Artesia Healthcare & Rehabilitation Center, LLC

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure residents were free from abuse for 2 (R #9 and R #10) of 2 (R #9 and R #10) residents reviewed for abuse, when:1. Licensed Practical Nurse (LPN) #3 verbally abused and R #10.2. The accused staff member was no prohibited from providing resident care during the investigation putting other residents at risk for abuse. 3. LPN #3 has since confronted R #9 (reporter and witness to the verbal abuse of R #10) which could be considered an attempt at intimidation. This deficient practice likely resulted in R #10 experiencing psychosocial harm in the form of fear, anxiety, tearfulness, sleep disturbance, emotional distress, and concern for retaliation.

Inspectors wroteBased on record review and interview, the facility failed to provide services that meet professional standards of quality when Administrator (ADM) #1 performed duties outside of her scope of practice (nursing duties). This deficient practice has the potential to put all 53 residents residing in the facility according to the census provided by the Business Office Manager (BOM) on 07/23/26, at risk of receiving inappropriate care that could harm the residents' health.

Inspectors wroteBased on record review and interview, the facility failed to:Maintain sufficient nursing staffing to ensure the highest practicable physical, mental, and psychosocial well-being of each resident. Have Licensed Nursing Coverage 24-hours/day. This failure has the potential to affect all 54 residents (residents were identified by the facility census list provided by the Business Office Manager on 07/23/26). These deficient practices are likely to negatively impact resident safety, comfort, and impede processes such as timely showers and appropriate assistance with care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to post nurse staffing data daily at the beginning of the shift to include the following:- Facility name.- The current date.- 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 nurse,2. Licensed practical nurse,3. Certified nurse aides,4. Resident census. This deficient practice has the potential to affect all 53 residents identified by the census provided by the Business Office Manager on 07/23/26. This could likely result in residents and visitors not having the updated staffing information readily available.

Inspectors wroteBased on record review, observation, 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) when the facility failed to ensure Enhanced Barrier Precaution (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signs were posted and visible outside of resident rooms. This deficient practice has the potential to affect all 53 residents identified on the facility census provided by the Business Office Manager on 07/23/26. This deficiency is likely to put residents at risk of contracting and spreading infections, hospitalization, and death.

Inspectors wroteBased on record review and interview, the facility failed to report incidents involving allegations of abuse or neglect to the State Agency (SA) no later than 24 hours after the allegation was made, for 2 (R #9 and R #10) of 3 (R #9, R #10, and R #13) residents reviewed for abuse. If the facility fails to report allegations of abuse or neglect to the State Agency, then residents are at risk for delayed investigation to identify or rule out abuse or neglect, lack of timely interventions to prevent resident harm.

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 3 (R #46, R #55, and R #60) of 6 (R #1, R #7, R #9, R #46, R #55 and R #60) 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 observation and interviews, the facility failed to maintain a clean, safe, and comfortable environment for 11 (R #1, R #4, R #20, R #25, R #28, R #32, R #46, R #50, R #51, R #55, and R #61) of 15 (R #1, R #2, R #4, R #18, R #20, R #25, R #28, R #32, R #42, R #46, R #50, R #51, R #55, R #61, and R #63) residents reviewed when staff failed to:1) Repair broken outlet covers in resident rooms #301 and #305.2) Repair damaged drywall in resident rooms #203, #208, #209, #212, #301, #302 and #305.3) Empty trash timely room [ROOM NUMBER].4) Repair or repaint handrails throughout the building. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities. These deficient practices could likely result in residents feeling frustrated, embarrassed, and unimportant.

