Artesia Palms Care Center in Artesia: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH received a facility-reported incident and two complaints in May 2025 about two residents with dementia, Resident 1 and Resident 2, who went missing. CDPH found that both women, a 74-year-old and a 67-year-old who had been assessed as high risk for wandering, eloped (left without supervision or permission) from the locked facility through its front door at about noon on 5/18/2025, without staff awareness. Staff did not notice Resident 1 was missing until about 5:41 p.m., when a "Code Black" search was started.

The department determined that a family member found both residents about 20 miles away the next afternoon, roughly 27 hours after they were believed to have left. Both were taken to an acute care hospital, where they stayed four days. According to the citation, Resident 1 was admitted with altered mental status (a change from her normal mental state) and Resident 2 was treated for a urinary tract infection. Inspectors found the facility did not supervise the two residents and did not follow its own wandering and elopement policy. CDPH said 144 residents assessed as high risk for wandering were placed at risk.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689 (accident hazards and supervision) at severity J and states an immediate jeopardy was called on 5/20/2025. According to the report, the facility's removal plan included reviewing every resident's elopement risk, adding a keypad and magnetic locks on entrance doors, changing staff entry routes, adding receptionist screening, and processing the termination of the receptionist and CNA involved. Inspectors verified the plan and removed the immediate jeopardy on 5/23/2025.

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The federal 2567 report states that inspectors investigated a complaint involving Resident 1, who had atrial fibrillation (an irregular, fast heartbeat that can cause blood clots) and was taking warfarin, a blood thinner. Inspectors found the facility did not give Resident 1's warfarin as ordered by the physician's nurse practitioner.

According to the report, licensed nurses gave Resident 1 duplicate warfarin therapy on ten dates in November and December 2024, including a dose that should have been discontinued on 11/19/2024. Inspectors also found nurses did not monitor medication administration times or critical lab values to catch the error. The report states Resident 1 was transferred to an acute care hospital on 12/27/2024 and diagnosed with a subdural hematoma (a collection of blood on the surface of the brain) measuring 12 millimeters. At the hospital he was intubated (a breathing tube was placed) and given a drug used to reverse blood thinners in cases of serious bleeding.

The report cites F760 (significant medication errors) at severity K. Inspectors called an immediate jeopardy on 1/4/2025. According to the 2567 report, the facility's removal plan included a three-way audit of 13 medication carts with the pharmacy, a drug regimen review by the consultant pharmacist for the 23 residents on blood thinners, facility-wide audits of anticoagulant orders and bleeding monitoring, and in-service training for licensed nurses on warfarin, lab monitoring and discontinuing old orders. Inspectors verified the plan and removed the immediate jeopardy on 1/5/2025.

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According to the citation, CDPH investigated a facility-reported incident in June 2024 involving Resident 1, a 73-year-old woman with muscle weakness and difficulty walking. CDPH found she was at high risk for falls, had moderately impaired thinking, and needed staff to steady her during transfers. She had an unwitnessed fall on 1/2/2024.

The department determined the facility did not revise her care plan after that first fall to address her poor safety awareness and her habit of getting up without asking for help. Inspectors found staff left her wheelchair next to her bed, within reach, which let her move into it without calling for assistance. According to the citation, staff also did not follow the facility's fall policy. On 6/2/2024 at about 4:45 a.m., a CNA found Resident 1 on the floor beside her wheelchair, reporting left leg pain of 10 out of 10. She was sent by 911 to an acute care hospital, where she was treated for a displaced, comminuted fracture of the left tibia (the shin bone broken into three or more pieces and out of alignment).

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689 (accident hazards, supervision and devices) at severity G, finding the facility did not prevent the resident from falling during an unsupervised transfer from bed to wheelchair.

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According to the citation, CDPH received a facility-reported incident on 4/22/2024 about a resident who had been improperly discharged, and visited the facility the next day. CDPH found the facility did not assess whether Resident 1 had the capacity to make an informed, voluntary decision to leave and sign out against medical advice (AMA), as its own policy required.

