident alone and give her some time. CNA F was asked if she or other staff reported the resident's allegation of rape to licensed staff. CNA F stated she informed Licensed Staff B after they got out of the room. CNA F stated she told Licensed Staff B that when they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 7 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tried to change the resident the resident accused them of raping her. CNA F stated Licensed Staff B stated to just leave the resident alone and only female staff should go in there. CNA F stated Resident 1 had a history of making things up and she did not believe anything she said. During an interview on 4/3/17 at 12 p.m., Licensed Staff B stated she worked the p.m. shift on 3/18/17. Licensed Staff B stated around 7:30 p.m. that night, a CNA informed her Resident 1 agreed to go to bed. She stated two male CNAs (CNA E and CNA D) and one female, CNA F, went in Resident 1's room to assist her to bed. Licensed Staff B stated she did not hear anything the whole time they were in the room. Licensed Staff B stated CNA F came out later and told her Resident 1 had called the two male CNAs racially inappropriate statements and made vulgar comments to CNA F. Licensed Staff B stated she was fairly new to working with Resident 1 but stated her behavior was not new and was not a change from her normal behavior. She stated Resident 1 had a history of yelling at staff and confabulation (making up stories) and stated it was not a change from her normal state. Licensed Staff B stated after the CNAs had left Resident 1's room and were helping other residents, she went in to check on Resident 1 who swore at her and told her to get out of the room. Licensed Staff B stated Resident 1 did not report any allegation of rape to her at that time. Licensed Staff B stated no CNAs reported that Resident 1 had made any allegations of rape. Licensed Staff B stated if she had been told that, she would have immediately notified the BOM, who was the facility's abuse coordinator, initiated female only staff and would have had the involved staff clock out during the investigation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 8 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 4/3/17 at 2:50 p.m., CNA C stated he worked as a "float" (no specific assigned resident) on 3/18/17 and worked a 12 hour shift that day until after 7 p.m. CNA C stated he did not usually work in the hall where Resident 1 lived but he did that day due to his float status. CNA C stated he was next door to Resident 1's room and he could hear a bunch of commotion. When he went outside the door of Resident 1's room he could hear her yelling "they're raping me" repeatedly. When he went into the room, CNA F, CNA D and CNA E were trying to assist the resident into bed. CNA C stated Resident 1 sometimes kicked and bites at staff. CNA C stated he did not assist in changing Resident 1's brief, but stated he may have assisted to strap one side of a velcro strap to her brief. CNA C stated Resident 1 told him he had touched her private part, that it was rape and she would see him in court. CNA C stated he "brushed it off" and went next door to assist another resident. CNA C stated he did not report the resident's allegations and stated he now realized he should have reported it to licensed staff. He stated Resident 1 was often combative and made things up. He stated since he was the float CNA, he assumed someone else would report it. CNA C stated he had no knowledge if any other staff reported the allegation to licensed staff or administration. CNA C stated he frequently worked in the dining room at lunch time with Resident 1 and she often referred to him as [X] and "as the guy who serves food in the dining room." CNA C stated other staff have often heard Resident 1 refer to him that way. Review of the policy and procedure, Abuse Prevention, revised 11/28/16 documented under the sections: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 9 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Prevention: Staff had knowledge of the individual residents care need. Assess, care plan and monitor residents with history of aggressive behaviors, communication disorders. Identification: All identified events were reported to the Administrator / Designee immediately and would be thoroughly investigated. When an incident or allegation of resident abuse was identified, the Administrator would initiate an investigation. A licensed nurse shall immediately examine the resident upon receiving reports of alleged physical or sexual abuse. The findings of the examination shall be recorded in the resident's medical record. The investigation shall consist of an interview with the person reporting the incident; an interview with the resident; interviews with any witness to the incident, including the alleged perpetrator as appropriate; a review of the resident's medical record; an interview with staff members (on all shifts) having contact with the accused employee and a review of all circumstances surround the incident. Protection: If a resident incident was reported, the facility would take the following steps to prevent further potential abuse while the investigation was in progress: If the suspected perpetrator was an employee: Remove employee immediately from the care of any resident; Suspend employee during the investigation. The policy did not identify specific interventions related to allegations of sexual abuse / rape in regards to guidelines for reporting to law enforcement, physician notification or procedures in event forensic exam (collect and secure evidence for criminal investigation) was indicated in coordination with the resident or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 10 of 11 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055756 (X3) DATE SURVEY COMPLETED 05/03/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CLOVERDALE HEALTHCARE CENTER 300 Cherry Creek Rd Cloverdale, CA 95425 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE responsible party, the resident's physician and / or law enforcement. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0L1T11 Facility ID: CA010000037 If continuation sheet 11 of 11