Cloverdale Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 14 (room [ROOM NUMBER], room [ROOM NUMBER]. Rooms 7 through 14, and Rooms 19 through 22) of 22 resident rooms in the facility.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.