Clovis Healthcare and Rehabilitation Center

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following:1. Facility name.2. The current date.3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:-Registered nurses.-Licensed practical nurses.-Certified nurse aides.-Resident census. This deficient practice has the potential to affect all 59 residents as identified by the census provided by the Director of Nursing on 05/15/26 and could likely result in residents and visitors not having the staffing information readily available.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) for 2 (R #1 and R #2) of 3 (R #1, R #2, and R #3) residents reviewed by not ensuring Enhanced Barrier Precaution (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) readily available. [...]

Inspectors wroteBased on observation and interviews, the facility failed to safeguard residents' Private Health Information (PHI) for 1 (R #3) of 3 (R #1, R #2, and R #3) residents reviewed for privacy and confidentiality of records when staff left clinical information on the medication cart where unauthorized people had ability to access it. If the resident's clinical information is not sufficiently safeguarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice has the potential to affect all 62 residents as identified by the census provided by the Administrator on 12/01/25 and could likely result in residents and visitors not having the staffing information readily available.

Inspectors wroteBased on observation and interview, the facility failed to ensure safe medication storage practices by not ensuring the following:1. The medication carts were locked while unattended,2. The medical supply storage rooms were kept free of expired medications,3. Personal drinking cups were not kept stored in the medication cart. These deficient practices have the potential to affect all 62 residents as identified by the census provided by the Administrator on 12/01/25. If the facility does not ensure safe storage practices, then residents are at risk for unauthorized persons to have access to medications and adverse effects due to improper storage.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to:1. Properly store dishes in sanitary conditions.2. Properly label food items in the refrigerator.3. Properly wear hair nets while in the kitchen. These deficient practices are likely to affect all 62 residents listed on the resident census list provided by the Administrator on 12/01/25 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and food stored properly.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by not ensuring Enhanced Barrier (EBP) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection). This failed practice has the potential to affect all 62 residents living in the facility as identified by the census provided by the Administrator 12/01/25. These deficiencies place residents at risk of contracting infections, hospitalization, and death.

Inspectors wroteBased on observation and interview, the facility failed to ensure that residents have a safe and functional environment for all 62 residents reviewed. This deficient practice could likely result in residents being injured and living in an environment in poor repair, which would put the residents at risk of unwanted items, including insects and dust particles to come into their living space.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #3) of 5 (R #1, R #3, R #5, R #9 and R #27) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 3 (R #3, R #9 and R #60) of 5 (R #1, R #3, R #5, R #9, and R #60) residents reviewed for unnecessary medications, when staff failed to ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 6 (R #3, R #4, R #7, R #24, R #27 and R #48) of 9 (R #1, R #3, R #4, R #5, R #7, R #9, R #24, R #27 and R #48) residents reviewed when staff failed to:1. Revise R #3's care plan to include use of psychotropic drugs (drugs that affect a person's mental state),2. Update R#4's care plan to remove the use of Voltaren (medication used for pain),3. Revise R#7's care plan to include appropriate interventions for falls.4. Revise R #24's discharge goals in the care plan to include current discharge goals. 5. Revise R #27's care plan to include the current size of bed rails.6. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain physician orders and informed consent prior to installation of bed rails for 2 (R # 3 and R #5) of 5 (R #3, R #5, R #9, R #27 and R #60) resident reviewed for accidents. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis for 5 (R #1, R #3, R #5, R #9, and R #60) of 7 (R #1, R #3, R #5, R #9, R #11, R #40 and R #60) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical records contained documentation that each resident received, or was offered the COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 2 (R #4 and R #5) of 5 (R #3, R #4, R #5, R #8, and R #40) residents reviewed for immunizations. This deficient practice could likely result in residents not having the knowledge or opportunity to get needed vaccinations.

Inspectors wroteBased on record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) and a five day follow up report to the State Survey Agency (SSA) for 1(R#7) of 1 (R #7) resident reviewed for incidents when staff failed to report the following incidents:1) Unwitnessed fall with injury for R #7.2) Injury of left hand for R #7 within two hours of becoming aware of the injuries. This deficient practice is likely to result in the State Survey Agency (SSA) not being aware of facility incidents and being unable to assure residents safety.

