Deficiencies (last 2 years)
Deficiencies (over 2 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
275% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 19, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide required discharge notification to the State Long-Term Care Ombudsman, failure to ensure professional standards of care including oxygen therapy orders and medication administration, discrepancies in controlled drug records, and improper storage of medications and supplies.
Complaint Details
The visit was complaint-related, investigating failures in discharge notification, professional care standards, medication record accuracy, and medication storage. The deficiencies were substantiated with evidence from interviews, observations, and record reviews.
Findings
The facility failed to provide timely discharge notification to the Ombudsman for a resident transferred to hospital. It also failed to ensure proper physician orders for oxygen therapy and correct timing of insulin administration. Controlled drug counts showed discrepancies for three residents. Additionally, expired and improperly stored medications and supplies were found in the medication rooms and carts.
Deficiencies (4)
F 0628: The facility failed to provide the Office of the State Long-Term Care Ombudsman a copy of the notification of discharge for a resident transferred to the hospital, risking inappropriate discharge and lack of advocacy.
F 0658: The facility failed to ensure professional standards of care by not having a physician order for continuous oxygen therapy for one resident and administering insulin after a meal instead of before for another resident.
F 0755: The facility failed to maintain accurate controlled drug records, with discrepancies found in medication counts for three residents, risking medication errors or diversion.
F 0761: The facility failed to ensure medications and supplies were stored properly, with multiple expired dressing kits, syringes, and medications found, including illegible expiration dates and loose pills in medication carts.
Report Facts
Residents sampled: 19
Controlled drug discrepancies: 3
Expired dressing change kits: 19
Insulin dose: 10
Oxygen therapy setting: 2
Loose pills: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding failure to fax discharge notification to Ombudsman | |
| Licensed Nurse 1 | Observed administering insulin after meal to Resident 48 | |
| Licensed Nurse 2 | Confirmed no physician order for oxygen therapy and controlled drug discrepancies | |
| Director of Nursing | Interviewed regarding medication administration policies and controlled substance reconciliation | |
| Infection Preventionist Resource | Interviewed regarding expired supplies in medication room |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Dec 19, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including documentation, medication administration, pharmaceutical services, and storage of drugs and supplies.
Findings
The facility was found deficient in multiple areas including failure to notify the State Long-Term Care Ombudsman of a resident's discharge, lack of physician orders for oxygen therapy, improper timing of insulin administration, discrepancies in controlled drug counts, and storage of expired medications and supplies. These deficiencies posed potential risks to resident safety and care quality.
Deficiencies (8)
Failed to provide the Office of the State Long-Term Care Ombudsman a copy of the Notification of discharge for Resident 61 when transferred to hospital.
No physician order for Resident 66's continuous oxygen therapy at 2 Liters-Per-Minute via nasal cannula.
Resident 48 was administered insulin Lispro after breakfast instead of before meals as ordered.
Controlled drug count discrepancies found for Residents 23, 66, and 32 with one tablet missing/unaccounted for each.
Expired medication and supplies stored with ready-to-use supplies including dressing change kits, infusion sets, syringes, and continuous ambulatory delivery device administration sets.
Two bottles of Aspirin with illegible expiration dates found in medication carts.
Expired allergy relief medication found in medication cart.
Fifteen loose unidentified pills found scattered in medication cart drawer.
Report Facts
Residents sampled: 19
Insulin Lispro dose: 10
Oxygen therapy rate: 2
Controlled drug discrepancies: 3
Expired dressing change kits: 19
Loose unidentified pills: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Administered insulin Lispro to Resident 48 after breakfast | |
| Licensed Nurse 2 | Confirmed no physician order for Resident 66's oxygen therapy and identified controlled drug discrepancies | |
| Director of Nursing | Director of Nursing | Acknowledged facility policies and deficiencies related to medication administration and storage |
| Social Services Director | Social Services Director | Interviewed regarding failure to notify Ombudsman of Resident 61's discharge |
| Licensed Nurse 3 | Confirmed presence of expired medications and loose pills in medication carts | |
| Infection Preventionist Resource | Infection Preventionist | Acknowledged presence of expired supplies and reviewed facility policy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's Responsible Party (RP) after a fall incident.
