Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morning Star Post Acute during CMS and state inspections, most recent first.
Nursing staff did not recognize or appropriately act on a resident's clinical decline, including failing to notify the physician of abnormal lab results, low blood pressure, and elevated heart rate. The resident's condition worsened to altered mental status and low oxygen saturation, with action only taken after a family member intervened. This resulted in emergency hospital transfer and a diagnosis of sepsis and acute kidney injury.
A resident with multiple chronic conditions was not given several prescribed medications due to unavailability, and the nurse did not notify the physician or document the missed doses as required by facility policy. The resident had no cognitive impairment and required these medications for ongoing health issues, but the necessary communication and documentation were not completed.
The facility failed to maintain sanitary conditions in the kitchen, with debris found on ventilator fans, vents, cabinet shelves, and food carts, leading to potential cross-contamination. Additionally, a toaster and a beef roast in the freezer were not properly maintained, risking bacterial growth. Staff acknowledged these issues, and the facility's sanitation and storage policies were not followed.
The facility failed to implement its Water Management Program to reduce Legionella risk, placing residents at risk for undetected waterborne pathogens. Additionally, two residents' oxygen nasal cannulas were found on the floor, and an LPN did not sanitize a resident's inhaler mouthpiece after use, both actions risking cross-contamination and infection. The facility's infection control policies were not followed in these instances.
A facility failed to ensure resident dignity and privacy during medical procedures. An LVN checked a resident's blood sugar without closing the privacy curtain, while another LVN administered medications and checked blood pressure for multiple residents without ensuring privacy. These actions were acknowledged by the staff involved, and the DON confirmed the expectation for privacy during such procedures.
The facility failed to ensure the expiration dates of medications in the emergency kit were checked and updated, resulting in expired lorazepam being available for use. The DON and LVN acknowledged the oversight, and the pharmacist did not notice the expired medication during her monthly visit, contrary to the facility's policy.
The facility failed to properly store and label medications, leaving a treatment cart unlocked and unsupervised, and not labeling inhalers and nasal sprays with open or expiration dates for two residents. Discontinued medications were also improperly stored without labels or identifiers. These actions violated the facility's policies, posing potential health risks.
The facility was found to have three bedrooms each accommodating eight residents, exceeding the regulatory limit of four residents per room. Despite this, the rooms met the required needs, including adequate space, privacy, and accessibility, and the facility requested a waiver to maintain this setup.
The facility failed to ensure call lights were within reach for three residents, leading to potential harm. A resident's call light was under the bed, while two others had call lights on the floor, making them inaccessible. Staff interviews confirmed the failure to follow the facility's policy, which requires call lights to be within easy reach.
A resident with COPD and asthma was allowed to self-administer inhaler medications without the required assessment, physician's order, or care plan, contrary to the facility's policy. The LVN permitted this action, which was confirmed by interviews with the Infection Preventionist and DON, highlighting a lapse in following established procedures for medication administration.
A resident with severe cognitive deficits did not receive necessary assistance with personal hygiene, resulting in long, dirty fingernails and food particles in her mouth. Staff interviews revealed inconsistencies in providing nail and oral care, despite facility policies requiring regular maintenance. The resident's refusal of care was not consistently reported to licensed nurses, contributing to the deficiency.
Failure to Recognize and Respond to Change in Condition
Penalty
Summary
Nursing staff failed to recognize and appropriately act on a significant clinical change in condition for a resident with multiple complex medical diagnoses, including hemiplegia, hemiparesis, cerebral infarction, dysphagia, and diabetes mellitus. The resident exhibited abnormal laboratory results, specifically an elevated white blood cell count and blood urea nitrogen, which were not communicated to the physician as required by facility policy. Additionally, daily resident assessments were not completed on two consecutive days, which could have detected early signs of decline. On subsequent days, the resident presented with low blood pressure and elevated heart rate, yet these abnormal vital signs were not reported to the physician. The resident's condition further deteriorated, with altered mental status, increased weakness, decreased communication, shortness of breath, and distress, accompanied by a critically low oxygen saturation. Despite these significant changes, nursing staff did not promptly notify the physician or take appropriate action until the resident's family member intervened and insisted on emergency medical attention. The lack of timely assessment, failure to report abnormal findings, and inadequate response to the resident's clinical decline resulted in the resident being transferred to an acute care hospital, where she was diagnosed with sepsis and acute kidney injury, requiring intensive care. Interviews and record reviews confirmed that staff did not follow facility protocols for assessment, notification, and escalation of care in response to abnormal findings and changes in the resident's condition.