Inspectors wroteBased on record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #8) of 1 (R #8) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #67) of 1 (R #67) resident reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #8) of 3 (R #8, R #12, and R #25) residents reviewed for care plans when staff failed to include R #8's use of an external catheter (external catheter (a non-invasive medical device used to collect urine from outside the body) and interventions needed to care for R #8 and the external catheter. This deficient practice could likely result in an increase in infections and other health concerns.

Inspectors wroteBased on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, transfers, toileting, and eating) assistance for transfers (assisting a resident from one place such as a bed to another place such as a wheelchair) for 1 (R #50) of 3 (R #27, R #50, and R #60) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident with an external catheter (a non-invasive device worn over the genitals) had an order that demonstrated that a catheter was necessary, what type of catheter was needed, and how to care for the catheter for 1 (R #8) of 1 (R #8) resident reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of infections for residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain appropriate staffing levels to meet the needs of the 1 (R #8) of 2 (R #8 and R #27) residents reviewed for staffing. This deficient practice could likely result in residents not receiving the care and service needed while in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R 48) of 1(R 48) resident reviewed, when the facility failed to document an admit to Hospice (palliative and supportive services to meet the physical, psychological, social, and spiritual needs of terminally ill residents).order upon admission to facility. This deficient practice is likely to result in residents having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 1 (CNA #2) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed for training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure medication and biological refrigerator temperatures were maintained within the required range and recordings logged for three of three refrigerators in two medication rooms. This failure had the potential to result in residents being subject to unsafe or ineffective treatment or adverse effects leading to more serious illnesses.

Inspectors wroteBased on interviews and records review, the facility failed to ensure resident representatives (RR) and two (R14 and R30) of two residents reviewed for transfer requirements were provided with a written transfer notice that contained all the required information. This failure had the potential to affect the residents and their RRs by not having knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on interviews and records review, the facility failed to ensure resident representatives and two of two residents (Resident (R) 14 and R30) reviewed for transfer requirements out of a total sample of 18 were provided with written notification of the facility's bed hold policy prior to transfer to the hospital. This created a potential for the residents to experience distress or confusion related to readmission to the facility due to the facility-initiated discharge.

Inspectors wroteBased on observations, record review, interviews, and review of the facility policy, the facility failed to ensure resident Care Plans were updated and revised with new goals and interventions for two residents (R30 and R41) of 18 sampled residents. The facility failed to update the Care Plan for R30 related to oxygen usage and for R41 related to falls. This failure created an increased risk for the residents' care and services to not be appropriate for the current clinical condition.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the designated resident smoking area was safe for one of 13 residents (Resident (R) 10) reviewed for smoking. The facility failed to provide a safe smoking environment by permitting non-self-extinguishing trash cans to be available for cigarette ashes and cigarette butts to be disposed of on top of trash. The failure created the potential for cigarette butts and ashes to ignite when thrown in the non-self-closing trash cans.

Inspectors wroteBased on record review and interview, the facility failed to complete and document a thorough investigation, implement measures to prevent further abuse, and implement corrective actions regarding allegations of neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness) and abuse (knowingly causing physical or mental harm or failing to provide goods and services necessary to avoid physical or mental harm) for 3 (R #s 4, 8 and 9) of 7 (R #s 4, 5, 6, 7, 8, 9 and 10) residents reviewed for abuse/neglect allegations when staff failed to: 1. Complete and document a thorough investigation, remove staff identified while the investigation was conducted, and implement corrective actions for R #4, R #8 and R #9. 2. Provide a follow-up report within five working days from the date of the incident to the State Survey Agency (SSA) for R #4. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff demonstrated appropriate competency and skills when: 1) LPN #2/Unit Manager failed to administer accurate medication dosages to a resident; 2) LPN #2 failed to follow facility process for receiving emergency medications; 3) LPN #2 inaccurately documented on the medication administration record to intentionally deceive; 4) LPN #1 began working without completing an application, having a background clearance, training and demonstration of competency prior to providing care to residents. This deficient practice likely resulted in: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of significant medication errors for 1 (R #1) of 1 (R #1) residents reviewed for neglect, when nursing staff administered the wrong dose of medication to R #1. This deficient practice likely resulted in the overdosing of R #1 which resulted in an immediate increased in heart rate, decrease in blood pressure, inability to respond and fatigue requiring admission to the hospital.

