Artesia Healthcare & Rehabilitation Center, LLC
For profit - Limited Liability company
65 Beds
Independent
Data: November 2025
Trust Grade
35/100
#53 of 67 in NM
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Artesia Healthcare & Rehabilitation Center in Artesia, New Mexico has received a Trust Grade of F, indicating significant concerns about its operations. It ranks #53 out of 67 facilities in the state, placing it in the bottom half, and #2 out of 2 in Eddy County, meaning there is only one local option rated higher. The facility's trend is worsening, with issues increasing from 11 in 2024 to 18 in 2025. Staffing appears to be a strength, with a rating of 4 out of 5 stars and a turnover rate of 45%, which is below the state average. However, there have been serious incidents, including a failure to ensure residents were free from abuse, with one resident being taken into a dining room against her will, and another incident where an allegation of sexual assault was not thoroughly investigated, raising significant safety concerns.
- Trust Score
- F
- In New Mexico
- #53/67
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Mexico facilities.
- Skilled Nurses ✓ Good
- Each resident gets 46 minutes of Registered Nurse (RN) attention daily — more than average for New Mexico. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 21%
Needs review
11 → 18 violations
★☆☆☆☆
1.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 11 issues
2025: 18 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
1-Star Overall Rating
Below New Mexico average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 45%
Near New Mexico avg (46%)
Higher turnover may affect care consistency
The Ugly 33 deficiencies on record
1 actual harm
Jun 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report an an incident of abuse to the State Survey Agency for 1 (R ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
A. Record review of R #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] section C revealed a Brief Interview for Mental Status (BIMS) score of zero (significant impairment).
B. Record review of a grievance report dated 05/25/25 revealed staff reported an allegation of possible sexual assault on R #1 from R #2.
C. Record review of the New Mexico Health Care Authority (HCA) complaints intake revealed HCA had not received a report from the facility regarding the allegation of possible resident sexual abuse for the grievance report dated 05/25/25.
D. On 06/03/25 at 9:25 am during an interview, Housekeeper (HK) #1 confirmed she was told by another staff that R #2 was seen kissing R #1. HK stated she was concerned because R #1 is vulnerable and cannot defend or speak for herself. HK reported her concerns to the Social Worker (SW).
E. On 06/03/25 at 10:03 am during an interview, the Social Worker (SW) confirmed she received a grievance from staff on 05/25/25. The SW confirmed R #1 cannot communicate verbally and does not have the ability to defend herself if needed. SW stated R #2 denied the allegation and R #1 looked at SW. The SW stated she did report the allegation to the Administrator.
F. On 06/03/25 at 10:08 am during an interview with the Administrator (ADM), he confirmed he is the Abuse Coordinator. ADM stated he did not believe that sexual abuse had occurred and did not believe that the allegation needed to be reported to the State Agency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based 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 comp...
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Based 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. The findings are:
A. Record review of a grievance report dated 05/25/25 revealed:
1. Staff reported an allegation of possible sexual assault on R #1 from R #2.
2. R #2 denied the allegation and R #1 looked at the SW.
3. The administrator was informed of the allegation.
4. Follow/up Action taken stated Final outcome, no sign of abuse was detected.
B. On 06/03/25 at 10:03 am during an interview, the Social Worker (SW) confirmed she received a grievance from staff on 05/25/25. The SW confirmed R #1 cannot communicate verbally and does not have the ability to defend herself if needed. SW stated R #2 denied the allegation and R #1 looked at SW. The SW stated she did report the allegation to the Administrator.
C. On 06/03/25 at 10:08 am during interview with the Administrator (ADM), he confirmed a thorough investigation of the allegation was not done and should have been.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based 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 resi...
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Based 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. The findings are:
A. Record review of a grievance report dated 05/25/25 revealed staff reported an allegation of possible sexual assault on R #1 from R #2 to the Social Worker (SW).
B. On 06/03/25 at 10:03 am during an interview, the SW confirmed she received a grievance from staff on 05/25/25 reporting an allegation of sexual assault on R #1. The SW stated she did report the allegation to the Administrator (ADM) on 05/25/25.
C. Record review of the New Mexico Health Care Authority (HCA) complaints intake revealed HCA had not received a report from the facility regarding the allegation of possible resident sexual assault.
D. On 06/03/25 at 10:08 am, during an interview with the ADM, he stated that he did not report the allegation of sexual assault because we can't have too many dings against us. The ADM confirmed he was aware of the allegation and chose not to report it to the State Agency.
Mar 2025
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
A. Record review of R #45's face sheet revealed R #45 was admitted into the facility on [DATE].
B. Record review of R #45's physician orders dated [DATE], revealed R #45 was a Do Not Resuscitate (DNR- a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops) for her advanced directive code status.
C. Record review of R #45's EHR revealed the record did not contain a valid advanced directive form. The New Mexico medical orders for scope of treatment (MOST) indicated the form must be signed by an authorized healthcare provider and the patient/decision maker to be valid and the form was not singed.
D. On [DATE] at 12:00 pm, during an interview with the Director of Nursing (DON), she confirmed R #45's advanced directive code status was not signed by the physician and uploaded into R #45's EHR. The DON also confirmed there was not a valid written form available for nursing staff to complete and confirmed this should have been a available.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
R #9
A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE], with the following diagnoses:
1. Anxiety (feeling of worry, nervousness, or unease),
2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified,
3. Neuromuscular (dysfunction of bladder), unspecified,
4. Repeated falls,
5. Need for assistance with personal care.
B. Record review of R #9's electronic health record (EHR) revealed a change of condition assessment was completed for R #9 falls on 11/04/24, 11/05/24, 01/01/25, 01/05/25, 01/06/25, and 01/28/25.
C. Record review of R #9's care plan dated 10/31/24, revealed R #9 was at risk for falls and had the following interventions in place:
1. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.
2. Ensure adequate lighting and visual aids are in place on admission assess for communication needs as indicated.
3. Ensure [Name of R #9] is wearing appropriate footwear when ambulating (walk, move about) or mobilizing (make moveable or capable of movement) in w/c (wheelchair).
4. Resident needs a safe environment with high-low bed in low position while resident is in bed.
D. Record review of R #9's quarterly MDS assessment dated [DATE], section J1700, revealed R #9 had not had any falls since admission.
E. On 03/07/25 at 10:35 am, during an interview with the Director of Nursing (DON), she confirmed R #9 has had several falls since he was admitted to the facility. She stated she would expect R #9's MDS assessment to be accurate and reflect the falls that he has had.
