Artesia Christian Home Inc.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage of food was done under sanitary conditions affecting 46 out of 46 residents by not labeling a salad with the date it was prepared and by not labeling raw meats with the date it was placed in the refrigerator. These deficient practices placed residents at risk for food-borne illnesses (any illness resulting from eating contaminated/spoiled foods) had the potential to cause nausea, vomiting and diarrhea .

Inspectors wroteBased on observation, interview and record review, the facility failed to: Ensure staff performed hand hygiene prior to entering Resident 16 and Resident 30's room. Ensure Restorative Nursing Aide (RNA nursing aide program that helps residents maintain any progress made after therapy intervention to maintain their function) 2 wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assisting with range of motion (ROM, full movement potential of a joint) exercises to Resident 8's both arms and both legs which required direct contact with Resident 8 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of four residents' (Resident 16 and 31) oral medications were not crushed and administered together during medication pass. This deficient practice placed Resident 16 and Resident 31 at risk for dangerous chemical interactions and had the potential for altered drug effects, and incorrect dosage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion (ROM, full movement potential of a joint) for three (3) of six sampled residents (Residents 1, 2, and 8) with ROM concerns by failing to: 1. Objectively measure and identify the location of Resident 1's ROM limitations of both legs during the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 12/23/2025. 2. Objectively measure Resident 2's ROM limitations of both shoulders and both hands during the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 10/3/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aides (RNA, trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) were competent to provide RNA services to one of six sampled residents (Resident 8) by failing to: 1. Ensure Restorative Nursing Aide 2 (RNA 2) was competent to perform active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to Resident 8's both arms and both legs in accordance with physician orders. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer psychotropic medications (chemical substance that treat mental illnesses that affect the brain that modifies mood, thought, emotions, and behavior) in a timely manner for one of four sampled residents (Resident 39). This deficient practice had the potential to cause delay in treatment and exacerbate Resident 39's condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records for two of six sampled residents (Residents 2 and 8) were accurate by failing to: Ensure Restorative Nursing Aides (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) accurately documented RNA services provided for Resident 2 in December 2025 and January 2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of COVID-19 (contagious infectious disease) education and vaccination (medications used to prevent diseases) status for four of four sampled employee records (Certified Nursing Assistant (CNA1, CNA2), Food Service Worker (FSW) and Laundry Staff (LS). This failure had the potential to place staff and residents at risk for Covid 19. During an interview and record review on 1/22/2026 at 11:03 a.m., with the Assistant Director of Nursing (ADON), the facility's employee records of COVID-19 status were reviewed, four of four sampled facility employee records of COVID-19 immunization, the ADON stated status was unknown. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 45) was treated with respect and dignity when the trash bag was placed on Resident 45's bed during a treatment. This failure had the potential affect resident's sense of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was formulated for one (1) out of the four (4) sampled residents (Resident 26). This deficient practice had the potential to cause conflict with Resident 26's wishes regarding health care and end of life wishes.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one of three sampled residents (Resident 45's) wound progressed from a pressure injury (PI- localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) to a PI Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound). This failure had the potential to delay care in treating and preventing Resident 45's PI from getting worse.

