Inspection Reports for
Artesia Healthcare & Rehabilitation Center Llc
1402 WEST GILCHRIST AVE, ARTESIA, NM, 88210
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than New Mexico average
New Mexico average: 7.1 deficiencies/year
Deficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
83% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report the results of all investigations to the State Survey Agency within five working days of an incident involving resident #1.
Complaint Details
The complaint investigation found that the facility did not submit the investigation results to the State Survey Agency within five working days as required. The Administrator confirmed the facility's responsibility but could not confirm submission of the report.
Findings
The facility failed to submit the summary of the investigation results for an incident dated 11/13/2025 involving resident #1 to the State Survey Agency within the required five working days, as confirmed by the Administrator during an interview on 12/11/2025.
Deficiencies (1)
Failure to report the results of all investigations to the State Survey Agency within five working days of an incident for resident #1.
Report Facts
Residents reviewed for abuse or neglect: 4
Incident date: Nov 13, 2025
Date of interview: Dec 11, 2025
Inspection Report
Routine
Census: 54
Deficiencies: 5
Date: Sep 23, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and sanitization standards, including monitoring dishwasher temperatures, food temperatures, and sanitizing solution concentrations.
Findings
The facility failed to consistently complete daily logs for dishwasher temperatures, food temperatures, and sanitizing solution concentrations, resulting in inadequate sanitization and potential exposure of residents to foodborne illnesses. Observations confirmed dishwasher water temperatures and sanitizer concentrations were below required standards, and food temperatures during delivery were too low.
Deficiencies (5)
Failure to complete daily sign-off sheets and record dishwasher temperatures and sanitizing solution concentrations as required.
Failure to complete daily food temperature logs for all meals.
Dishwasher water temperatures and sanitizer concentrations did not meet manufacturer or regulatory standards during observations.
Food trays delivered to residents had cooked scrambled eggs at an unsafe temperature (96.7 F) and were improperly covered with plastic wrap instead of heat-preserving dome covers.
Sanitizing solution testing logs were incomplete for multiple dates in August and September 2025.
Report Facts
Dishwasher wash temperature: 119
Dishwasher wash temperature: 115
Dishwasher water temperature: 110
Dishwasher water temperature: 125
Dishwasher water temperature: 135
Sanitizer concentration (PPM): 0
Cooked scrambled eggs temperature: 96.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Dietary Manager (ADM) | Confirmed daily temperature logs and sanitizing solution testing were not consistently completed | |
| Administrator (ADMIN) | Operated dishwasher during demonstration and confirmed inadequate sanitizer concentration and improper food temperature delivery |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 31, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to inform a resident and their legal guardian in writing about room changes prior to the changes occurring.
Complaint Details
The complaint investigation found that the resident and legal guardian were not notified in writing prior to room changes on 07/14/25, 07/17/25, and 07/19/25. The complaint was substantiated by interviews and record review.
Findings
The facility failed to notify resident #1 and their legal guardian in writing before multiple room changes on 07/14/25, 07/17/25, and 07/19/25, which could cause frustration and mental anguish. Interviews confirmed the lack of notification despite documented room change authorizations.
Deficiencies (1)
Failed to inform resident and legal guardian in writing of room changes prior to the changes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed the legal guardian was not notified of room changes prior to the changes. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Date: Jun 3, 2025
Visit Reason
The inspection was conducted due to a complaint alleging possible sexual assault of a resident by another resident, focusing on the facility's failure to report and thoroughly investigate the allegation.
Complaint Details
The complaint involved an allegation of possible sexual assault on Resident #1 by Resident #2. The allegation was reported by staff on 05/25/25 but was not reported to the State Agency by the facility. The Social Worker reported the allegation to the Administrator, who did not believe the abuse occurred and chose not to report it. The investigation was incomplete, and the final outcome stated no sign of abuse was detected.
Findings
The facility failed to timely report the suspected abuse to the State Survey Agency and did not complete a thorough investigation of the allegation. The administrator acknowledged awareness of the allegation but chose not to report it, citing concerns about facility reputation.
Deficiencies (3)
Failed to timely report suspected abuse to the State Survey Agency.
Failed to complete a thorough investigation for allegations of abuse.
Failed to administer the facility in a manner that enables effective and efficient use of resources, including failure to report and investigate an allegation of sexual assault.