R #30
F. Record review of R #30's admission Record revealed R #30 was admitted to the facility on [DATE] with the following diagnoses:
1. Hemiplegia (weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke; blood vessel blockage in the brain) affecting the right dominant (most important, powerful) side,
2. Cerebral Palsy (a group of neurological disorders that appear in infancy or early childhood that permanently affect body movement and muscle coordination), unspecified,
3. Personal history of other mental and behavioral disorders,
4. History of falling.
G. On 03/04/25 at 9:30 am, during an observation of R #30's room, R #30's bed had rails on both sides of the bed.
H. Record review of R #30's care plan dated 03/18/21, revealed Resident may use bed rails bilateral (two sides, affecting both sides) upper sides of bed to enhance mobility/positioning.
I. Record review of R #30 MDS assessment dated [DATE], section P revealed the bed rails are not in use.
J. On 03/07/25 at 10:35 am, during an interview with the DON, she confirmed R #30's MDS assessment is not accurate because R #30 does utilize bed rails. The DON stated she expects all MDS assessments to reflect accurate person-centered information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop and implement an accurate, person-centered co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
R #3
A. Record review of R #3's face sheet revealed R #3 was admitted to the facility on [DATE], with the following diagnoses:
1. Pain in right hip,
2. History of falling,
3. Pain in right knee,
4. Muscle weakness (generalized),
5. Difficulty in walking,
6. Lack of coordination.
B. On 03/04/25 at 10:06 am, during an observation of R #3's bed, revealed grab bars on each side of the bed
C. Record review of R #3's care plan dated 12/18/24, revealed R #3 did not have a care plan for the use of grab bars.
D. On 03/04/25 at 10:06 am, during an interview, R #3 stated she was aware she had grab bars on each side of the bed and used the garb bars to help with repositioning herself and with bed mobility.
E. On 03/04/25 at 12:00 pm, during an interview with the Director of Nursing (DON), she stated R #3 did not have a care plan for the grab bars and should have.
R #45
F. Record review of R #45's face sheet revealed R #45 was admitted to the facility on [DATE], with the following diagnoses:
1. Legal Blindness,
2. Difficulty walking,
3. Lack of coordination,
4. Abnormalities of gait and mobility (a change in walking patterns and the ability to move around)
5. Angioneurotic edema (condition characterized by sudden, localized swelling of the skin and mucous membranes).
G. On 03/04/25 at 8:41 am, during an observation of R #45's bed, revealed a grab bar on upper left side of his bed.
H. Record review of R #45's care plan, dated 01/28/25, revealed R #45 did not have a care plan for the use of grab bars
I. On 03/04/25 at 8:41 am, during an interview, R #45 stated he was aware he had grab bar on the left side of his bed and used the garb bar to help with getting up from his bed.
J. On 03/07/25 at 12:00 pm, during an interview with the Director of Nursing (DON), she stated R #45 did not have a care plan for use of grab bar and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
R #3
A. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE].
B. Record review of R #3's care plan dated 12/18/24, revealed R #3 is at risk for abnormal bleeding or hemorrhage (the loss of blood from the circulatory system) due to anticoagulant (medication used to prevent and treat blood clots in blood vessels and the heart) use related to daily use of Plavix (a medicine used to prevent problems caused by blood clots).
C. Record review of R #3's electronic health record (EHR), revealed a physician order for Plavix dated 12/18/24 and was discontinued 01/11/25.
D. Record review of R #3's Medication Administration Record (MAR) for the month of March 2025, revealed R #3 was not administered Plavix nor any other anticoagulant medication.
E. On 03/07/25 at 12:00 pm, during an interview with the Director of Nursing (DON), she confirmed R #3 was not currently taking any anticoagulant medications and the medication Plavix was discontinued in January 2025. The DON confirmed the revision of the care plan for R #3 was not revised should have been.
R #4
F. Record review of R#4's facility Nursing progress note dated 02/08/25, revealed the following:
1. R #4 sustained a fall without injuries.
2. A change in condition completed R #4 for falls.
G. Record review of the Care Plan initiated on 09/06/24 revealed the following:
1. Addresses risk for falls due to Metabolic Encephalopathy (condition in which brain function is disturbed either temporarily or permanently), Malignant Neoplasm of sigmoid colon, (colon cancer) psychotropic medication use, difficulty in walking, with classified falls that occurred on 09/10/24 fall in her room with no injuries and on 09/15/24 fall in her room with no injuries.
2. There were no additional updates on interventions in R #4's care plan for fall on 02/08/25.
H. On 03/07/25 at 9:40 am during an interview, with the Director of Nursing (DON), she confirmed the care plan R #4 was not revised to include interventions for the 02/08/25 fall and should have been.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based 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 sample...
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Based 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. The findings are:
A. On 03/03/25 10:37 am a random observation of the facility environment revealed 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.
R #9
B. On 03/05/25 12:15 PM during an observation of R #9's room, the back of door had paint chipping off.
R #28
C. On 03/05/25 10:32 AM during an observation of R #28's room, wall in room repaired but not repainted to match remainder of wall.
R #34
D. On 03/05/25 02:27 PM during an observation of R #34's room paint was chipped around closet door.
R #152
E. On 03/05/25 10:33 AM during an observation of R# 152's room, paint was chipped around closet door and sheetrock exposed and crumbling at the bottom of closet door frame.
F. On 03/05/25 at 3:14 pm, during an interview with the Director of Maintenance (DOM), he confirmed the handrails wear and tear, damage to walls and trim in resident rooms, paint chipping, stained and soiled carpet, and incomplete repairs does not constitute a homelike environment in it's current state.
G. On 03/05/25 at 3:33 pm, during an interview with the Director of Nursing (DON), she confirmed the environment in it's current condition does not meet her expectations because it is not homelike.
H. On 03/05/25 at 3:43 pm, during an interview with Corporate Representative (CP) #1, she stated they are aware of these environmental issues because they noticed these things a week ago. She stated her expectations are for the smaller repairs such as painting to be completed in house and the larger repairs to be completed after a request is submitted and will be done through outside vendor. She stated that she expects all facilities they run to be homelike and agreed this facility is not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a sc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
Should S/S be D, 3 residents and each had on PASRR assessment
R #9
A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE] with the following diagnoses:
1. Anxiety (feeling of worry, nervousness, or unease),
2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified,
3. Neuromuscular dysfunction of bladder, unspecified,
4. Repeated falls,
5. Need for assistance with personal care.
B. Record review of R #9's PASRR dated 10/31/24, revealed staff documented the following:
1. R #9 does not have a diagnosis or evidence of intellectual disability or developmental disability prior to the age of 18.