Inspectors wroteBased on record review, observation, and interview, the facility failed to: 1. Ensure staff properly stored narcotic medications in a locked container. 2. Properly dispose of unused and expired medications. This deficient practice had the potential to affect all 52 residents identified on the facility census list provided by the Director of Nursing (DON) on 05/06/24. Improperly stored medications could result in a resident, staff member, or visitors taking the medications not prescribed to them.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1(R #3) of 2 (R #3 and #5) residents when they failed to follow through with physician's orders to place a peripherally inserted central catheter (PICC; a long thin tube that is inserted through a vein in your arm and passed through to the larger veins near your heart) line to administer intravenous (IV) antibiotic treatment and to order and apply a wound vacuum [a medical device that uses negative pressure (suction) to help bring the edges of your wound together. It also removes fluid and dead tissue from the wound area and aids in healing] for R #3. This deficient practice likely resulted in the resident experiencing medical complications or a worsened condition.

Inspectors wroteBased on interview, observation, and record review, the facility failed to keep residents free from abuse for 1 (R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed. This deficient practice likely resulted in staff to resident abuse in which R #4 had bruising to her neck and wrists.

Inspectors wroteBased on interview, observation, and record review, the facility's Administrator and the Director of Nursing (Administrative Staff) failed to administer the facility when they knew/ should have known and prevented the following deficient practices which occurred in the facility: 1. Unavailability of Administrative staff causing staff to reschedule resident meetings and to be without leadership or direction. 2. Administration unavailable to report absences timely by staff members delaying ability of scheduler to find appropriate coverage. 3. LPN #1 began working without completing an application, having a background clearance, training and demonstration of competency prior to providing care to residents 4. Nursing staff changed or wrote orders without Practitioner's knowledge or consent. 5. Not reporting or investigating allegations of abuse and neglect. 6. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide Facility Initiated Reports (mandatory self-initiated facility report of an incident) to the State Survey Agency (SSA) for 6 (R #1, #4, #5, #8, #9 and #10) of 8 (R #1, #4, #5, #8, #9 and #10) residents reviewed for incidents when staff failed to report the following incidents: 1) Medication error for R #1 2) Injury of unknown origin for R #4 within two hours of becoming aware of the injuries. 3) Unwitnessed falls with injuries for R #5 and #10; 4) Allegations of abuse reported by R #8 and #9; This deficient practice is likely to result in the SSA not being aware of facility incidents and unable to assure residents safety.

Inspectors wroteBased on record review and interview, the facility failed to prevent misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) of resident property, when a resident's pain medication was given to another resident for 1 (R #2) of 1 (R #2) residents reviewed for misappropriation. This deficient practice could likely result in residents not receiving needed medications to maintain or improve their quality of life.

Inspectors wroteBased on observation and interview the facility failed to maintain an environment that was in good condition when staff failed to: 1. Paint walls that were patched with plaster, had patches of a different paint color, and food debris on the wall and ceiling; 2. Repair holes in walls; 3. Replace a heating/cooling vent cover in room [ROOM NUMBER]; 4. Properly repair various exposed wires and replace a missing ceiling tile in the dining room. These deficiencies could affect the 57 residents who lived in the facility and were listed on the resident census provided by the Administrator on 02/21/24. If the facility fails to maintain the building, then residents could feel uncomfortable in their environment.

Inspectors wroteBased on record review and interview, the facility failed to ensure for 2 (R #2 and 8) of 3( R #2, 7 and 8) residents that the facility: 1. Provided a follow-up report within 5 working days from the date of the incident to the State Survey Agency for R #2 and R#8. 2. Implemented any preventative measures following an abuse accusation for R #2. Theses deficient practices could likely cause residents to feel frustrated and unsafe.