Report Facts
Residents affected: 46
Date of grievance report: May 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper #1 | Housekeeper | Reported concerns about possible sexual assault to the Social Worker |
| Social Worker | Social Worker | Received grievance report and reported allegation to Administrator |
| Administrator | Administrator and Abuse Coordinator | Did not report the allegation to the State Agency and acknowledged incomplete investigation |
Inspection Report
Routine
Census: 49
Deficiencies: 15
Date: Mar 7, 2025
Visit Reason
Routine inspection of Artesia Healthcare & Rehabilitation Center to assess compliance with regulatory requirements including resident rights, environment, assessments, care plans, medication administration, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain valid advance directives, inadequate environment maintenance, inaccurate assessments and care plans, medication errors, improper catheter orders, unsecured medications, incomplete neurological evaluations post-falls, lack of binding arbitration agreement provisions, infection control lapses, and hallway accessibility issues.
Deficiencies (15)
Failed to ensure resident's current advance directive was available and valid in the EHR.
Failed to provide a comfortable and homelike environment due to peeling paint, unrepaired walls, worn handrails, stained carpets, and stained ceiling tiles.
Failed to complete accurate Minimum Data Set (MDS) assessments for residents.
Failed to ensure accurate Pre-admission Screening and Resident Review (PASRR) assessments.
Failed to develop and implement complete, person-centered care plans for residents.
Failed to revise care plans timely after changes in resident condition.
Failed to prevent accidents by not completing post-fall neurological evaluations.
Failed to have medical orders for catheter use, type, and care for a resident with an indwelling catheter.
Medication error rate exceeded 5% due to administration of blood pressure medications outside prescribed parameters.
Failed to ensure residents were free from significant medication errors by administering medications outside physician's orders.
Failed to secure medications properly; wound gel left unattended on medication cart accessible to unauthorized persons.
Binding arbitration agreement did not explicitly grant residents or representatives the right to rescind within 30 days.
Binding arbitration agreement lacked provision for selection of a convenient venue for arbitration.
Failed to maintain proper infection prevention practices by not cleaning blood pressure cuff and vital sign equipment between residents.
Failed to ensure hallway on 200 hall was accessible and free of obstructions for residents.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Medication errors: 3
Residents affected: 20
Residents affected: 14
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed multiple deficiencies including missing advance directives, inaccurate assessments, medication errors, and infection control lapses. |
| Licensed Practical Nurse #1 | LPN | Observed administering blood pressure medications outside prescribed parameters and failing to clean vital sign equipment between residents. |
| Director of Maintenance | Director of Maintenance | Confirmed environmental deficiencies such as worn handrails, paint chipping, and stained carpets. |
| Corporate Representative #1 | Corporate Representative | Acknowledged environmental issues and repair plans. |
| Director of Staff Development | Director of Staff Development | Confirmed wound gel should not be left unattended on medication cart. |
| Housekeeper #1 | Housekeeper | Confirmed hallway obstructions on 200 hall. |
| Nurse #1 | Nurse | Observed failing to clean vital sign equipment between residents. |
| Administrator | Administrator | Confirmed binding arbitration agreement deficiencies. |
Inspection Report
Routine
Census: 44
Deficiencies: 3
Date: Apr 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding residents' rights, safety, and the facility environment, including treatment of residents, cleanliness, and accident hazards.
Findings
The facility failed to treat a resident with dignity related to the removal of cats using mothballs without prior notice, failed to maintain a clean and safe courtyard environment, and placed mothballs in the courtyard creating potential health hazards for all residents.
Deficiencies (3)
Failed to treat residents with respect and dignity by not informing a resident about plans to remove cats prior to placing mothballs in the courtyard.
Failed to provide a clean and safe environment in the courtyard, including bird feces covering 75% of the sidewalk, trash overflow, tall grass, and a garden hose creating a safety hazard.
Failed to keep residents free from accident hazards by placing mothballs in the courtyard, which posed potential health risks due to chemical exposure.
Report Facts
Residents affected: 44
Number of mothballs: 100
Percentage of sidewalk covered with bird feces: 75
Grass height in courtyard: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed prior agreement about cats and approved use of mothballs without proper chemical knowledge | |
| Director of Nursing | Confirmed courtyard was not maintained clean and safe | |
| Activities Assistant | Reported over 100 mothballs in courtyard and residents' dislike of the smell | |
| CNA #1 | Assisted in picking up and disposing of mothballs |
Inspection Report
Routine
Census: 48
Deficiencies: 8
Date: Mar 14, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, facility environment, medication management, and food safety.