2. R #9 does not have a diagnosis or suspected mental illness.
C. On 03/07/25 at 12:00 pm, during an interview with the Director of Nursing (DON), she stated R #9 does have a diagnosis of Down Syndrome and anxiety which is a mental illness and confirmed that R #9's PASRR is incorrect.
R #30
D. Record review of R #30's admission Record revealed R #30 was admitted to the facility on [DATE], with the following diagnoses:
1. Hemiplegia (weakness on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke; blood vessel blockage in the brain) affecting the right dominant (most important, powerful) side,
2. Cerebral Palsy (a group of neurological disorders that appear in infancy or early childhood that permanently affect body movement and muscle coordination), unspecified,
3. Personal history of other mental and behavioral disorders.
E. Record review of R #30's PASRR dated 01/27/25, revealed R #30 does not have a diagnosis or evidence of intellectual disability or developmental disability prior to the age of 18.
F. On 03/07/25 at 12:00 pm, during an interview with the DON, she stated R #30 does have a diagnosis of Cerebral Palsy which is specifically listed on section E, Identification of Related Condition Evaluation Criteria, of the PASRR and the question is marked no so the PASRR is not correct.
R #45
G. Record review of R #45's face sheet revealed R #45 was admitted into the facility on [DATE] with the following diagnoses:
1. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),
2. Anxiety disorder (feelings of fear or apprehension),
3. Depression (persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily life),
4. Suicidal ideations (Intrusive thoughts and a preoccupation with death and dying),
5. Stimulant abuse with stimulant-induced mood disorder (related conditions that can occur when someone uses stimulants[stimulant, a class of drugs that speed up messages traveling between the brain and body]).
H. Record review of R #45's PASRR, dated 01/27/25, revealed staff documented R #45 did not have a diagnosis or suspected mental illness.
I. On 03/07/25 at 12:00 pm, during an interview with the Director of Nursing (DON), she stated the facility should have made sure R #45's, PASRR level 1 was correct prior to admission, but they did not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE], with the following diagnoses:
1. Anxiety (feeling of worry, nervousness, or unease),
2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified,
3. Neuromuscular dysfunction of bladder, unspecified,
4. Repeated falls,
5. Need for assistance with personal care.
B. Record review of R #9's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 02/06/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 3, severe impairment.
C. Record review of R #9's electronic health record (EHR), revealed a change of condition assessment was completed for R #9 for falls on 11/04/24, 11/05/24, 01/01/25, 01/05/25, 01/06/25, and 01/28/25.
D. Record review of the facility's Neurological Evaluation (neurological assessment completed by facility staff)Flow Sheet, revealed the following:
1. Residents are to be evaluated every 15 minutes for the first two hours after the completion of the initial evaluation following a fall.
2. After the first two hours, residents are to be evaluated every thirty minutes for two hours.
3. After the first four hours, residents are to be evaluated every hour for four hours.
4. After the first eight hours, residents are to be evaluated every eight hours for an additional 64 hours.
5. The full neurological evaluation should take no less than 72 hours.
E. Record review of R #9's Neurological Evaluation Flow Sheets, revealed the following:
1. The facility failed to complete a neurological evaluation after the fall on 11/04/24.
2. The facility failed to complete a full neurological evaluation after the fall on 11/05/24.
3. The facility failed to complete a neurological evaluation for R #9 following his fall on 01/01/25.
4. The facility failed to complete a neurological evaluation for R #9 following his fall on 01/05/25.
5. The facility failed to complete a full neurological evaluation for R #9 following his fall on 01/06/25.
F. On 03/07/25 at 10:45 am, during an interview with the Director of Nursing (DON), she confirmed the facility failed to complete neurological evaluations as required. She stated that neurological examinations are to be completed for every unwitnessed fall for at least 72 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident with a foley catheter (a thin, steri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE], with the following diagnoses:
1. Anxiety (feeling of worry, nervousness, or unease),
2. Down Syndrome (a genetic condition caused by the presence of an extra copy of chromosome, affects development, leading to intellectual disability and delays, and certain physical traits), unspecified,
3. Neuromuscular dysfunction of bladder, unspecified,
4. Repeated falls,
5. Need for assistance with personal care.
B. Record review of R #9's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 02/06/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 3, severe impairment.
C. On 03/04/25 at 8:52 am, during an observation of R #9, revealed a catheter tube and urine bag attached to his wheelchair.
D. Record review of R #9's current medical orders revealed, no order for the use of a catheter, the type of catheter that is needed, or the care that the catheter requires.
E. Record review of R #9's care plan dated 10/31/24, revealed R #9 has an indwelling foley catheter.
F. On 03/07/25 at 10:45 am, during an interview with the Director of Nursing (DON), she confirmed R #9 does have an indwelling catheter. The DON stated that the facility should have orders for the catheter and confirmed they do not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based 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 opportuni...
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Based 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. The findings are:
A. On 03/05/25 at 9:40 am, during an observation of Licensed Practical Nurse (LPN) #1, obtained vital signs (measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) for R #28, blood pressure was 121/75 (121; systolic number: maximum pressure during contraction of heart, 75; diastolic number: minimum pressure at the end of hearth contraction) and a pulse (rhythmic throbbing of blood vessels) of 78 beats per minute.
B. On 03/05/25 at 9:42 am during a medications administration observation, LPN #1 poured and administered the following medications to R #28:
- Amlodipine (medication to manage blood pressure) 10 milligrams (mg),
- Metoprolol Succinate (medication to manage blood pressure) 50 mg,
- Valsartan (medication to manage blood pressure) 320 mg.
C. Record review of R #28's physician orders revealed the following:
- Dated 12/10/24, Amlodipine 10 mg by mouth one time a day, for hypertension (pressure in the blood vessels is too high). Hold if pulse is below 60 and notify provider, hold if bp (blood pressure) is less than 140/90.
- Dated 12/12/24, Metoprolol 50 mg by mouth one time a day, for hypertension. Hold if pulse is below 60 and notify provider, hold if bp is less than 140/90.
- Dated 12/12/24, Valsartan 320 mg by mouth one time a day, for hypertension. Hold if pulse is below 60 and notify provider, hold if bp is less than 140/90.