Complaint Details
The complaint investigation found the facility did not notify Resident 1's Responsible Party of the fall, and the licensed nurse failed to complete the required SBAR communication form. The deficiency was substantiated based on interviews and record reviews.
Findings
The facility failed to notify the Responsible Party of Resident 1's fall, resulting in the RP not knowing the resident's pain was due to the fall. The Director of Nursing confirmed the licensed nurse did not complete required communication and documentation following the fall.
Deficiencies (1)
F 0580: The facility failed to notify a Responsible Party for one resident after a fall, resulting in the RP not being informed of the resident's pain related to the fall.
Inspection Report
Deficiencies: 1
Date: Mar 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to notification of a resident's Responsible Party following a fall incident.
Findings
The facility failed to notify the Responsible Party of Resident 1's fall, resulting in the Responsible Party not being aware of the resident's pain caused by the fall. The Director of Nursing confirmed the licensed nurse did not complete required communication and documentation regarding the incident.
Deficiencies (1)
Failure to notify the Responsible Party of Resident 1's fall and pain resulting from the fall.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Verified licensed nurse did not complete required communication and documentation for Resident 1's fall. |
Inspection Report
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The inspection was conducted to assess compliance with room size requirements for residents in the facility.
Findings
The facility failed to ensure that residents' rooms measured at least 80 square feet per resident in 14 of 22 resident rooms. Measurements showed rooms with four beds each had only 76.95 square feet per resident, below the minimum requirement.
Deficiencies (1)
F 0912: The facility failed to provide rooms that are at least 80 square feet per resident in multiple rooms. Four-bed rooms measured only 76.95 square feet per resident, which is below the required minimum.
Report Facts
Rooms with deficient square footage: 14
Total resident rooms: 22
Room size per resident: 76.95
Approved capacity per room: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding room size requirements and expectations | |
| Operations Manager | Interviewed regarding room size policy and facility room capacities | |
| Maintenance Supervisor | Conducted room measurements confirming deficient room sizes |
Inspection Report
Deficiencies: 1
Date: Jan 9, 2025
Visit Reason
The inspection was conducted to assess compliance with room size requirements for residents, specifically to verify that rooms measured at least 80 square feet per resident in multiple occupancy rooms and 100 square feet for single resident rooms.
Findings
The facility failed to ensure that 14 of 22 resident rooms met the minimum room size requirement of 80 square feet per resident in multiple occupancy rooms. Measurements showed each resident in these rooms had only 76.95 square feet of space, which is below the required minimum.
Deficiencies (1)
Rooms measured 76.95 square feet per resident, below the required 80 square feet per resident in multiple occupancy rooms.
Report Facts
Rooms with deficient size: 14
Total resident rooms: 22
Approved capacity per room: 4
Measured square footage per room: 307.8
Square footage per resident: 76.95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding room size requirements and expectations. |
| Operations Manager | Operations Manager | Interviewed regarding facility room size policy and confirmation of deficient rooms. |
| Maintenance Supervisor | Maintenance Supervisor | Measured room dimensions confirming deficient square footage per resident. |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 21, 2022
Visit Reason
Routine inspection survey conducted to evaluate compliance with professional standards of quality, safety, medication management, food and nutrition services, and environmental safety at Cloverdale Healthcare Center.
Findings
The facility had multiple deficiencies including failure to ensure proper nutritional assessments and communication with the Registered Dietitian, unsafe environmental conditions due to a tripping hazard in the parking lot, medication management issues including improper labeling and disposal of controlled substances, failure to follow food safety and preparation standards, and inadequate staff training on sanitation procedures.
Deficiencies (7)
F 0658: The facility failed to follow professional standards for one resident by not formalizing nursing communication with the Registered Dietitian for pressure or diabetic ulcer assessments, resulting in a missed nutritional assessment.
F 0689: The facility failed to maintain a safe environment by not timely repairing a known tripping hazard in the parking lot, causing a visitor to fall and posing fall risks to residents.
