Health inspection·December 19, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm 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 lungs can't get enough oxygen into the blood), and Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease that makes it hard to breathe due to inflamed, narrow airways and damaged air sacs called alveoli).A review of Resident 66's physician order summary report, dated 12/18/25, indicated there was no documented evidence that Resident 66 had an order for continuous oxygen therapy.A review of Resident 66's care plan, dated 12/12/25 to 12/17/25, did not include a care plan specifically for oxygen therapy.A review of Resident 66's Medication Administration Record (MAR), dated 12/1/2025 to 12/31/25, indicated there was no documented evidence for administration of oxygen therapy.During an observation and concurrent interview on 12/18/25 at 12 p.m., Resident 66 was wearing a NC and her oxygen concentrator was set at 2 liters (L, a unit of measurement) of oxygen. Resident 66 stated she always had to wear her oxygen because of her respiratory problems. During a concurrent interview and record review on 12/18/25 at 12:20 p.m., with Licensed Nurse 2 (LN 2), Resident 66's Physician order summary, dated 12/18/25, were reviewed. LN 2 stated Resident 66 was on 2 L of continuous oxygen. During a review of Resident 66's physician orders, LN 2 confirmed there was no order for Resident 66's oxygen therapy.During a review of the facility policy and procedure titled, Physician Orders, Revised 02/2025, indicated, It is the policy of this facility that drugs or biological shall be administered only upon written order of a person duly licensed and authorized to prescribe such drugs.Orders for mediations must include.Name and strength of the drug.Quantity or specific duration of therapy.Dosage and frequency of administration.During a review of the facility policy and procedure titled, Oxygen Therapy, revised 11/2007, indicated, Plan of Care: the resident's plan of care should be addressed.That oxygen is to be administered.When and how often oxygen is to be administered.The type of oxygen device to use.Any special procedures or treatment to be administered.2. During an observation on 12/18/25 at 8:57 a.m., Licensed Nurse (LN) 1 administered Insulin Lispro 10 units (measurement for insulin) injection on the left upper outer arm of Resident 48. LN 1 asked Resident 48 if she had eaten her breakfast and Resident 48 nodded and confirmed she did.A review of Resident 48's physician order summary, for 11/2025, indicated the resident was ordered, Insulin Lispro Injection Solution . Inject 10 unit subcutaneously before meals .During an interview on 12/18/25 at 10:48 a.m. LN 1 confirmed Resident 48 had already finished eating breakfast when she administered the Lispro insulin injection. LN 1 confirmed the physician ordered the insulin Lispro to be administered to Resident 48 before meals.During a concurrent interview and record review on 12/18/25 at 1:19 p.m., with the Director of Nursing (DON) the facility's policy titled, General dose preparation and medication administration, last revised 11/15/24, was reviewed. The DON acknowledged the policy indicated, .medication should be administered within timeframes specified by facility policy or manufacturer's information. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055756 If continuation sheet Page 2 of 4 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 12/19/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. 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 remaining (one missing/unaccounted for). The controlled substance count sheet of Resident 66's Oxycodone (an opioid medication used to treat pain) 5mg tablet indicated 16 tablets. LN 2 showed Resident 66's Oxycodone 5mg tablet package had 15 tablets remaining (one missing/unaccounted for). The controlled substance count sheet of Resident 32's Tramadol 50mg tablet indicated 9 tablets should be remaining. LN 2 showed Resident Tramadol 50mg tablet package showed 8 tablets remaining (one missing/unaccounted for).During the interview on 12/18/25 at 1:56 PM, LN 2 stated the danger of not accounting and reconciling controlled medication could lead to administration of extra doses and overdose.During an concurrent interview and record review on 12/18/25 at 1:46 p.m. with the Director of Nursing (DON), the facility policy titled Inventory Control of controlled substances, last revised 8/1/24, was reviewed. The DON acknowledged the facility policy indicated, the facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled substance verification/shift count sheet to the medication administration record. Event ID: Facility ID: 055756 If continuation sheet Page 3 of 4 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 12/19/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **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 (CADDsspecialized 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 unidentified pills were left scattered in the top drawer of the South medication cart.These failures can lead to use of medication and supplies with reduced effectiveness or with compromised packaging which can further threaten the frail condition of the residents in the facility.Findings:1. During an observation on [DATE] at 9:13 AM, with Licensed Nurse 1 (LN 1), during an inspection of the medication room, LN 1 confirmed the presence of the following items stored with other ready to use supplies: 19 dressing change kits which have expired on the following dates: three expired on [DATE], two expired on [DATE], one expired on [DATE], five expired on [DATE], and eight expired on [DATE]. One safety infusion-set which expired on [DATE] One continue-Flo solution set which expired on [DATE] Three 10 ml syringes which expired on [DATE] 19 CADD administration-sets which expired April and [DATE], and five expired in 2024.During a concurrent interview and record review on [DATE] at 10:14 a.m., with the Infection Preventionist (IP) Resource, the facility's policy titled, Equipment and supplies, revised 11/2019, was reviewed. The IP Resource stated she was aware of the presence of expired supplies in the medication room and that the facility's policy indicated that expired supplies needed to be removed from storage. The IP Resource stated the facility should ensure that expired supplies are not available for resident use, to ensure the best level of patient care. 2. During an observation on [DATE] at 8:47 AM at the North Hall, LN 2 confirmed the presence of an Aspirin bottle with illegible expiration date in the medication cart.During an observation on [DATE] at 8:57 AM at the South Hall, LN 3 confirmed the presence of an Aspirin bottle with illegible expiration date in the medication cart.During an interview on [DATE] at 10:50 AM, the Director of Nursing (DON) acknowledged the Aspirin bottles found in the medication carts had illegible expiration dates.3. During an inspection of the medication cart at the South Hall on [DATE] at 11:51 AM, A white plastic bottle of allergy relief medication (Loratadine) 10 mg tablets had expired on 10/2025.4. During an inspection of the medication cart at the South Hall on [DATE] at 11:51 AM, LN 3 confirmed the presence of 15 loose pills of various sizes and colors littered the top drawer of the cart.During a concurrent interview and record review on [DATE] at 1:19 p.m. with the Director of Nursing (DON) the facility policy titled, Storage and expiration dating of medication, biologicals, syringes and needles was reviewed. The DON acknowledged the policy indicated, the facility should ensure medications and biologicals that have an expired date on the label are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The DON confirmed the policy also indicated that the facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions. Event ID: Facility ID: 055756 If continuation sheet Page 4 of 4