D. On 03/07/2025 at 1:03 pm, during an interview with the Director of Nursing (DON), she stated orders for blood pressure medication should be held for the blood pressure under 140/90, she confirmed that LPN #1 had made a medication error after giving blood pressure medications outside the prescribed parameters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based 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...
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Based 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. The findings are:
A. Record review of R #28's Physician's orders revealed the following:
- Metoprolol (beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) ER (extended release) Start date 12/10/24. Metoprolol succinate (beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) ER (extended release), oral tablet, extended release 24-hour, 50 mg (milligram; dose of medication); Give 50 mg by mouth one time a day for hypertension (high blood pressure). Hold if pulse is below 60 and notify provider, hold if BP (blood pressure) is less than 140/90.
-Amlodipine Besylate (calcium channel blocker used for high blood pressure and chest pain)- Start date 12/10/24. Amlodipine Besylate oral tablet, Give 10 mg by mouth one time a day for hypertension. Hold if pulse is below 60 and notify provider, hold if BP is less than 140/90.
- Valsartan (angiotensin(hormone) II receptor blocker to treat high blood pressure)- Start date 12/10/24. Valsartan 320 mg; Give 320 mg by mouth one time a day for hypertension. Hold if pulse is below 60 and notify provider, hold if BP is less than 140/90.
B. Record review of R #28's Medication Administration Record (MAR) for February 2025, revealed staff administered the following medications:
-Metoprolol succinate ER, 50 mg, on 02/01/25, 02/02/25, 02/05/25, 02/06/25, 02/10/25, 02/11/25, 02/14/25, 02/15/25, 02/16/25, 02/19/25, 02/20/25, 02/24/25, 03/05/25, 03/06/25 for blood pressure under 140/90.
-Amlodipine Besylate, 10 mg, on 02/01/25, 02/02/25, 02/05/25, 02/06/25, 02/10/25, 02/11/25, 02/14/25, 02/15/25, 02/16/25, 02/19/25, 02/20/25, 02/24/25, 03/05/25, 03/06/25 for blood pressure under 140/90.
-Valsartan, 320 mg, on 02/01/25, 02/02/25, 02/05/25, 02/06/25, 02/10/25, 02/11/25, 02/14/25, 02/15/25, 02/16/25, 02/19/25, 02/20/25, 02/24/25.
C. Record review of R #28's blood pressures were documented as follows:
1. 02/01/25 - 102/60 at 10:19 am,
2. 02/02/25 - 102/68 at 10:22 am,
3. 02/05/25 - 109/69 at 11:22 am,
4. 02/06/25 - 128/70 at 8:37 am,
5. 02/10/25 - 108/58 at 7:33 am,
6. 02/11/25 - 118/66 at 7:14 am,
7. 02/14/25 - 118/86 at 8:13 am,
8. 02/15/25 - 118/62 at 8:24 am,
9. 02/16/25 - 120/68 at 10:19 am,
10. 02/19/25 -118/68 at 10:01 am,
11. 02/20/25 - 124/64 at 9:21 am,
12. 02/24/25 - 118/62 at 10:18 am,
13. 03/05/25 - 121/75 at 9:54 am,
14. 03/06/25 - 138/68 at 7:08 am.
D. Record review of R #28's MAR for February and March of 2025 revealed staff administered Metoprolol ER, Amlodipine Besylate, and Valsartan for blood pressure under 140/90 on fourteen different occasions.
E. On 03/07/25 at 1:03 pm, during an interview with the Director of Nursing (DON), she stated the following:
1. R #28 received her three blood pressure medications outside the prescribed parameters.
2 Medication were administered outside the prescribed parameters causing a significant medication error.
3. She stated her expectations are for the nurses to follow the orders as written, hold the medication and call the doctor to verify parameters.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to assure medications were secured and inaccessible to unauthorized staf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings are:
A. On 05/14/25 at 8:10 am a random observation of the 200 hall revealed a medication cart near room [ROOM NUMBER], had seven boxes of wound gel on top of the cart. Staff were not present in the area near the cart.
B. On 05/14/25 at 8:14 am, during an interview with Director of Staff Development (DSD), she stated the wound gel should have been placed in the medication storage room and not left on top of the cart unattended.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected multiple residents
Based 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...
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Based 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 residents. Only 20 of those 49 residents agreed to sign the arbitration agreement. That's why I had it like this to start-
Based on record review and interview, the facility failed to ensure their binding arbitration agreement explicitly grants the resident and/or representative the right to rescind the agreement within 30 calendar days of signing the agreement. This deficient practice has the potential to affect all 20 residents that have signed the agreement as identified by the list the Administrator (ADM) provided on 03/05/25. The findings are:
agreement as identified by the list the Administrator (ADM) provided on 03/5/25. The findings are:
A. Record review of the facility's binging arbitration agreement, undated, revealed it does not include a provision for the resident's and/or resident's representative ability to rescind the agreement within 30 calendar days.
B. On 03/07/25 at 11:22 am, during an interview with the ADM, he confirmed the facility's binding arbitration agreement does not address residents being able to rescind the agreement within 30 calendar days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0848
(Tag F0848)
Could have caused harm · This affected multiple residents
Based 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 (arbitra...
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Based 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. Failure to include this provision in the agreement could likely result in residents who choose to seek arbitration experiencing frustration and difficulty deterring (discourage or prevent from acting on) them from exercising their rights 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) residents that have signed the agreement as identified by the list the Administrator (ADM) provided on 03/5/25. The findings are:
A. Record review of the facility's binging arbitration agreement, undated, revealed it does not include a provision for the selection of a convenient venue should arbitration become necessary.
B. On 03/07/25 at 11:22 am, during an interview with the ADM, he confirmed that the facility's binding arbitration agreement does not contain a provision for a convenient venue selection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based 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 ...
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Based 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. The findings are:
A. On 03/05/25 at 9:42 am, during an observation of Nurse #1 revealed the following:
1. Nurse #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #22.
2. Nurse #1 then took vital signs on R #28 without cleaning the blood pressure cuff and vital sign equipment.
3. Nurse #1 then took vital signs on R #152 without cleaning the blood pressure cuff and vital sign equipment.
B. On 03/05/25 at 10:18 am, during an interview with Nurse #1, he stated he should have cleaned off all vital sign equipment before taking R #22's vitals and in between each resident afterwards.
