Clovis Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Clovis Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF610May 16, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF726May 16, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF760May 16, 2024

  Based 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. The findings are: A. Record review of R #1's Face Sheet revealed an initial admitted [DATE] and a discharge date of [DATE]. B. […]

• Immediate jeopardy, isolatedF761May 16, 2024

  Based 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. The findings are: A. On 05/06/24 at 12:42 pm, observation of the Director of Nursing's (DON) office revealed the office was unlocked, the door was open, and the office was accessible to residents, staff, and visitors. […]

• Actual harm, patternF684May 16, 2024

  Based 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. […]