Inspectors wroteBased on interview and record review, the facility failed to verify the dose of Vitamin B-12 (supplement) order for one of two sample residents (Resident 35). This deficient practice had the potential to result in medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an opened Tuberculin, Purified Protein Derivative ([PPD] medication used to do a skin test to help detect tuberculosis serious lung infection) for one of two medication rooms was labeled with the date opened. These deficient practices had the potential to result in the loss of viability (ability to work) of the PPD if used beyond recommended date.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physical Therapy (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 12/23/2025, and Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation, dated 12/23/2025, were completed under the written order of a physician for one of six sampled residents (Resident 1). These deficient practices had the potential to result in inaccurate care planning, harm, inaccurate provision of care and services, and lack of physician verification and coordination of skilled needs and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bedrooms measure at least 80 square (sq) foot (ft) per resident for six of twelve resident rooms. This failure had the potential to result in compromised resident safety due to limited bedroom space. During an interview with the Administrator (ADMIN) on 1/23/2026 at 2:49 p.m., the ADMIN stated the residents in the affected rooms were not negatively impacted. The ADMIN stated there was sufficient room for the provision of nursing services for these group of residents, the rooms were approved during ( Office of Statewide Health Planning and Development (OSHPD) inspection. During a review of the letter provided by the ADMIN dated 1/20/2026 , the ADMIN requested a room waiver for the residents' room sizes less than 80 sq ft per resident for six of 18 rooms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they reported a suspected scabies (a contagious skin condition caused by tiny insects called microscopic mites which infest and irritate the skin causing intense itching, red patches and inflammation outbreak (two or more clinically suspect or confirmed cases identified in patients/residents, healthcare workers, volunteers and/ or visitors) to the California Department of Public Health (CDPH) for three of fourteen sampled residents (Resident 1, Resident 2 and Resident 3). This deficient practice resulted in CDPH being unaware that a possible scabies outbreak existed and a delay in their investigation, placing placed residents, staff and visitors at risk of acquiring and spreading scabies.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) belongings were safe. This deficient practice resulted in Resident 1 jewelry being lost.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve requested menu items to one of three sampled residents (Resident 1). This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure one of three sampled residents (Resident 1) left arm bruise was assessed and reported as a change of condition after being reported to a licensed nurse. This deficient practice resulted in a delay of care for Resident 1 and had the potential to cause pain, infection and lead to hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident was assessed and evaluated after an unwitnessed fall on 12/7/2024 for one out of 2 high risks for falls (Resident 1). This deficient practice resulted in Resident 1 falling in bed sustaining multiple skin tears to the left forearm.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility's consulting pharmacist (PH) conducted monthly and as needed Drug Regiment Reviews ([DRR]thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) and made recommendations for gradual dose reduction ([GDR] - tapering mediation dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) or medication dosage adjustments to control behavioral symptoms for two of two residents with dementia (a progressive state of decline in mental abilities) for 2 of 25 sampled [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the psychiatrist's (medical practitioner specializing in the diagnosis and treatment of mental illness) services were provided to residents who were receiving psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication for four out of six sampled residents (Residents 2, 17, 19, and 51). Resident 2 had a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Residents 17, 19, and 51 had diagnoses of dementia (a progressive state of decline in mental abilities), The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) titled, Scabies Identification, Treatment and Environmental Cleaning, and Infection Control Program, for five of 23 residents (Residents 5, 18, 19, 21, and 31) who had a suspicious skin rashes ( the skin that has changes in texture or color and may be inflamed or irritated) by failing to: 1. Ensure Residents 5, 18, 19, 21 and 21, who had red scattered inflamed red spots with bumps and itching, were placed on isolation (separation of residents with an infection from residents without an infection). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of a pressure injury (skin breakdown from prolonged pressure on the skin and tissue underneath) on the inferior (lower) fold of the left buttock area for one of five sampled residents (Resident 50) by failing to: a. Ensure Resident 50 was repositioned every two hours, as indicated in the care plan titled Skin Condition, to relieve the pressure off the left buttocks area. b. [...]

Inspectors wroteBased on interview and record review the facility failed to: 1. Inform the physician (MD) of the abnormally low urine output (a measurement of how much urine a person produces) for one of one sampled resident (Resident 58), when Resident 58's urine output was 50 Cubic Centimeter (cc- a unit of measure of volume), (Reference Range of 280-560 cc for 8 hour) on 8/26/2024 during 7:00 a.m.- 3p.m. shift. 2. Initiate a change of condition (COC-tool used by health care professionals when a patient's condition suddenly changes) when Resident 58's urine output was observed to be 50 Cubic Centimeter on 8/26/2024 during 7:00 a.m.- 3p.m. shift. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the Quality Assessment Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies)Committee and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) failed to identify: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assessed for the use of pressure pad alarms (pressure sensitive devices that sound if a resident's position changes) and either the residents or their representatives were given the choice to give informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for two of two sampled residents (Resident 27 and 2). This deficient practice resulted in a violation of resident rights to be free from restraints (any manual method, physical or mechanical device, equipment, or material that is adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement).

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of 10 hours of continued education in the field of Infection Prevention and Control (IPC) for the Director of Nursing (DON), Assistant Director of Nursing ADON), and Director of Staff Development (DSD). This failure had the potential to result in negative health outcomes for the staff and residents of the facility.

Inspectors wroteBased on interview, and record review, the facility failed to implement its protocol for antibiotic stewardship program (coordinated program that promotes the appropriate use of antibiotics at the right dose, for the right duration, and only when needed by clinicians) by not monitoring and addressing triple antibiotic (a substance used to kill bacteria and to treat infection) ointment use for two of two sampled residents (Resident 1 and 60). This failure had the potential for the Resident 1 and 60 to receive an inappropriate antibiotic.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence of all employees screening, education offering, and current Corona virus (COVID-19 a highly contagious infectious disease) disease, vaccination (medications used to prevent diseases usually given by injection or by mouth) status. This failure had the potential to place staff and residents at risk for negative outcomes such as being hospitalized and dying due to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin for one of one sampled resident (Resident 210), when Resident 210 was found to have a 1.5 centimeter (cm-unit of measurement) by 1.5 cm small bluish bump on the left side of her forehead, which staff and resident could not provide an explanation of its origin. This deficient resulted in a delay of an onsite inspection by the California Department of Public Health (CDPH) and had potential for an ongoing unknown injury.

Inspectors wroteBased on interview and record review, the facility failed to investigate injuries of unknown origin for one of one sampled resident (Resident 210). Resident 210 had a 1.5 centimeter (cm-unit of measurement) by 1.5 cm small bluish bump on the left side of her forehead, which staff and resident could not provide an explanation of its origin. This deficient practice had the potential for undetected abuse.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan addressing the resident's noncompliance for one of two sampled residents (Resident 1). This deficient practice had the potential to result in the delay of care and services.