C. On 03/05/25 at 10:45 am, during an interview with the (Director of Nursing) DON, she stated she would expect all nurses to clean the vital machines before and after use with each resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the hallway in the 200 hall was accessible for residents. This...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
A. On 05/14/25 at 8:10 am a random observation of the 200 hall revealed the following:
1. A medication cart on the left side of the hallway near room [ROOM NUMBER].
2. A housekeeping cart on the right side of the hallway near room [ROOM NUMBER],
3. A housekeeping cart on the left side of the hallway near room [ROOM NUMBER],
4. A mechanical lift on the right side of the hallway near rooms [ROOM NUMBERS].
B. On 05/14/25 at 8:30 am during an interview with Housekeeper (HK) #1, she confirmed there were objects on both sides of the hallway blocking the residents' path. She stated that everything should be on one side of the hallway, so residents had a clear path.
Apr 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based 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...
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Based 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. The findings are:
A. On 04/24/24 at 1:50 pm during an interview, R #1 stated that she saw mothballs in the courtyard, and she picked some of them up to throw them away. R #1 further stated she was not informed of the facility's attempt to remove the cats prior to the mothballs being placed in the courtyard. R #1 started to cry and said, I was scared for my cats. She stated she did not understand why the facility would want to remove the cats, because she had an agreement with the facility allowing her to keep three cats. R #1 stated she met with the Ombudsman (a person who investigates, reports on, and helps settle complaints for residents in nursing homes) and the previous administrator, and they made an agreement to allow her to keep three cats.
B. On 04/24/24 at 3:38 pm during an interview with the Administrator (ADM), he confirmed the previous administrator met with R #1 and the Ombudsman, and they agreed R #1 could keep three cats at the facility. The ADM stated they did not have documentation of this agreement. The ADM further stated staff did not notify R #1 prior to the facility enacting the plan to remove the cats using mothballs.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based 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 Re...
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Based 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. The findings are:
A. On 04/24/24 at 1:06 pm, a random observation of the facility's courtyard area revealed
- A black office chair on wheels on the sidewalk with bird feces on it.
-The sidewalk, which served as the walking path for residents, was 75 percent covered with bird feces, pecans, and pecan shells and made the sidewalk impassable for residents.
-The lid on the trash can could not be closed due to the trash can was full with empty cigarette boxes.
-The grass was approximately 8 to 10 inches tall in some areas of the courtyard.
- Items, such as used napkins, a coffee cup, cigarette box wrappers, and used tissues, were on the ground throughout the courtyard.
- A garden hose stretched across the sidewalk, from the faucet to the grass area, which posed a safety risk for residents walking on the sidewalk.
B. On 04/24/24 at 3:38 pm during an interview with the Administrator (ADM), he stated the courtyard did not provide a safe and clean environment. The ADM stated the expectation was for courtyard to be kept safe and clean for all residents to use. He said the Maintenace Department was responsible to keep the courtyard clean, and they should check it on a daily basis for any trash or hazards.
C. On 04/24/24 at 4:31 pm during an interview with the Director of Nursing (DON), she confirmed the observations regarding the courtyard did not provide a safe and clean environment. She stated the yard should be maintained by maintenance, but she had to run the lawnmower in the past to cut the grass.
D. On 04/24/24 at 5:09 pm, during a random observation of the facility's courtyard area, a water hose streched across the sidewalk creating a hazard for residents, and a resident used her walker to walk over a water hose twice.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based 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 t...
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Based 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. The findings are:
A. Record review of the facility's Material Safety Data Sheet (MSDS; a document that contains information on the potential hazards and procedures of working with a chemical) book revealed a naphthalene (the main chemical found in mothballs) sheet which listed short-term or long-term side effects could be caused if inhaled or absorbed through the skin.
B. On 04/24/24 at 12:59 pm during an interview with R #2, he stated he saw mothballs in the courtyard area a few weeks back when he would go outside to smoke. R #2 said the mothballs had a strong odor.
C. On 04/24/24 at 1:06 pm, during an interview with R #3, he stated he saw and smelled mothballs in the courtyard at the beginning of April 2024, but he could not remember the exact date.
D. On 04/24/24 at 1:17 pm, during an interview with R #4, she stated she saw a bunch of mothballs in the courtyard when she went out to smoke. She stated the smell of the mothballs irritated her eyes.
E. On 04/24/24 at 1:50 pm during an interview with R #1, she stated she saw the mothballs, picked some of them up, and threw them away.
F. On 04/24/24 at 2:42 pm during an interview with CNA #1 she stated she first saw the mothballs in the courtyard on 04/03/24. CNA #1 stated she assisted in picking up and disposing of the mothballs on 04/04/24.
G. On 04/24/24 at 3:05 pm during an interview with R #5, he stated he saw golf-ball sized mothballs in the courtyard. R #5 stated the strong odor of the mothballs irritated his mouth, eyes, and throat.
H. On 04/24/24 at 3:38 pm during an interview with the Administrator (ADM), he confirmed the facility used mothballs in the courtyard area as a way to keep the cats away from the facility. He stated he approved the use of the mothballs without proper knowledge of the chemicals contained in mothballs.
I. On 04/24/24 at 5:10 pm during an interview with Activities Assistant (AA), she stated there were well over 100 mothballs in the courtyard. The AA also stated the residents stated they did not like the smell.
Mar 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create an accurate Baseline Care Plan (minimum healthcare informati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings are:
R #6
A. Record review of R #6's face sheet revealed she was admitted into the facility on [DATE].
B. Record review of R #6's Care Plan, dated 12/04/23, revealed staff did not develop a baseline care plan which included the resident's advanced directives within 48 hours of admission.
R # 38
C. Record review of R #38's face sheet revealed she was initially admitted into the facility on [DATE].
D. Record review of R #38's Care Plan, dated 07/24/23, revealed staff did not develop a baseline care plan which included the resident's advanced directives within 48 hours of admission.
R #46
E. Record review of R # 46's face sheet revealed she was initially admitted into the facility on [DATE].
F. Record review of R #46's Care Plan, dated 08/09/23, revealed staff did not develop a baseline care plan which included the resident's advanced directives within 48 hours of admission.
G. On 03/14/23 at 4:15 pm, during an interview with the Minimum Set Data nurse (MDS; a nurse that monitors, assesses, and documents resident's health at a long-term care facility. This data is used to create state and federal reports) confirmed the residents' advanced directives were not in the baseline care plans. The MDS nurse stated staff should have put the residents' advanced directives in the baseline care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based 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 pra...