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 2 (R #55 and R #60) of 3 (R #3, R #55 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 record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 3 (R #18, R #47, and R #60) of 6 (R #1, R #2, R #18, R #26, R #47, and R #60) residents 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 ensure staff revised the care plan for 3 (R #4 and R #7) of 4 (R #4, R #7, R #26, and R #55) residents reviewed when staff failed to:1. Revise R #4's care plan to:-Include use of a camera in R #4's room,-Include appropriate interventions for falls,-Include the changes in R #4's diet,-Remove the use of oxygen therapy,2. Revise R #7's care plan to remove the use of insulin therapy. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following:- Facility name.-The current date.-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 nurse,2. Licensed practical nurse,3. Certified nurse aides,4. Resident census. The deficient practice has the potential to affect all 51 residents as identified by the census provided by the Manager on Duty (MOD) on 02/22/26 and could likely result in residents and visitors not having the staffing information readily available.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen (plan to manage a person's medication) was free from unnecessary drugs by ensuring indication of use is based on the residents' current diagnosis for 8 (R #1, R #4, R #7, R #9, R #46, R #55, R #60, and R # 63) of 9 (R #1, R #4, R #6, R #7, R #9, R #46, R #55, R #60,and R #63) residents reviewed for unnecessary medication. This deficient practice cold likely lead to adverse drug effects and poor patient outcomes.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to ensure:1. Staff wore hairnets and beard nets while in the kitchen. 2. Food items were labeled and dated. These deficient practices are likely to affect all 51 residents listed on the resident census list provided by the Administrator on 02/22/26 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 record review and interview the facility failed to ensure residents were only liable for services rendered for 1 (R #64) of 4 (R #3, R #8, R #59 and R #64) residents reviewed for discharge when the facility failed to refund the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge.

Inspectors wroteBased on record review and interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis or need for secondary screening for 2 (R #26 and R #31) of 5 (R #18, R #26, R #31, R #45, and R #55) residents reviewed for accuracy of PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #4) of 4 (R #1, R #2, R #4, and R #26) residents reviewed for care plans when staff failed to implement R #4's care plan for falls by utilizing the fall mat. This deficient practice could likely result in proper care not being provided to residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #42) of 1 (R #42) resident reviewed when the staff failed to follow physician orders. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on record review, and interview, the facility failed to provide quality of care when staff failed to implement and follow discharge orders for wound care for 1 (R #60) of 3 (R #1, R #4, and R #60) resident reviewed. These deficient practices could likely result in residents to not getting the treatment needed and/or potentially worsening conditions.

Inspectors wroteBased on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #60) of 2 (R #1 and R #60) residents reviewed for pain when the facility failed to:1. Administer medications as per physician's orders.2. Monitor pain.3. Implement a care plan and interventions for pain management. This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain appropriate physician orders prior to installation of bed rails for 1 (R #60) of 2 (R #46 and R #60) residents reviewed for bedrails. 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 residents were free of any significant medication errors for 1 (R #42) of 1 (R #42) residents reviewed for medication administration when they failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure hospice services met professional standards for 1 (R #4) of 1 (R #4) residents reviewed for hospice services by:1. Not having a qualifying diagnosis for R #4.2. Not having hospice plans of care for R #4. These deficient practices are likely to result in the resident not receiving the services that she needs.

Inspectors wroteBased on observations and interviews, the facility failed to utilize enhanced barrier precautions (an infection control intervention) when providing personal care to 1 (R #10) of 2 (R #10 and R #23) residents. Failure to utilize enhanced barrier precautions when performing personal care has the potential to spread organisms, diseases, and other health conditions among the residents.

Inspectors wroteBased on record review and interview, the facility failed to report the results of all investigations to the State Survey Agency within five working days of an incident for 1 (R #1) of 4 (R #1, R #2, R #3 and R #4) residents reviewed for abuse or neglect. If the facility is not submitting the summary of the facility's investigation to the State Survey Agency, then the State Survey Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on observation, record review and interview, the facility failed to: 1. Complete the sign-off sheet and record the measurement of the dishwasher temperatures and sanitizing solutions daily. 2. Complete the sign-off sheet and record the food temperatures daily. 3. Ensure the sanitization logs were signed with the appropriate concentrations of sanitizer and water measured the proper dilution strength after dilution [cleaning solutions are measured in parts per million, (PPM). Greater than 50 PPM is required after diluting the concentrated sanitizing liquid] were completed daily. These failures could potentially affect all 54 residents in the facility who eat food prepared in the kitchen (residents were identified by the census provided by the Administrator on 09/23/25). [...]

