Health inspection·March 5, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interviews and record reviews, the facility failed to notify a Responsible Party (RP, a person appointed to make healthcare decisions for a person who is unable) for one resident (Resident 1) of three sampled residents when Resident 1 fell. This failure resulted in Resident 1's RP not knowing Resident 1's pain was a result of the fall. Findings: A review of Resident 1's admission Record indicated admission to the facility in January 2025 with diagnoses which included cerebral infarction due to embolism (the lack of oxygen to the brain due to a blockage in a blood vessel from a blood clot) and cognitive communication deficit (difficulty communicating caused by brain injury). The admission record also indicated Resident 1's wife was his, Emergency Contact #1. A review of a facility document titled Facility Verification of Informed Consent dated 1/23/25, indicated, [Resident 1] .DOES NOT [check marked as option] have the capacity to understand and consent .If not, see name and phone number of resident's surrogate .[Resident 1's RP signed the document] .Date 1/23/25 .[Physician also signed the document] .Date 1/24/25 . A review of Resident 1's Progress Notes dated 2/14/25 at 1:31 a.m., indicated, COC [Change of Condition] Day 1 Fall: Resident [Resident 1] was found by a CNA [Certified Nursing Assistant] trying to get out of bed, when resident fell against the standing pole next to his bed .causing an abrasion to his forehead, right side and shoulder right side .after helping him back to bed .had a C/O [complained of] 7/10 [severe pain on a pain scale out of 10] pain to his right shoulder .DON [Director of Nursing] was contacted as well as [the Physician]. This progress note did not indicate nursing staff notified Resident 1's RP of Resident 1's fall. During a concurrent record review and interview on 3/5/25 at 4:20 p.m., the DON verified the licensed nurse did not complete a Situation, Background, Appearance, Review and Notify (SBAR) Communication Form for Resident 1's fall. The DON reviewed Resident 1's progress dated 2/14/25 at 1:31 a.m. and confirmed the progress note did not indicate Resident 1's RP was notified of the fall. The DON stated the licensed nurse was expected to have notified Resident 1's RP of the fall and have documented it. A review of a facility policy and procedure titled Change of Condition Reporting dated 2/2025 indicated, Acute Medical Change .The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken .All nursing actions will be documented in the licensed progress notes .Routine Medical Change .Document resident change of condition and (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: 055756 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 055756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cloverdale Healthcare Center 300 Cherry Creek Rd Cloverdale, CA 95425 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)