F 0755: The facility failed to provide pharmaceutical services meeting resident needs by not identifying medication administration risks for one resident and failing to reconcile inventory of fentanyl patches, risking medication diversion.
F 0761: The facility failed to ensure all medications were properly labeled and stored, finding unlabeled medications and opened liquid medications without documented open dates, risking administration errors and ineffective treatment.
F 0802: One diet aide was unable to properly test the chemical strength of the sanitation bucket, risking ineffective sanitization of food service equipment.
F 0805: The facility failed to puree two food items per recipe, resulting in one puree item not holding its shape and another tasting grainy.
F 0812: The facility failed to follow food safety requirements by storing flour in the original bag inside a plastic tub, a cook not wearing a beard cover, expired nutritional supplements in a resident refrigerator, and an employee lunch bag and unlabeled water pitcher in the nursing unit refrigerator/freezer.
Report Facts
Residents with ambulation goals: 14
Residents affected by tripping hazard: 15
Expired nutritional supplements: 15
Medication administration errors: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse M | Licensed Nurse | Named in medication administration and disposal process for fentanyl patches. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication management and resident ambulation. |
| Director of Food Services | Director of Food Services | Interviewed regarding food preparation, sanitation, and hair covering policies. |
| Physical Therapy Assistant C | Physical Therapy Assistant | Interviewed regarding resident ambulation and awareness of tripping hazards. |
| Diet Aide H | Diet Aide | Observed and interviewed regarding sanitation bucket chemical testing. |
| Facility Pharmacist | Pharmacist | Reviewed medication regimen and policies related to controlled substances. |
| Director of Plant Management | Director of Plant Management | Interviewed regarding repair of parking lot tripping hazard. |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 21, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, safety, medication management, food and nutrition services, and environmental safety in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to follow professional standards for nutritional assessments, unsafe environmental conditions due to a tripping hazard in the parking lot, medication management errors including improper labeling and disposal of controlled substances, failure to properly prepare pureed foods, and food safety violations such as improper storage and expired nutritional supplements.
Deficiencies (7)
Failure to follow professional standards for nursing communication with the Registered Dietitian (RD) regarding residents with pressure or diabetic ulcers, resulting in missed nutritional assessments.
Unsafe environment due to a known tripping hazard in the parking lot that was not repaired timely, causing a visitor to trip and fall.
Failure to provide pharmaceutical services meeting resident needs, including medication administration errors and lack of proper reconciliation of fentanyl patches.
Failure to label and properly store medications, including unlabeled vials and expired liquid medications without open dates.
Dietary staff failure to properly test chemical strength of sanitation buckets, risking ineffective sanitization.
Failure to puree food items according to recipe standards, resulting in poor texture and taste of pureed meatballs and eggs.
Failure to follow food safety requirements including improper storage of flour, lack of beard cover for cook, expired nutritional supplements in resident refrigerators, and presence of employee lunch bag and unlabeled water pitcher in resident refrigerator.
Report Facts
Residents with ambulation goals: 14
Expired nutritional supplements: 15
Tripping hazard depth: 3
Hydromorphone dosage: 4
Hydromorphone dosage: 6
Protein needed for wound healing: 75
Resident 41 average meal intake: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse M | Licensed Nurse | Described medication administration and disposal process for fentanyl patches. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication disposition and awareness of resident ambulation. |
| Director of Food Services | Director of Food Services (DFS) | Interviewed regarding dietary sanitation and food preparation practices. |
| Physical Therapy Assistant C | Physical Therapy Assistant | Described ambulation goals and walking locations for residents. |
| Diet Aide H | Dietary Aide | Observed and interviewed regarding sanitation bucket chemical testing. |
| Licensed Staff O | Licensed Nurse | Interviewed regarding administration of Hydromorphone medication. |
| Pharmacist Consultant | Pharmacist Consultant (PC) | Interviewed regarding fentanyl patch disposal policy and medication review. |
| Director A | Director of Plant Management | Interviewed regarding repair of tripping hazard in parking lot. |
| Activity Director | Activity Director | Interviewed regarding resident walking activities. |
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