Failure to Administer and Report Missed Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident was not administered multiple prescribed medications, including Allopurinol, Duloxetine, Empagliflozin, Linagliptin, and Rifaximin, as ordered by the physician. The Medication Administration Record (MAR) indicated that these medications were not given due to their unavailability, coded as 'code 11.' The licensed nurse did not document any notification to the prescribing physician regarding the missed doses, nor was there evidence that the provider was informed of the situation. The resident involved had a medical history that included encephalopathy, diabetes mellitus type 2, liver cirrhosis, chronic gout, anxiety disorder, and recurrent major depressive disorder. The resident was assessed as having no cognitive impairment according to the Brief Interview for Mental Status (BIMS) score. Despite the resident's complex medical needs, the required medications were not administered, and the necessary communication with the physician was not documented. Facility policy required that nursing staff notify the attending physician when medications are unavailable, explain the circumstances, and obtain new orders or alternative therapies. The policy also required documentation of this communication and timely administration of medications. Both the Licensed Vocational Nurse and the Director of Staff Development confirmed that these procedures were not followed, and the nurse failed to adhere to professional standards and facility policy regarding missed medication doses.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Multiple areas in the kitchen, including a ventilator fan in the milk refrigerator, vents above the dishwasher, and a vent in front of the milk refrigerator, were found to have brown, grey, and black debris. The Dietary Manager (DM) acknowledged that these areas should have been cleaned, and the drinks stored underneath the ventilator fan were ready for resident consumption. The Infection Preventionist (IP) and other staff members confirmed that the debris could lead to cross-contamination and potential gastrointestinal infections for residents. Additionally, black and brown debris was found on cabinet shelves next to stored clean bowls, and brown debris was present on every shelf inside a food cart. The DM and other staff members recognized that these areas should have been cleaned or replaced to prevent cross-contamination. The presence of debris on nonfood-contact surfaces was noted as a potential environment for the growth of microorganisms, which could be transferred to food, leading to food-borne illnesses among residents. Further observations revealed brown debris on top of and inside a toaster, and a beef roast inside a plastic bag covered in ice stored in the meat freezer. The DM and other staff members stated that the toaster should have been clean and the roast should not have had ice buildup, as these conditions could lead to bacterial growth and food-borne illnesses. The facility's policies and procedures for sanitation and freezer storage were not followed, contributing to the deficiencies observed during the survey.
Infection Control Deficiencies in Water Management and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. Firstly, the Water Management Program (WMP) was not implemented since April 8, 2022, to reduce the risk of Legionella and other waterborne pathogens. The Maintenance Director, who was responsible for Legionella oversight, had not been part of an annual review or committee for Legionella since taking the position in April 2024. The Infection Preventionist and the Administrator also confirmed that they had not participated in an annual review for Legionella, and the facility did not follow the WMP policy and procedure. This lack of review and implementation placed residents at risk for undetected Legionella in the water system. Additionally, the facility failed to ensure proper infection control practices concerning oxygen nasal cannulas for two residents. Observations revealed that the nasal cannulas for these residents were on the floor while their oxygen concentrators continued to deliver oxygen. Licensed Vocational Nurse (LVN) 2 acknowledged that the nasal cannulas should not be on the floor and recognized the potential for cross-contamination. The Infection Preventionist and the Director of Nursing confirmed that the facility's policy and procedure for Oxygen Administration were not followed, and the residents were at risk of acquiring bacteria and germs from cross-contamination. Furthermore, the facility did not adhere to proper infection control practices regarding the use of inhalers for another resident. LVN 2 failed to wipe or sanitize the mouthpiece of the resident's inhalers after use, which could lead to bacterial growth and infection. The Infection Preventionist and the Director of Nursing emphasized the importance of cleaning the inhaler's mouthpiece after each use to prevent infection. The facility's policy and procedure for administering medications, which includes infection control procedures, were not followed in this instance.
Failure to Provide Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple instances where privacy was not provided during medical procedures. Licensed Vocational Nurse (LVN) 1 checked a resident's blood sugar level without closing the privacy curtain or door, despite the presence of another resident, facility staff, and a visitor in the room. This action was acknowledged by LVN 1, who admitted that privacy should have been provided. Similarly, LVN 3 was observed checking another resident's blood pressure without ensuring privacy by closing the curtain or door. This occurred while staff and other residents were walking by in the hallway. LVN 3 admitted to not providing the necessary privacy and acknowledged the oversight. Furthermore, LVN 3 administered medications to several residents without closing the privacy curtains, despite the presence of other residents, staff, and visitors in the vicinity. This was confirmed by LVN 3, who recognized the violation of residents' rights to privacy. The Director of Nursing (DON) also confirmed that the expectation was for licensed nurses to provide privacy during medication administration, emphasizing the importance of maintaining resident dignity and respecting their rights.