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Based 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. The wound had undermining (occurs when significant erosion occurs underneath the outwardly visible wound edges resulting in more extensive damage beneath the skin surface) located at 8 to 3 o'clock (a clock face is used to explain where the undermining is located in relation to the wound) with a maximum depth of 6.4 cm.
- The record did not contain any other documentation for wound measurements.
B. On 03/13/24 at 10:56 am, during an observation of wound care for R #46 revealed, the wound was improving with current treatment. Measurements of the stage 4 coccyx wound were 1.7cm by 1.3 cm by 3.6 cm, and drainage was not noted. The wound had undermining located at 8 to 3 o'clock with a maxium depth of 6 cm.
C. On 03/14/24 at 3:40 pm during an interview, the Assistant Director of Nursing (ADON) stated staff should document the wound measurements weekly, but he was not able to find the current wound measurements.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a comfortable and homelike environment that was clean, in go...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings are:
A. On 03/13/24 at 2:45 pm during an observation in room [ROOM NUMBER], on the wall next to the closet had a scrape which measured 3 inches by 5 inches, a chipped area which measured 1 inch by 1 inch, and exposed drywall. Further observation revealed scuff marks along the wall close to the bathroom, and the ceiling tiles were worn and broken, which created a hole in the ceiling.
B. On 03/14/24 at 2:00 pm during an interview with the Maintenance Director (MD), he stated he was in the process of patching and painting the walls, and replacing the ceiling tiles. The MD stated the walls and ceilings in residents' rooms should not look like that.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
Based 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 pr...
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Based 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. The findings are:
A. On 03/11/24 at 2:33 PM, during an interview and observation with R #28, she stated she had glasses. R #28 picked up her glasses from her tray.
B. Record review of R #28's medical appointments revealed R #28 had an optometrist (eye doctor) appointment on 08/23/23. Further record review revealed the resident had her vision checked and received a new prescription.
C. On 03/13/24 at 11:46 am, during an interview with Social Worker (SW), she stated R #28 received the new glasses a few weeks after appointment on 08/23/23.
D. Record review of R #28's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment, dated 01/27/24, revealed the resident did not use glasses.
E. On 03/14/24 at 4:04 pm during an interview with MDS Coordinator, she stated R #28's MDS should state the resident uses glasses.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based 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 ca...
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Based 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. The findings are:
R #7
A. On 03/11/24 at 1:55 pm during an interview with R #7, she stated she had several urinary tract infections (UTIs) recently.
B. Record review of the care plan for R #7, dated 03/13/24, revealed the following:
- The care plan included information regarding the resident's UTIs through 08/04/23, but it did not include information on her last two diagnosed UTIs, dated 10/29/23 and 01/30/24.
- R #7 took Macrobid, an antibiotic medication used to treat bladder infections.
C. Record review of R #7's physician orders revealed the following:
-A discontinued order, dated 08/16/23 for Macrobid Oral Capsule 100 milligrams (mg) (Nitrofurantoin Monohyd Macro).
-A current order, dated 02/19/24, for Cephalexin 500 mg
D. On 03/14/24 at 4:04 pm during an interview with MDS Coordinator (MDS), she stated it was expected staff would update the resident's care plan to have accurate antibiotics.
R #28
E. On 03/11/24 at 2:33 PM, during an interview and observation with R #28, she stated she had glasses. R #28 picked up her glasses from her tray.
F. Record review of R #28's medical appointments revealed R #28 had an optometrist (eye doctor) appointment on 08/23/23. Further record review revealed the resident had her vision checked and received a new prescription.
G. Record review of R #28's care plan revealed the care plan did not include her vision impairment or use of glasses.
H. On 03/14/24 at 4:04 pm during an interview with MDS Coordinator (MDS), she stated staff should include vision impairments and glasses the resident's care plan.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based 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 resi...
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Based 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. The findings are:
A. During an interview with the Assistant Director of Nursing (ADON) on 03/14/24 at 3:42 pm, he confirmed the facility did not designate a registered nurse to serve as DON on a full-time basis. He stated there are three nurses that share the DON duties. The ADON stated, We meet together collaboratively and figure out what needs to be done. The ADON stated the staff normally call him or the Director of Staff Development when they need a DON. The ADON stated he told facility staff to call him, since his home is close to the facility and he can have a quick response time.
B. During an interview on 03/14/24 at 4:04 pm, the MDS Director stated three nurses shared the duties of DON. The MDS Director stated the three nurses that share DON duties are herself, the ADON, and the Director of Staff Development.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based 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 sta...
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Based 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. The findings are:
A. On 03/11/24 at 1:30 pm, an observation of the Medication Supply room revealed:
1. Four and a half boxes of On Guard Blood Collection Set expired on 12/31/22.
2. Benadryl, 25 mg, unopened box expired on 01/24.
B. On 03/11/24 at 2:00 pm during an interview with Registered Nurse (RN) #1 confirmed the lab kits and medication were expired.
C. On 03/14/24 at 9:30 am and 1:45 pm during an interview, the Central Supply Clerk (CSC) confirmed the medication and supplies were expired. The CSC stated it was expected staff would remove expired medications or supplies from the storage unit. The CSC stated the medication and supply storage room were checked weekly, and staff disposed of medications in the medication disposal bin so the pharmacist could pick-up at the end of month.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based 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 ...
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Based 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. The findings are:
Findings for proper food handling techniques
A. On 03/11/2024 at 5:14 pm during an observation of the dinner meal served in the dining room, receptionist #1 put her thumb in the bowl prior to serving the meal to the resident.
B. On 03/11/24 at 5:21 pm during an observation of the dinner meal in the dining room, the Administrator handled a cup of cranberry juice by the rim of the cup while distributing the drink to the resident.
C. On 03/14/24 at 3:40 pm during an interview with the Assist Director of Nursing (ADON), he stated staff should grab the sides of the bowls and the base of the cups. The ADON stated staff should not touch the opening of the bowl or the rim of the cup.
Findings for proper food temperature
D. On 03/14/24 at 11:55 am during observation of lunch meal preparation and service, temperature of the pre-cooked turkey on the steam table measured 112 degrees Farenheit. Further observation revealed the steam table temperature set at 109 degrees Farenheit.
E. Record Review of the FDA Food Code, 2022 edition, revealed staff should serve cold foods at an internal temperature of 41° F or lower and hot foods at 135° F or higher.
