Cloverdale Healthcare Center

In the surveyor’s words

From the most serious findings on record at Cloverdale Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF755Dec 19, 2025

  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. […]

• No harm, potential for more than minimal, patternF761Dec 19, 2025

  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… […]

• No harm, potential for more than minimal, patternF689Oct 21, 2022

  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… […]

• No harm, potential for more than minimal, patternF755Oct 21, 2022

  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, [MEDICATION(S)] ([MEDICATION(S)] is used as a pain reliever. [MEDICATION(S)] is two to eight times more potent than [MEDICATION(S)] 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. […]

• No harm, potential for more than minimal, patternF761Oct 21, 2022

  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. […]