Inspectors wroteBased on record review and interview, the facility failed to inform residents and the resident representative in writing of a room change prior to the resident changing rooms and include the reason for the room change for 1 (R #1) of 1 (R #1) resident reviewed for room change. This deficient practice is likely to result in frustration and confusion for the residents which could lead to mental anguish.

Inspectors wroteBased on record review and interview, the facility administrator failed to report and thoroughly investigate an allegation of sexual assault. This deficient practice could affect all 46 residents residing in the facility according to the daily census provided by the Administrator (ADM) on 06/03/25. If the facility is not thoroughly reporting and investigating allegations of sexual assault, then residents are at a higher risk of being abused, neglected, or mistreated.

Inspectors wroteBased on record review and interview, the facility failed to report an an incident of abuse to the State Survey Agency for 1 (R #1) of 1 (R #1) resident reviewed for abuse. If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation for allegations of abuse for 1 (R #1) of 1(R #1) resident reviewed for abuse. If the facility is not completing an accurate and thorough investigation for an allegation of abuse and submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on observation and interviews, the facility failed to provide a comfortable and homelike environment for 4 (R #9, R #28, R #34, and R #152) of 4 (R #9, R #28, R #34, and R #152) residents sampled for environment by not repairing or cleaning the following: 1. Peeling and chipped paint 2. Wall repairs not repainted to match rest of wall 3. Hand rails in 300 hall appeared worn and needed repair/refinishing. 4. The carpet in the 200 hall and 300 hall were stained, worn and faded. 5. The wall near the main entrance by fire alarm had been repaired with plaster but has no paint. 6. The ceiling tiles near nurses station have brown stains covering most of the tile. These deficient practices could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 3 (R #9, R #30, and R #45) of 4 (R #9, R #14, R #30, and R #45) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need.

Inspectors wroteBased on record review and interview, the facility failed to prevent an accident for 1 (R #9) of 3 (R #6, R #9, and R #30) residents reviewed for falls when staff failed to complete a post-fall neurological evaluations (neurocheck; a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status). This deficient practice is likely to put residents at risk of unsafe situations.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident with a foley catheter (a thin, sterile tube inserted into the bladder to drain urine) 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 #9) of 2 (R #9 and R #30) residents reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of infections for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed three medication errors out of 29 opportunities for 1 (R #28) of 9 (R #2, R #4, R #12, R #17, R #20, R #22, R #25, R #28, R #152) residents reviewed during medication administration. This resulted in a medication error rate of 10.34%. This deficient practice could likely result in the residents receiving the incorrect medication, not receiving the desired therapeutic effect, and exposing the resident to a higher risk of side effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #28) of 1 (R #28) residents reviewed for medication administration when they failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication.

Inspectors wroteBased on observation and interview, the facility failed to assure medications were secured and inaccessible to unauthorized staff, visitors, and residents. This deficient practice has the potential to affect all 14 residents residing on the 200 hall as identified on the resident census provided by the Administrator on 05/14/25. Improperly stored medications could result in a resident, staff member, or visitor taking the medications not prescribed to them.