F. On 03/14/24 at 4:34pm during and interview with the Dietary Director, she stated the temperature of the turkey was too cold. She stated her expectation was for staff to check food temperatures prior to serving to ensure foods are not undercooked.
Mar 2023
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on record review and interviews, the facility failed to ensure residents were free from abuse and neglect for 2 (R #21 and R #24) of 4 (R #21, R #24, R #40 and R #195) residents reviewed for abu...
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Based on record review and interviews, the facility failed to ensure residents were free from abuse and neglect for 2 (R #21 and R #24) of 4 (R #21, R #24, R #40 and R #195) residents reviewed for abuse and neglect. These deificenct practices likely resulted in R #21 and R #24 experiencing psychosocial harm. The findings are:
R #21
A. Record review of Facility Reportable Incident form to the state survey agency for R #21 revealed that there was an initial report filed on 11/17/22 stating that a staff member had popped up (tilting the wheelchair backwards so that the front wheels and the resident's feet did not touch the floor) the front of R #21's wheelchair and taken the resident into the dining room against her will; causing the resident undue distress and for her to scream out.
B. Record review of facility face sheet for R #21 revealed admitting diagnosis which included: Dementia (memory loss), Psychotic Disturbance (mental disease), Mood Disturbance, And Anxiety (feeling of fear), Hypothyroidism (low hormone), Major Depressive Disorder (feeling of sadness), Fracture Of Right Femur (break of large leg bone), Hypokalemia (low potassium), Gastro-Esophageal Reflux Disease (acid reflux), Hypertension (high blood pressure), Muscle Weakness, Difficulty In Walking, Need For Assistance With Personal Care, and History Of Falling.
C. On 03/21/23 at 2:00 pm, during an interview R #21 was unable to recall incident due to disease process of dementia.
D. On 03/21/23 at 1:30 pm, during an interview, the Admissions Director (AD) stated that she and the Business Office Manager (BOM) were sitting at the reception desk when they heard R #21,crying out to leave her alone. When I looked Certified Nursing Assistant (CNA) #9 was seen popping her (R #21) wheelchair back, forcing her to go into the dining room. She stated resident was very upset and it took a while to calm her down. By upset AD stated resident was verbally yelling out and crying. AD and BOM spoke with her and used redirection to calm her down. (BOM) called the resident's daughter and had her to talk to R #21 over the phone to help calm her down.
E. On 03/21/23 at 1:45 pm, during an interview BOM stated she remembered seeing CNA #9 going into the dining hall with R #21 who was crying and screaming that she didn't want to go in there. CNA #9 put her wheelchair on two wheels to get her there. BOM stated she did not know why R #21 did not want to go into the dining room but it was not uncommon for her to act this way (upset, refusing to go into dining area). BOM further stated it was meal time which she assumes was why CNA #9 was taking R #21 into the dining area.
F. On 03/21/23 at 1:15 pm, during an interview, the Social Services Director (SSD) stated that she witnessed CNA #9 rolling (name of R #21) while legs were suspended in the air and not touching the floor. Resident was upset and crying.
G. On 03/23/23 at 2:30 pm, CNA #9 was interviewed, CNA #9 denied abusing R #21. CNA #9 also stated she did push the wheelchair back so that it was only on the two rear wheels and R #21's feet were not touching the floor.
R #24
H. Record review of Facility Reportable Incident form to the state survey agency for R #24 revealed that there was an initial report filed on 11/17/22 stating that a staff member (CNA #9) calls (R #24) ugly and a pig in Spanish. (R #24) has dementia and carries two baby dolls with her believing they are her children. CNA #9 was reported to hit and abuse the babies in front of the resident to make her cry. CNA #9 was seen popping R #24 wheelchair back in order to force her to go down the 100 hall against her will. This caused great distress to R #24.
I. Record review of facility face sheet for R#24 revealed admission diagnosis which included: Hypertension(high blood pressure), Hypothyroidism (underactive thyroid), Need For Assistance With Personal Care, Depression (sadness), History Of Falling, Insomnia (trouble sleeping), Anemia (low red blood cells), Osteoarthritis (joint problems), Muscle Weakness, Lack Of Coordination, Abnormalities Of Gait (walking) And Mobility (ability to move around), Hyperlipidemia (high levels of fat), Pain, Muscle Spasm (sudden involuntary contraction), Manic Episode (mood swings), Muscle Atrophy (wasting away), Olecranon Bursitis (fluid filled sac), Difficulty Walking, Dementia (memory loss), Behavioral Disturbance (mood disorder).
J. Record review of the care plan dated 01/17/2023 for R#24 revealed resident self propels in wheelchair up and down hallways saying, hello, hello. She is always carrying 2 baby dolls with her.
K. On 03/21/23 at 2:20 pm, during an interview R #24 was unable to recall the incident due to disease process of dementia.
L. On 03/21/23 at 1:45 pm, during an interview CNA #2 stated I witnessed [name of R #24] being verbally and physically mistreated by [name of CNA #9]. CNA #2 also stated CNA #9 would call R #24 names in Spanish. CNA #9 would bang her chair into R #24's chair during meals and hit R #24's dolls which the resident believed were her babies. CNA #2 stated this would cause R #24 to become scared, upset, and cry.
M. Record review of the facility notice of disciplinary action and five day follow up to the investigation dated 11/28/22 indicated CNA #9 was place on leave and then subsequently terminated due to these allegations.
N. Record review of undated Abuse and Neglect - Clinical Protocol policy revealed the following:
1. Abuse is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the nurse failed to report an allegation of abuse to the Administrator for 1 (R #40) of 1 (R #40) resident reviewed for incidents. If the facility staff do not ti...
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Based on record review and interview, the nurse failed to report an allegation of abuse to the Administrator for 1 (R #40) of 1 (R #40) resident reviewed for incidents. If the facility staff do not timely report incident to the facility Administrator, then residents are likely to be a risk of further harm. The findings are:
A. Record review of Facility Incident Report dated on 01/16/23 revealed that R #40 was found by CNA #7 with a scarf wrapped around and tied to her neck. R #40 stated that she wanted to end her life to CNA #7, who was able to get resident to remove the scarf and calm down. CNA #7 after helping R #40 went to the charge nurse and reported the incident, however this was not relayed to the provider (medical director/MD) or Administrator timely.