Failure to Monitor Expiration Dates in Emergency Kit
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for 54 residents by not ensuring the expiration dates of medications in the emergency kit (E-kit) were checked and updated. During an observation and interview, it was found that the E-kit contained two vials of lorazepam with an expiration date of 11/30/24, which had not been replaced. The Director of Nursing (DON) acknowledged that the E-kit should have been replaced before the medication expired, and a resident could have needed the medication after its expiration, leaving no available medication to administer. Interviews with the Licensed Vocational Nurse (LVN) and the pharmacist revealed that the pharmacist, who visits the facility monthly, did not notice the expired lorazepam during her last visit. The LVN admitted to not checking the expiration dates of medications in the E-kit, assuming it was the pharmacist's responsibility. The facility's policy indicated that the pharmacy should inspect the condition and expiration dates of medications stored in the dispensing machine regularly, but this was not adhered to, resulting in the potential risk of administering expired medication during emergencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, as observed during a survey. A treatment cart was found unlocked and unsupervised in front of the nursing station, which contained medicated ointments and other medications. This oversight was confirmed by an LVN, who acknowledged that the cart should have been locked to prevent unauthorized access by residents or staff, potentially leading to serious health conditions. The Director of Nursing (DON) also stated that the expectation was for licensed nurses to ensure the treatment cart was locked when not supervised. Additionally, the facility did not label medications with open dates or expiration dates for two residents. Resident 14's inhalers and nasal spray, used for treating COPD and asthma, lacked these critical labels. An LVN admitted not knowing when the medications were opened, emphasizing the importance of labeling to avoid administering expired medications, which could be less effective. Similarly, Resident 18's inhaler also lacked an open date or expiration date, with an LVN noting that the medication would not be effective after 30 days of being opened. Furthermore, discontinued medications were improperly stored in a clear plastic container in the medication room without labels or resident identifiers. The DON acknowledged that medication labels should not have been removed and that these medications should have been destroyed or returned to the pharmacy. The facility's policies and procedures require that medications be stored in locked compartments and properly labeled, but these were not followed, leading to the potential for adverse reactions if medications were administered incorrectly.
Exceeding Resident Capacity in Bedrooms
Penalty
Summary
The facility failed to comply with the regulation that limits the number of residents per bedroom to a maximum of four. During the survey conducted from December 3, 2024, to December 10, 2024, it was observed that three resident bedrooms each housed eight residents, exceeding the allowed capacity. Despite this non-compliance, the facility ensured that each room met the required needs of the residents, including adequate square footage, privacy, storage space, and accessibility for wheelchairs and other devices. The health and safety of the residents were not adversely affected, and the facility requested a waiver to continue this arrangement.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to potential harm. Resident 104's call light was found under the bed and not accessible, despite the resident's severe cognitive deficit and medical conditions such as heart failure and end-stage renal disease. Observations and interviews with staff, including an LVN and CNAs, confirmed that the call light was not within reach, which is against the facility's practice and policy. Similarly, Resident 19's call light was observed hanging off the bedframe and touching the ground, making it inaccessible. This resident also had a severe cognitive deficit and was diagnosed with generalized muscle weakness. Staff interviews revealed that the call light should have been within reach to ensure the resident could call for assistance when needed. Resident 30's call light was found on the floor, out of reach, despite the resident's ability to communicate and understand. The resident had medical conditions such as acute respiratory failure and morbid obesity, which limited mobility. Staff acknowledged the safety issue and the failure to follow the facility's policy, which requires call lights to be clipped to the bed and within easy reach of residents.
Failure to Follow Self-Administration Policy for Inhaler Medications
Penalty
Summary
The facility failed to adhere to its own policy and procedure regarding the self-administration of medication for one resident, identified as Resident 14. Resident 14, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and asthma, was observed self-administering her inhaler medications without having undergone the required self-administration assessment, physician's order, or care plan. The Licensed Vocational Nurse (LVN) 2 allowed Resident 14 to self-administer her inhalers, despite the facility's policy requiring an interdisciplinary team assessment to determine the resident's capability to safely self-administer medications. Interviews with the Infection Preventionist, LVN 2, and the Director of Nursing (DON) confirmed that Resident 14 did not have the necessary assessment, physician's order, or care plan in place. The facility's policy, dated 2/2021, mandates that residents must be assessed by an interdisciplinary team to ensure they are capable of safely self-administering medications, and this must be documented in the medical record and care plan. The failure to follow these procedures had the potential to result in Resident 14 not receiving the correct medication dose as ordered by the physician.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, identified as Resident 22, who was unable to maintain personal hygiene and grooming independently. Observations revealed that Resident 22 had long, jagged, and dirty fingernails with dark particles underneath, and food particles were present in her mouth and between her teeth. The resident expressed a need for assistance with nail trimming and oral care, which she had not received. Interviews with staff, including the Director of Staff Development (DSD), Certified Nurse Assistants (CNAs), and a Licensed Vocational Nurse (LVN), confirmed that the facility's practice was to provide nail care on scheduled shower days and oral care twice daily. However, staff admitted to not remembering when they last provided these services to Resident 22. The CNAs noted that Resident 22 sometimes refused care, but they did not consistently report refusals to licensed nurses as required by facility policy. The facility's policies on nail and oral care emphasized the importance of regular maintenance to prevent health issues. Despite these guidelines, the staff failed to ensure that Resident 22 received the necessary care, resulting in poor personal hygiene. The Director of Nursing (DON) acknowledged the potential health risks associated with inadequate nail and oral care, such as infections, but the deficiency persisted due to lapses in staff adherence to care protocols.
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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.
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Nursing homes near Clovis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Horizon Health & Subacute Center | 2.2 mi | — | 5 | 0 |
| Willow Creek Healthcare Center | 2.3 mi | — | 2 | 0 |
| The Terraces At San Joaquin Gardens Village | 3.9 mi | — | 0 | 0 |
| North Point Healthcare & Wellness Centre Lp | 3.9 mi | — | 0 | 0 |
| Keystone Post-acute | 4 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.