Inspectors wroteBased on record review and interview, the facility failed to report an incident of alleged sexual inappropriateness to the State Survey Agency for 1 (R #2) of 3 (R #'s 2, 7 and 8) residents reviewed for sexual abuse allegations. If the facility fails to report incidents of abuse, then the State Agency will be unable to appropriately assess allegations for further investigation. This deficient practice could likely cause residents to feel frustrated and unsafe.

Inspectors wroteBased on record review and interview, the facility failed to provide the necessary care to effectively manage pain for 1 (R # 47) of 1 (R #47) resident reviewed for pain. This deficient practice likely resulted in R #47 experiencing significant (long) periods of pain without sufficient relief.

Inspectors wroteBased on observation and interview, the facility failed to ensure that they had sufficient staff to guarantee the needs of all 73 residents residing in the facility by not: 1. Using the appropriate number of staff to transfer resident with a Hoyer Lift (a mechanical device that helps staff to lift and transfer residents). 2. Having enough facility staff to meet the activities of daily living needs of the residents and providing baths/showers. These deficient practices are likely to negatively impact resident safety, comfort, and to impede (delay or prevent) processes such as timely showers and appropriate assistance.

Inspectors wroteBased on record review and interview the facility failed to provide quality care for 1 (R #12) of 1 (R #12) resident reviewed for transfers/mobility. Failing to ensure that residents are allowed to transfer and have mobility around the facility is likely to cause psychosocial wellbeing and behavioral issues.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the consultant pharmacist review for irregularities was acted upon by the medical director on a monthly basis for 1(R #21) of 1 (R #21) residents reviewed for unnecessary medications. If the facility fails to have the medical director act upon the monthly reviews, there is potential for residents to experience unnecessary drug interactions and potentially adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure Insulin pens were labeled and dated. 2. Ensure that expired medications were not being stored with unexpired medications on the North Units medication cart and inside the North 100 and 200 unit's medication storage rooms. 3. Ensure that medications were stored properly and not found out of original labeled packaging. 4. Ensure expired medications were properly secured and stored inside of the 100 and 200 units medication storage room. 5. Ensure expired medication was not administered to R #27. These deficient practices are likely to negatively impact the health of all the residents on the 100 and 200 halls and on the North unit. [...]

Inspectors wroteBased on observation and interview the facility failed to provide proper infection control practices by: 1. Not having a closed door between the soiled laundry area and the clean laundry area. There is no negative pressure system observed in the soiled laundry area. 2. Not keeping doors to Covid 19 positive rooms closed off to hallways/common areas. 3. Not utilizing proper Personal Protective Equipment (PPE) such as gloves, during a Covid 19 outbreak, 4. Not utilizing bio hazard bags (a specially designed plastic or paper bag that is used to collect and transport bio hazard items) in laundry receptacles for means of transporting and identifying soiled contaminated laundry items to the washroom for proper laundering. 5. Not properly labeling Covid 19 contaminated laundry receptacles to identify them from common trash receptacles and storing them in hallway. 6. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that there was a functioning call light system that allowed resident to call for assistance for 1 (R #223) of 1 (R #223) residents review for call lights. If the facility does not have a functioning call light system then residents are unlikely to get their immediate needs met by facility staff. A. On 08/14/23 at 5:27 PM, during observation of call light and interview R #223 stated the call light was not working. Call light was observed to be a push light on her bedside table marked with a red cross, plugged into wall pushed several times to confirm it is not functioning. B. On 08/14/23 at 5:30 PM during interview, LPN #1 confirmed the call light was not functioning. C. On 08/17/23 9:43 AM during interview, CNA #5 confirmed the call light not working and out of residents reach. D. [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to develop a comprehensive care plan for 1 (R #24) of 1 (R #24) reviewed for comprehensive care plans. This failure is likely to delay residents in developing plans of care that are effective for their optimal well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 Certified Nurse Aides (CNA's #6) out of 5 sampled CNA's received the required in-service training of no less than 12 hours per year. This deficient practice is likely to result in the nurses' aides not receiving the necessary training to meet the care needs of the residents.