Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cloverdale Healthcare Center during CMS and state inspections, most recent first.
Controlled Substance Count Discrepancies: The facility failed to accurately reconcile controlled medication counts for three residents. During a medication cart observation, an LPN confirmed one-tablet discrepancies for a resident’s Tramadol, another resident’s Oxycodone, and a third resident’s Tramadol, with the count sheets showing more tablets remaining than were actually in the packages. The DON reviewed the facility policy requiring routine reconciliation of doses remaining against the shift count sheet and MAR.
Expired sterile supplies were found stored with ready-to-use items in the medication room, including dressing change kits, infusion tubing, syringes, and CADD administration sets. Surveyors also found two bottles of Aspirin with illegible expiration dates in medication carts, an expired loratadine bottle in the South hall cart, and 15 loose unidentified pills scattered in a cart drawer; LN, IP, and DON all acknowledged the findings.
Failure to Notify Ombudsman of Resident Transfer: A resident with a L AKA was sent to the hospital after the facility physician noted the stump appeared infected with a foul smell. The SSD stated the copy of the discharge notification had not yet been faxed to the Ombudsman, despite the facility policy requiring timely written notice for involuntary transfers and emergency transfers as soon as practicable.
A resident with respiratory failure, hypoxia, and COPD was observed on 2 L O2 via NC even though there was no documented order for continuous oxygen therapy, no oxygen care plan, and no MAR documentation for oxygen. In a separate event, an LPN administered insulin lispro after breakfast even though the order was for the insulin to be given before meals.
A resident with cognitive deficits fell while trying to get out of bed, resulting in abrasions and severe shoulder pain. The facility failed to notify the resident's Responsible Party (RP) about the fall, as required by policy. The DON confirmed that the licensed nurse did not complete the necessary documentation or notify the RP.
The facility failed to meet the minimum square footage requirements for resident rooms, with 14 rooms providing only 76.95 sq ft per resident instead of the required 80 sq ft. The DON was unaware of the exact requirements, and the OM confirmed the lack of a room size policy, despite understanding the standards.
Controlled Substance Count Discrepancies
Penalty
Summary
The facility failed to ensure that controlled drug records were documented in sufficient detail to allow accurate reconciliation when count discrepancies were found for three sampled residents. During a concurrent observation and interview in the North Hall medication cart, LN 2 confirmed discrepancies involving Resident 23’s Tramadol 50 mg tablets, Resident 66’s Oxycodone 5 mg tablets, and Resident 32’s Tramadol 50 mg tablets. For each resident, the controlled substance count sheet showed one more tablet remaining than was actually present in the medication package. Resident 23’s Tramadol count sheet indicated 18 tablets remaining, but the package contained 17 tablets. Resident 66’s Oxycodone count sheet indicated 16 tablets, but the package contained 15 tablets. Resident 32’s Tramadol count sheet indicated 9 tablets, but the package contained 8 tablets. During interview, LN 2 stated that not accounting for and reconciling controlled medication could lead to administration of extra doses and overdose. The DON reviewed the facility policy titled Inventory Control of controlled substances, which stated that 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 and the MAR.
Expired and Unlabeled Medications and Supplies Found in Storage
Penalty
Summary
Medication and supply storage practices were found to be out of compliance when surveyors observed expired sterile supplies kept with ready-to-use items in the medication room. During the observation, LN 1 confirmed the presence of 19 expired dressing change kits, one expired safety infusion set, one expired continue-Flo solution set, three expired 10 mL syringes, and 19 expired CADD administration-sets, including items that had expired on multiple dates in prior years and in 2024. The Infection Preventionist Resource reviewed the facility policy on equipment and supplies and acknowledged that expired supplies were present in storage and should have been removed. Surveyors also found medication storage issues in the medication carts. LN 2 and LN 3 confirmed two bottles of Aspirin with illegible expiration dates in the North and South hall carts, and the DON acknowledged the illegible dates. In the South hall medication cart, surveyors observed an expired bottle of loratadine 10 mg tablets and 15 loose unidentified pills scattered in the top drawer. The DON reviewed the facility policy on storage and expiration dating of medications, biologicals, syringes, and needles and acknowledged that medications with expired, soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels should be destroyed or returned to the pharmacy or supplier.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide the Office of the State Long Term Care Ombudsman with a copy of the Notification of Discharge for one of three sampled closed records, Resident 61, when the resident was transferred to the hospital. Resident 61 was admitted to the facility in 11/2025 with a diagnosis of above-the-knee amputation of the left leg. Nursing progress notes dated 12/3/25 at 9:45 AM documented that the Facility Physician saw Resident 61, determined the resident's leg amputation stump looked infected on the underside with a foul smell, and ordered the resident to be sent to the hospital. A facility-to-hospital transfer form showed Resident 61 was transferred to the acute hospital on [DATE]. During an interview on 12/18/2025 at 3:52 PM, the Social Services Director stated she had not yet faxed the copy of the notification of discharge to the Office of the State Long-Term Care Ombudsman because she had been busy. The facility's undated policy titled Notice to Long-Term Care Ombudsman stated the facility shall provide a timely written notice of all involuntary transfers and discharges to the Long-Term Care Ombudsman, and that for an emergency transfer or discharge, notification should be made as soon as practicable following the transfer.