Findings
The facility was found deficient in multiple areas including maintaining a clean and homelike environment, completing accurate resident assessments and care plans, proper wound care documentation, designation of a full-time Director of Nursing, proper storage of medications and supplies, and safe food handling practices. All deficiencies were assessed as minimal harm or potential for actual harm.
Deficiencies (8)
Failed to maintain a comfortable and homelike environment that was clean and free from ceiling and wall debris in a resident room.
Failed to complete an accurate comprehensive assessment for a resident, resulting in inaccurate documentation of glasses use.
Failed to create an accurate Baseline Care Plan within 48 hours of admission for three residents, missing advanced directives.
Failed to revise care plans to reflect residents' current care needs and treatments for two residents.
Failed to ensure proper documentation and monitoring of a stage 4 pressure injury wound for one resident.
Failed to designate a registered nurse to serve as Director of Nursing on a full-time basis.
Failed to properly store medications and supplies, with expired items found in the medication supply room.
Failed to serve food under sanitary conditions, including improper handling of drinks and bowls and serving food at improper temperatures.
Report Facts
Residents affected: 48
Wound measurements: 1.7
Wound measurements: 1.1
Wound measurements: 3.5
Wound undermining depth: 6.4
Wound measurements: 112
Wound measurements: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding room wall and ceiling conditions | |
| Social Worker | Interviewed regarding resident's receipt of glasses | |
| MDS Coordinator | Interviewed regarding resident assessments and care plans | |
| Minimum Set Data nurse (MDS nurse) | Interviewed regarding baseline care plans and advanced directives | |
| Assistant Director of Nursing (ADON) | Interviewed regarding wound care documentation, DON duties, and food handling | |
| Registered Nurse #1 | Confirmed expired medications in supply room | |
| Central Supply Clerk (CSC) | Confirmed expired medications and supplies in storage | |
| Dietary Director | Interviewed regarding food temperature and handling |
Inspection Report
Routine
Census: 43
Deficiencies: 1
Date: Mar 24, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program and compliance with proper infection control measures.
Findings
The facility failed to ensure that soiled utility/linen area doors remained closed as required, potentially exposing residents and guests to infectious or biohazardous materials. Observations and interviews confirmed doors were propped or ajar despite signage indicating they should remain closed.
Deficiencies (1)
Failure to keep soiled utility/linen area doors closed, risking spread of communicable diseases.
Report Facts
Residents affected: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding the door being propped open and confirmed doors should remain closed |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 24, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and failure to report incidents involving residents at Artesia Healthcare & Rehabilitation Center.
Complaint Details
The complaint investigation involved allegations of abuse and neglect against residents R #21, R #24, and R #40. CNA #9 was implicated in verbal and physical abuse and was terminated. The facility failed to timely report abuse incidents and failed to submit required follow-up reports. Substantiation status is not explicitly stated.
Findings
The facility was found to have failed in protecting residents from abuse and neglect, including physical and verbal mistreatment by staff, failure to timely report abuse allegations, and failure to submit thorough follow-up investigations. Several residents experienced psychosocial harm due to these deficiencies.
Deficiencies (3)
Failure to protect residents from abuse and neglect, including staff forcibly tilting wheelchairs and verbal abuse.
Failure to timely report suspected abuse and neglect to proper authorities.
Failure to respond appropriately to all alleged violations, including failure to submit timely 5-day follow-up investigation reports.
Report Facts
Residents reviewed for abuse and neglect: 4
Residents affected by abuse: 2
Residents reviewed for incident reporting: 1
Days late for follow-up report: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Certified Nursing Assistant | Named in findings for physical and verbal abuse of residents R #21 and R #24 |
| LPN #2 | Licensed Practical Nurse | Failed to timely report abuse incident involving R #40 and was placed on administrative leave and self-terminated employment |
| Administrator | Facility Administrator | Interviewed regarding failure to submit follow-up reports and awareness of abuse incidents |
| Admissions Director | Admissions Director | Witnessed abuse incident involving R #21 |
| Business Office Manager | Business Office Manager | Witnessed abuse incident involving R #21 and assisted in calming resident |
| Social Services Director | Social Services Director | Witnessed abuse incident involving R #21 |
| Wound Nurse #1 | Wound Nurse | Interviewed about reporting failure of abuse incident involving R #40 |
| CNA #2 | Certified Nursing Assistant | Witnessed verbal and physical mistreatment of R #24 by CNA #9 |
| CNA #7 | Certified Nursing Assistant | Found R #40 with scarf tied around neck and reported incident to charge nurse |
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