B. Record review of facility face sheet for R #40 revealed admitting diagnosis which included: Dementia (memory loss), Psychotic Disturbance (mental disease), Mood Disturbance, and Anxiety (feeling of fear), Macular Degeneration, Bilateral (vision loss), Paroxysmal Atrial Fibrillation (irregular heartbeat).
C. On 03/21/23 at 3:00 pm, during an interview R #40 was unable to recall the incident due to disease process of dementia.
D. On 03/23/23 at 11:00 am, during an interview, the Wound Nurse (WN #1) stated that she was present when CNA #7 had reported the incident to Licensed Practical Nurse (LPN) #2, where LPN #2 stated that that incident needed to be reported to the Medical Director and that she would take care of that. WN #1 stated that during the stand-up (informational meeting) she did not hear anything about the incident the previous day and so WN #1 approached the Administrator (ADM) to inquire if she was aware. WN #1 stated that ADM and MD was not aware of that incident.
E. On 03/21/23 at 10:10 am, during an interview, the Administrator (ADM) stated that the incident involving R #40 happened on 01/16/23, where R #40 was found to have a scarf tied around her neck and having suicidal ideations. ADM stated that she was not made aware of the incident until 01/17/23. ADM stated that upon investigating the incident LPN #2 was offered training on reportable incidents and was pretty unresponsive to those trainings and LPN #2 was also placed on administrative leave pending the outcome of the investigation. The Administrator concluded that LPN #2 failed to report the incident and also was unresponsive to the trainings being offered. Admin stated that during a conversation that both the Administrator and LPN #2 decided that they should part ways (LPN #2 self-terminate employment).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to submit a thorough and timely 5-day follow-up investigation for 1 (R #21) of 4 (R #21, R #24, R #40, and R #195) reviewed for investigating a...
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Based on record review and interview the facility failed to submit a thorough and timely 5-day follow-up investigation for 1 (R #21) of 4 (R #21, R #24, R #40, and R #195) reviewed for investigating alleged violations. This failure could potentially lead to residents claims of abuse, neglect, or exploitation not being thoroughly investigated and determining the cause. The findings are:
A. Record review of Facility Reportable Incident form for R #21 revealed that there was an initial report filed on 11/17/22 for an incident that happened on 11/16/22, stating that a staff member had popped up (tilting the wheelchair backwards so that the front wheels and the resident's feet did not touch the floor) the front of R #21's wheelchair and taken the resident into the dining room against her will; causing the resident undue distress and for her to scream out.
B. Record review of original report revealed that a 5-day follow-up report was not submitted to the State Agency.
C. On 03/21/23 at 10:00 am, during an interview Administrator confirmed that she did complete the investigation, however she stated that she thought that she had submitted the follow-up report to the State Agency but that upon looking through the reportables binder, she could not find any evidence that the 5 day follow up report was submitted.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, record review, and interview the facility failed to follow proper Infection Prevention and Control measures by not ensuring that the soiled utility/linen area doors remained clos...
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Based on observation, record review, and interview the facility failed to follow proper Infection Prevention and Control measures by not ensuring that the soiled utility/linen area doors remained closed, which could likely cause the spread of communicable or infectious (spread from one person to another through direct or indirect contact) diseases. This failure has the potential to affect all 43 residents identified on the census provided by staff on 03/20/23. By not keeping the doors closed for the Soiled Utility/Linen it could likely allow exposure of infectious or biohazardous items to wandering residents and/or guests and lead to outbreaks within the facility. The findings are:
A. Record review of facility general infection control practices policy dated 2014 revealed:
Purpose: The purpose of this procedure is to provide a process for safe and aseptic (free from harmful microorganisms that can cause infections or diseases) handling, washing, and storage of linen.
. 3. Consider all soiled linen to be potentially infectious and handle with standard precautions.
B. On 03/22/23 at 10:10 am, during an observation of the soiled linen rooms revealed the following:
Hallway 100; room door was clearly marked with biohazard signage and keep closed, however the door was ajar.
Hallway 200; room door was clearly marked with biohazard signage and keep closed, however the door was ajar.
C. On 03/23/23 at 11:35 am, during an observation of the soiled utility/linen rooms revealed the following:
Hallway 100; room door was clearly marked with biohazard signage and keep closed, however the door was propped ajar.
D. On 03/23/23 at 1:18 pm, during an interview the Administrator was shown the door position (standing ajar) of hallway 100 soiled utility/linen room and asked if the door should be ajar like that. The administrator stated, absolutely not. She removed the plastic holding/allowing the door to be propped open and closed the door. She stated that all the doors should remain closed as labeled.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New Mexico facilities.
Concerns
- • 33 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (35/100). Below average facility with significant concerns.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Artesia Healthcare & Rehabilitation Center, Llc's CMS Rating?
CMS assigns Artesia Healthcare & Rehabilitation Center, LLC an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within New Mexico, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Artesia Healthcare & Rehabilitation Center, Llc Staffed?
CMS rates Artesia Healthcare & Rehabilitation Center, LLC's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 45%, compared to the New Mexico average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Artesia Healthcare & Rehabilitation Center, Llc?
State health inspectors documented 33 deficiencies at Artesia Healthcare & Rehabilitation Center, LLC during 2023 to 2025. These included: 1 that caused actual resident harm and 32 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Artesia Healthcare & Rehabilitation Center, Llc?
Artesia Healthcare & Rehabilitation Center, LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 65 certified beds and approximately 46 residents (about 71% occupancy), it is a smaller facility located in Artesia, New Mexico.
How Does Artesia Healthcare & Rehabilitation Center, Llc Compare to Other New Mexico Nursing Homes?
Compared to the 100 nursing homes in New Mexico, Artesia Healthcare & Rehabilitation Center, LLC's overall rating (1 stars) is below the state average of 2.9, staff turnover (45%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Artesia Healthcare & Rehabilitation Center, Llc?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Artesia Healthcare & Rehabilitation Center, Llc Safe?
Based on CMS inspection data, Artesia Healthcare & Rehabilitation Center, LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New Mexico. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Artesia Healthcare & Rehabilitation Center, Llc Stick Around?
Artesia Healthcare & Rehabilitation Center, LLC has a staff turnover rate of 45%, which is about average for New Mexico nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Artesia Healthcare & Rehabilitation Center, Llc Ever Fined?
Artesia Healthcare & Rehabilitation Center, LLC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Artesia Healthcare & Rehabilitation Center, Llc on Any Federal Watch List?
Artesia Healthcare & Rehabilitation Center, LLC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.