Missing oxygen order and late insulin administration
Penalty
Summary
The facility failed to ensure services met professional standards of quality for Resident 66 when there was no documented physician order for continuous oxygen therapy at 2 L via nasal cannula. Resident 66’s face sheet listed diagnoses including acute and chronic respiratory failure with hypoxia and COPD. The physician order summary dated 12/18/25 showed no order for oxygen therapy, the care plan did not include a specific oxygen therapy plan, and the MAR did not document oxygen administration. During observation, Resident 66 was wearing a nasal cannula with the oxygen concentrator set at 2 liters, and the resident stated she always had to wear oxygen because of respiratory problems. LN 2 later confirmed the resident was on 2 L of continuous oxygen but acknowledged there was no order for the oxygen therapy. Facility policy required written orders for medications and oxygen therapy to include the resident’s plan of care, when and how often oxygen is to be administered, and the type of device to use. The facility also failed to follow the ordered timing for insulin administration for Resident 48. The physician order summary directed insulin lispro 10 units subcutaneously before meals, but during observation LN 1 administered the insulin after breakfast had already been eaten. LN 1 confirmed the resident had finished breakfast before the injection was given and acknowledged the order was for insulin lispro to be administered before meals. The DON reviewed the facility’s medication administration policy, which stated medication should be administered within the timeframes specified by facility policy or manufacturer information.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the Responsible Party (RP) of a resident's fall, which resulted in the RP being unaware of the resident's pain stemming from the incident. The resident, who was admitted to the facility with diagnoses including cerebral infarction due to embolism and cognitive communication deficit, fell while attempting to get out of bed. This fall caused an abrasion to the resident's forehead, right side, and shoulder, and the resident reported severe pain in the shoulder. Although the Director of Nursing (DON) and the physician were contacted, the nursing staff did not inform the RP about the fall, as required by the facility's policy. The facility's policy on Change of Condition Reporting mandates that the RP be notified of any acute medical changes and that all nursing actions be documented in the progress notes. However, a review of the resident's progress notes revealed that the licensed nurse did not complete the required SBAR Communication Form, and there was no documentation indicating that the RP was notified of the fall. The DON confirmed that the licensed nurse was expected to notify the RP and document the notification, which did not occur in this instance.
Deficiency in Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms met the minimum square footage requirements, as observed in 14 out of 22 resident rooms. The Client Accommodations Analysis, dated January 8, 2025, revealed that these rooms, which were approved for four beds each, measured only 307.8 square feet in total, providing just 76.95 square feet per resident. This measurement falls short of the required 80 square feet per resident for multiple occupancy rooms. The Maintenance Supervisor confirmed these dimensions during a measurement on the same date. Interviews with facility staff highlighted a lack of awareness and policy regarding room size requirements. The Director of Nursing was unaware of the exact minimum square footage requirement, although she expected rooms to have sufficient space for residents' belongings, care, and mobility. The Operations Manager acknowledged the absence of a room size policy but confirmed the requirement for private rooms to measure 100 square feet and multiple occupancy rooms to provide 80 square feet per resident. Despite this understanding, the facility had 14 rooms that did not meet these standards, each housing four beds with insufficient space per resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cloverdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healdsburg Hospital D/p Snf | 14.4 mi | ★★★★★ | 11 | 0 |
| Lakeport Post Acute | 17.4 mi | ★★★★★ | 1 | 0 |
| Rocky Point Care Center | 18.6 mi | ★★★★★ | 14 | 0 |
| Meadowood Nursing Center | 23.8 mi | ★★★★★ | 29 | 0 |
| Ukiah Post Acute | 25.3 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cloverdale Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.