Cycle 1
Health 2025-12-05 · Fire 2024-09-26
20 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Clovis, NM
Clovis Healthcare and Rehabilitation Center
1-star overall rating with 1-star inspections with $81,641 in total fines with 20 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1201 North Norris Street, Clovis, NM
(575) 762-3753
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1992-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
0.65
Licensed practical nurse staffing
Aide hours / resident day
1.77
Nurse aide staffing
Weekend hours
2.60
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.6
0.6 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.4%
2.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.7%
1.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.5%
1.2 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
1.8%
2.1 pts worse
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.1% |
5.4%
0.7 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
14.1%
6.3 pts worse
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
14.7%
1.1 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.1% |
15.8%
2.3 pts worse
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
14.6%
8.6 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.3%
0.5 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.9%
0.4 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
20.6%
5.1 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.7%
1.1 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
86.6%
9.4 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
15.9%
4.4 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
86.4%
6.8 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
21.3%
2.8 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2023-08-18
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-08-18 · Fire 2022-09-16
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-21
F · Potential for more than minimal harm
2023-08-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-09-26
F · Potential for more than minimal harm
2023-08-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-26
F · Potential for more than minimal harm
2023-08-18
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-09-26
F · Potential for more than minimal harm
2023-08-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-26
F · Potential for more than minimal harm
2022-09-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-09-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-09-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-02-10
F · Potential for more than minimal harm
2025-12-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2026-02-10
F · Potential for more than minimal harm
2025-12-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-10
F · Potential for more than minimal harm
2025-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-10
F · Potential for more than minimal harm
2025-12-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-12-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-12-05
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-12-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-12-05
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-12-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-12-05
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-12-05
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2026-02-10
E · Potential for more than minimal harm
2024-09-26
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-09-26
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-09-26
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-09-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-09-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-05
K · Immediate jeopardy
2024-05-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-11
J · Immediate jeopardy
2024-05-16
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-11
J · Immediate jeopardy
2024-05-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-11
J · Immediate jeopardy
2024-05-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-11
H · Actual harm
2024-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-11
G · Actual harm
2024-05-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-11
F · Potential for more than minimal harm
2024-05-16
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-05-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-11
D · Potential for more than minimal harm
2024-05-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-11
E · Potential for more than minimal harm
2024-02-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-02-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-02-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-16
G · Actual harm
2023-08-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-26
F · Potential for more than minimal harm
2023-08-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-26
E · Potential for more than minimal harm
2023-08-18
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-26
D · Potential for more than minimal harm
2023-08-18
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-09-26
Penalties and ownership
What sits behind the stars
$81,641
2024-05-16
Fine
Fine · fine $81,641
Fine
$0
2023-08-18
Payment Denial
Payment Denial · denial start 2023-09-23 · 3 days
3 day denial
Ownership
Summit Care LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Ortiz, Raymond
Operational/Managerial Control · Individual
Paden, Cheryl
Operational/Managerial Control · Individual
Skilled Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Summit Care Parent LLC
5% Or Greater Indirect Ownership Interest · Organization
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
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#3
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