Inspectors wroteCROSS REFERENCE F686 Based on interview and record review the facility failed to ensure the care plan was revised when the resident developed a pressure injury (PI- skin injury from prolonged pressure on the skin and tissue underneath) on the inferior fold left buttocks area for one of five sampled residents (Resident 50). This deficient practice resulted in a delay in developing a person- centered care plan that could prevent a Stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) pressure injury from progressing to a Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 41) with limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received appropriate treatment and services to increase ROM, prevent decline in ROM, prevent further decline in ROM, and maintain mobility and/or improve mobility by failing to: 1. Ensure Resident 41 received ROM exercises on his upper bilateral (both) extremities as indicated in the facility's policy. Resident 41 was receiving ROM only on his lower bilateral extremities. 2. Ensure a physician's order for the application of a left-hand splint (a device that stabilizes a body part to protect it from further injury and help it heal) was followed as ordered. Resident 41 was observed to have a towel roll in the left hand. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 210) was free of accidents when facility staff continued to use the stand-up lift (mobility equipment used to help a person transfer from a seated position to a standing position) to transfer Resident 210 to and from the bed despite Resident 210 exhibiting agitation and combativeness during use of the stand-up lift upon transfer. The deficient practice resulted in Resident 210 suffering a 1.5 centimeter (cm-unit of measurement) by 1.5 cm small bluish bump on the left side of her forehead sustained during the use of a stand-up lift.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) resident (Resident 6) had equipment and supplies necessary to manage dialysis emergencies such as bleeding. at the bedside. The deficient practice has the potential to result in complications from dialysis and bleeding.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the controlled medications (Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was stored and kept with double locked and was not accessible for non- nursing staff. This deficient practice has the potential to have drug diversion or drug misuse.

Inspectors wroteDuring an interview with the Maintenance Supervisor(MS) on 11/09/2024 at 1043 AM, the MS stated the residents in the affected rooms were not negatively impacted. The MS stated there is sufficient room for the provision of nursing services for these group of residents. the rooms were approved during OSHPD inspection. During a review of the letter provided by the DON dated 11/09/2024 , the DON requested a room waiver for the residents' room sizes less than 80 sq ft per resident for six of 18 rooms. The following resident rooms measured as followed: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident ' s (Resident 1) Minimum data Set (MDS - a federally mandated resident assessment tool), dated 10/14/2024, indicated Resident 1 had broken teeth. This deficient practice resulted an inaccurate depiction of Resident 1 ' s current health status.

Inspectors wroteBased on observations, interview and record review, the facility failed to: a. Ensure an open box of red bean ice bar was labeled with open date and use by date in the freezer. b. Ensure an open bag of fresh peeled garlic was labeled with open date and expiry date in the refrigerator. c. Ensure a bag of Panko Breadcrumbs was not laying directly on the floor of the dry storage area. This failure had the potential to put residents at risk for food borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 15 sampled residents (Resident 47 and Resident 20) received restorative nurse aid (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) (restorative nurse aid) services and treatment to prevent the further decrease in range of motion [ROM, full movement potential of a joint (where two bones meet)] and contractures (chronic joint stiffness associated with joint deformities and pain). This failure resulted in Resident 47 and Resident 20 not receiving the needed RNA services placing them at risk for further decline in the range of motion and at risk to acquire contractures.

Inspectors wroteBased on observation and interview the facility failed to ensure handwashing or hand hygiene was performed before and after contact with a resident, before using gloves and after removing gloves during medication administration for 4 of 15 sampled residents, (Resident 16, Resident 43, Resident 4, and Resident 35.) This failure had the potential to result in the transmission of and exposure to infectious microorganisms, contaminants and increased the risk of the spread of infection to the residents.

Inspectors wroteBased on observation interview and record review the facility failed to ensure one of 15 sampled residents (Resident 51) right to refuse care was honored when two nursing staff transferred Resident 51 to the bathroom after Resident 51 refused. This failure resulted in Resident 51 crying causing distress, discomfort and resisting care.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor and address the use of antibiotics (a drug to treat infection) on one of two sampled residents (Resident 53) by prescribing an antibiotic that did not meet the clinical criteria (relevant signs and symptoms of the disease) of urinary tract infection( [UTI] infection in any part of the urinary system). This failure had the potential to result in Resident 53 developing multi-drug resistance (antibiotic will not be effective to treat infection) from unnecessary or inappropriate use of antibiotic.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a functional call light for one of five sampled residents (Resident 21). This failure had the potential to result in a delay in meeting Resident 21's needs for assistance and could lead to falls and accidents.

Inspectors wroteDuring an interview with the Administrator (ADMIN) on 11/17/2023 at 1040 AM, the ADM stated the residents in the affected rooms were not negatively impacted. The ADM stated there is sufficient room for the provision of nursing services for these group of residents. the rooms were approved during OSHPD inspection. During a review of the letter provided by the ADMIN dated 1/12/2023 , the ADMIN requested a room waiver for the residents' room sizes less than 80 sq ft per resident for six of 18 rooms. The following resident rooms measured as followed: [...]