Inspectors wroteBased on record review and interview, the facility failed to ensure their binding arbitration agreement (contract where parties agree to resolve disputes through a neutral third party instead of court) explicitly (in a clear and detailed manner, leaving no room for confusion or doubt) grants the resident and/or representative the right to rescind (to cancel) the agreement within 30 calendar days of signing the agreement for the 20 (R #3, R #5, R #7, R #8, R #10, R #11, R #13, R #15, R #17, R #18, R #19, R #20, R #23, R #24, R #25, R #28, R #30, R #32, R #35, and R #37) of 49 (R #1-R #49) This is not clear only 20 residents of the 49 residents binging arbitration agreement did not include a provision for the resident's and/or resident's representative ability to rescind the agreement within 30 calendar days and was not signed? Please provide evidence The census was 49, it's 49 total [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their binding arbitration agreement (a clause within a contract where parties agree to resolve disputes through arbitration (arbitration; formal out -of-court method of resolving disputes) and waive their right to a trial and agree to accept the arbitrator's decision as final) included a provision for convenient venue (a location in which to carry out arbitration proceedings which should be agreed upon and suitable for both parties) selection. [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain proper infection prevention practices when staff did not clean the blood pressure cuff and vital sign equipment prior to and after taking vital signs for 3 (R #22, R #28, and R #152) of 3 (R #22, R #28, and R #152) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the hallway in the 200 hall was accessible for residents. This deficient practice is likely to affect all 14 residents residing on the 200 hall as identified on the resident census provided by the Administrator on 05/14/25. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and life saving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #45) of 2 (R #3 and R #45) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially life saving procedures.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 2 (R #9 and R #30) of 5 (R #2, R #4, R #9, R #30, and R #44) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 2 (R #3 and R #45) of 3 (R #3, R #14 and R #45) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 2 (R #3 and R #4) of 5 (R #3, R #4, R #21, R #23, and R #36) residents reviewed for care plans. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and safe environment. This deficient practice is likely to affect all 44 residents living in the facility as listed on the Resident Census provided by the Administrator on 04/24/24. Failure to maintain a safe and clean environment is likely to prevent residents from enjoying everyday outdoor activities.

Inspectors wroteBased on interview and record review, the facility failed to keep all 44 residents residing in the facility free from the potential for accidents or hazards by placing mothballs (a solid chemical in the form of a ball that is normally used to control moths, silverfish, and other pests that like wool and other natural fiber materials) in the courtyard area. This deficient practice could likely result in new or worsening health issues for the residents.

Inspectors wroteBased on interview, the facility failed to treat residents with respect and dignity for 1 (R #1) of 1 (R #1) residents reviewed when staff did not discuss plans for removing the cats from the facility grounds prior to placing mothballs in the courtyard area. This deficient practice is likely to result in residents feeling that their feelings and preferences are unimportant.

Inspectors wroteBased on interviews, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. This deficient practice had the potential to affect all 48 residents living in the facility as identified by the census provided by the Adminisstrator on 03/11/24.

Inspectors wroteBased on observation and interview, the facility failed to properly store medications and supplies for all 48 residents, as identified by the matrix provided by the Administrator on 03/11/24, when staff failed to ensure the expired supplies and medications were not stored in the supply room. The deficient practice could likely result in all residents receiving medication that are expired or the use of supplies that are expired.

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to: 1. Use proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. 2. Have food at the proper temperature on the food steam table prior to serving. These deficient practices are likely to affect all 48 residents listed on the resident's census list provided by the Administrator on 03/11/24 and could likely lead to food borne illnesses in residents if safe food handling practices are not adhered to.

Inspectors wroteBased on observation and interview, the facility failed to maintain a comfortable and homelike environment that was clean, in good condition, and free from ceiling and wall debris for 1 resident occupied room (room [ROOM NUMBER]) in the facility. Failure to maintain the resident room in a clean and comfortable manner is likely to prevent residents living in a comfortable, homelike environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an accurate comprehensive assessment for 1 (R #28) of 1 (R #28) residents reviewed for assessments. This deficient practice is likely to result in residents not receiving an accurate assessment which could result in residents receiving less than optimal care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan for 2 (R #7 and R #28) of 2 (R #7 and R #28) residents reviewed for care plans. If the facility is not updating the care plan to reflect the residents' current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to create an accurate 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 3 (R #6, R #38, and R #46) of 4 (R #6, R #35, R # 38, and R #46) residents reviewed for baseline care plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care resident's need.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents with wounds had the correct documentation and monitoring in accordance with the professional standards of practice for 1 (R #46) of 1 (R #46) residents reviewed for pressure injury (localized damage to the skin/tissue occurs due to pressure). This deficient practice is likely to result in residents having worsened conditions. The finds are: A. Record Review of R #46's skin/wound notes, revealed the following: - On 02/14/24, a wound stage 4 (These sores extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments) to the coccyx (tailbone) which measured 1.7 centimeters (cm) by 1.1 cm by 3.5 cm, with copious serious drainage (type of fluid that comes out of a wound with tissue damage) noted. [...]