Cloverdale Healthcare Center

Based on observation, interview and record review, the facility failed to ensure that controlled drug (medications that the use and possession of are controlled by the federal government) records were documented in sufficient detail to enable accurate reconciliation for three out of 19 sampled residents when count discrepancies were found for Resident 23, Resident 66, and Resident 32 controlled drugs. This failure has the potential to cause medication errors or diversion of controlled medication.Findings:During a concurrent observation and interview on 12/18/2025 at 11:31 a.m. during and inspection of a medication cart at the North Hall, Licensed Nurse (LN) 2 confirmed the following discrepancies in controlled medications (drugs regulated by the government due to their potential for abuse, misuse, or dependence): The controlled substance count sheet of Resident 23's Tramadol (a synthetic opioid medication used to treat pain) 50 milligram (mg- unit of measure) tablet indicated 18 tablets should be remaining. LN 2 showed Resident 23's Tramadol 50 mg tablet package had 17 tablets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and records review, the facility failed to ensure medication and supplies were stored in accordance with professional principles for all residents of the facility when:1. 19 dressing change sets (sterile kits containing supplies to change wound dressings), one safety infusion set (sterile medical device used for administering fluids, drugs or drawing blood), one continue-Flo solution set (sterile tubing used for administering fluids and medications into a vein), three 10 ml syringes (medical device used to inject and withdraw fluids from the body), and 19 continuous ambulatory delivery device administration-sets (CADDs- specialized tubing used to deliver fluids and medications at controlled rates) were expired but kept with ready to use supplies in the medication room.2. Two bottles of Aspirin with illegible expiration dates were kept in medication carts.3. An expired allergy relief medication in a plastic container was kept in the South medication cart; and4. 15 loose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and records review, the facility failed to provide the Office of the State Long term Care Ombudsman (Ombudsman- an advocate for residents of nursing homes, board and care centers, and assisted living facilities) a copy of the Notification of discharge for one of three sampled closed records (Resident 61) when Resident 61 was transferred to the hospital on [DATE]This failure can result in inappropriate and unsafe discharge and deprive Resident 61 of access to an advocate who can provide information of her options and rights. Findings:A review of Resident 61's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated she was admitted to the facility in 11/2025 with diagnosis of above the knee amputation of the left leg.A review of Resident 61's Nursing Progress Notes, dated 12/3/25 at 9:45 AM, indicated the Facility Physician saw Resident 61, determined the resident's leg amputation (stump) looked infected on the underside with a foul smell,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for two out of 19 sampled residents (Resident 66 and Resident 48) when:1. there was no order for Resident 66's continuous oxygen therapy (provides extra oxygen for peoples whose bodies cannot get enough from the air) at 2- Liters-Per-Minute (LMP, a unit of measurement) via nasal cannula (NC, a common comfortable device with two small prongs that fit into the nostrils to deliver supplemental oxygen or increased airflow for respiratory support).2. Resident 48 was administered insulin Lispro (a rapid-acting, human-made version of human insulin used to manage blood sugar levels) after breakfast.These failures had the potential to risk the health and wellbeing of the affected residents.Findings:1. A review of Resident 66's face sheet indicated admission to the facility in 12/2025 with a diagnosis that included Acute and Chronic Respiratory Failure (a condition where the lungs cannot exchange enough oxygen) with Hypoxia (low blood oxygen occurs when the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services to meet the needs of each resident when: 1. The facility pharmacist failed to identify a risk for a potential medication administration error for one resident, Resident 144. The medication label on a controlled medication, Hydromorphone (Hydromorphone is used as a pain reliever. Hydromorphone is two to eight times more potent than morphine but shorter duration and greater sedation), was not the indication for use as written by Resident 144's physician. This failure had the potential to result in ineffective pain management or overdosing that could adversely affect the health and safety of Resident 144; and, 2. The facility failed to implement a system to consistently and accurately reconcile its inventory of Fentanyl Transdermal Patches (a potent opioid pain medication that is given and absorbed through the skin), which had the potential to result in medication diversion going unnoticed for an extended amount of time. Findings: 1. During a review of Resident 144's, Order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement its medication labeling and medication storage policies and procedures, when: 1. One vial and two boxes of medication, which had no prescription labels attached to them, were found among the active supply (current prescription) of medications in the Medication Storage Refrigerator. This failure had the potential to result in administration of the wrong medication to the wrong resident; and, 2. Three liquid medications, which had been previously opened, did not have a label to indicate the date opened and/or any changes to the medication use-by date. These failures had the potential to result in administration of deteriorated medications and increased risk for ineffective treatments, resulting in residents' lower quality of life. Findings: 1. During a Medication Storage Room inspection and concurrent interview with the Infection Prevention Nurse (IP), on 10/17/22, at 10:48 a.m., the IP stated the refrigerator inside the Medication Storage Room was used to store temperature-sensitive medications. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow food safety requirements during food prep and food storage, when: 1. The facility stored flour in the bag it was delivered in, opened in a plastic tub; 2. One Cook, [NAME] E, was not wearing a beard cover for two days; 3. The North nursing unit resident refrigerator contained 15 expired Nutritional supplements; and, 4. The South nursing unit resident refrigerator contained an employee lunch bag in the freezer and an unlabeled/undated pink water pitcher. These failures put residents at risk for consuming food prepared with contaminated flour, hairs falling into resident food, risk for consuming expired nutritional supplements, which could lead to dyspepsia (Dyspepsia is another word for indigestion. People with indigestion often report feelings of stomach pain, over-fullness and bloating during and after eating. Other common symptoms include acid reflux, heartburn, and excessive burping), as well as infection control concerns. Findings: 1. During a tour of the dry storage on 10/17/22 at 10:35 AM, flour,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow professional standards of practice for one Resident (Resident 41) when: 1) there was no formalized process for nursing to communicate with the RD to provide assessments for residents who had pressure or diabetic ulcers; and, 2) there was lack of inclusion of the RD in relevant patient care committees, in accordance with the approved job description. Resident 41 had a diagnosis of Diabetes Mellitus (Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar--glucose) and a Pressure ulcer. This failure resulted in a nutritional assessment not being completed, which had the potential to contribute to the wound not healing. Findings: It is estimated that up to 50% of hospitalized patients are malnourished. Malnutrition can lead to longer hospital stays, altered immune function, and impaired skin integrity and wound healing. Malnutrition has been found to be a significant factor influencing pressure injury (PI) risk and wound healing. While PI prevention requires…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the environment was safe for residents and visitors, when a known tripping hazard, located in the parking lot, was not repaired timely. Facility staff were aware of the tripping hazard for more than two months, had purchased asphalt for its repair, and did not execute the repair until after a visitor tripped and fell. This failure: 1) Caused potential for resident falls, and subsequent injury, for one unidentified resident know to wheel himself (in a wheelchair) outside independently (without supervision), 2) Caused potential for resident falls, and subsequent injury, for eight sampled residents (Resident 25, Resident 144, Resident 29, Resident 16, Resident 8, Resident 36, Resident 28, and Resident 39) and six Unsampled residents (Resident 27, Resident 17, Resident 9, Resident 34, Resident 55, and Resident 56), known to ambulate with physical therapy staff inside and potentially outside, the building, and 3) Caused one Confidential Visitor (CV) to trip, fall and sustain injuries while walking through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, one of two sampled Diet Aides was not able to verbalize or demonstrate how to properly test the chemical strength of the sanitation bucket in the kitchen. This failure had the potential for this Diet Aide not to have the correct concentration and would potentially result in ineffective sanitization of food service equipment. Findings: During an observation and concurrent interview on 10/18/22 at 3 PM, Diet Aide H was scooping ice cream. Upon completion of the task, Diet Aide H was asked to describe how surfaces were sanitized. Diet Aide H could not verbalize or demonstrate proper test procedure. The Director of Food Services (DFS) intervened and assisted Diet Aide H to find the correct measuring strips. Diet Aide H stuck the test strip in the solution in the red bucket for 10 seconds, read the strip on the back of the bottle of test strips, which showed Test 400. During a review of the department document titled, Verification of Job Competency-Cooks, dated 9/2/22, for Diet Aide H, it showed she was able to verbalize sanitizing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to puree two food items per the recipe. This failure caused one puree item not to hold its shape and the other to taste grainy. Findings: The International Dysphagia Diet Standardization (IDDSI) Framework July 2019, provides a common terminology to describe food textures. Foods are measured from Levels 3 - 7. Level 4 Pureed Usually eaten with a spoon (a fork is possible) o Cannot be drunk from a cup because it does not flow easily o Cannot be sucked through a straw o Does not require chewing o Should be smooth and can be piped, layered or molded because it retains its shape, but should not require chewing if presented in this form o No lumps o Not sticky o Liquid must not separate from solid. Cohesive enough to hold its shape on a spoon. During a tray line observation on 10/17/22 at 11:40 AM, [NAME] E was pureeing meatballs. [NAME] E stated he could add chicken broth or beef broth if he needed to. He pureed just the meatballs with nothing added. A taste test was conducted, based on surveyor observation of pureed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.