The federal 2567 report states the facility let Resident 1, who lacked the capacity to understand and make decisions, sign out AMA on 4/19/2024 without a valid order. Inspectors found staff gave him 41 tablets of a prescribed medication without checking whether he could take it safely on his own. According to the report, the facility made no referral to the shelter, put him in a ride-share vehicle to go there, and did not tell his responsible party beforehand. The shelter did not accept him when he arrived, and the report states his whereabouts were unknown. Inspectors said this placed him at high risk of exposure to harsh conditions, traffic accidents, medication overdose, malnutrition, dehydration and possible death.

CDPH issued a Class A citation with a $25,000 penalty. The 2567 report cites F622 (transfer and discharge requirements) at severity J and states an immediate jeopardy was called on 4/26/2024. According to the report, the facility's removal plan included updated out-on-pass and AMA discharge policies approved by the medical director, training for social services and licensed nurses, and physician capacity decisions at admission. The immediate jeopardy was removed on 5/1/2024.

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According to the citation, CDPH identified the problem during a recertification survey on 1/8/2024. Resident 110, a 76-year-old man with muscle weakness, adult failure to thrive and a feeding tube, had no range-of-motion limits in his right arm and hand when he was admitted in May 2023. CDPH found he later developed a contracture (shortening and stiffening of muscles and tendons that locks a joint) in his right hand and fingers, and that the decline was avoidable.

The department determined that from 9/12/2023 to 12/5/2023 staff did not monitor and report his worsening hand stiffness and pain to the physician. Inspectors found the facility did not consistently apply a splint to his right hand for about three months, did not give him Tylenol before occupational therapy as ordered, did not measure his right hand's range of motion at the 9/12/2023 therapy evaluation, and did not have him feed himself with his dominant right hand using built-up utensils. According to the citation, he developed pain, stiffness and reduced movement throughout his right arm, could not use the hand for daily care, and the resulting loss contributed to his feelings of hopelessness.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F688 (preventing a decline in range of motion and mobility) at severity G. The same report also lists F609 (reporting of alleged violations) and F610 (investigating and correcting alleged violations), each at severity D. The full narrative for those two tags is in the linked report.

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According to the citation, CDPH received a facility-reported incident about resident abuse on 8/29/2023 and made an unannounced visit on 9/6/2023. CDPH found that around 10 p.m. on 8/28/2023, Resident 2, a 57-year-old man, punched his roommate, Resident 1, an 80-year-old man, in the head. Resident 1 depended on staff for most daily care and had a fluctuating ability to make decisions.

The department determined that CNA 1 was assigned to monitor the East hallway from 9 p.m. to 10 p.m. that night and did not do so. According to the citation, CNA 1 told inspectors he had never monitored that hallway and that "everybody knew it." CDPH found the facility did not make sure CNA 1 followed its resident safety and supervision policy. Hospital emergency notes cited in the document show Resident 1 had a blunt head injury, bruising around the left eye and a subconjunctival hemorrhage (a broken blood vessel on the surface of the eye), reported occasional double vision, and was referred to an eye specialist.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F600 (freedom from abuse and neglect) at severity G, finding the facility did not protect Resident 1 from physical abuse by another resident.

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According to the citation, CDPH received a facility-reported incident about resident abuse on 7/3/2023 and investigated on 7/12/2023. CDPH found that on 7/2/2023, Resident 2, a 42-year-old man with dementia who had a history of pacing and wandering into other rooms, went into the room of Resident 1, a 68-year-old man, and fell asleep in his bed. When Resident 1 came back and saw him, he repeatedly hit Resident 2 in the head and face.

The department determined the facility did not protect Resident 2 from physical abuse by another resident. Resident 2's care plans called for monitoring his pacing every shift and one-to-one supervision as indicated, and Resident 1's care plans noted angry outbursts and threats to fight other residents. The federal 2567 report states that, according to a licensed vocational nurse, a CNA saw Resident 2 sleeping in Resident 1's bed and took no action.

According to the citation, Resident 2 was taken to an acute care hospital, where he was diagnosed with blunt head trauma, received three stitches to his left ear, and was treated for a facial laceration (cut) and skin tears. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report cites F600 (freedom from abuse and neglect) at severity G.

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The federal 2567 report states that Resident 236, who lacked the capacity to make decisions, had an infection of a left knee prosthesis (artificial joint) and a Hemovac drain, a suction drain placed under the skin during surgery to remove blood and fluid. Inspectors found the facility did not assess the drain site for infection or dislodgement, did not get a physician's order for wound care at the site, and did not secure the drain tubing to his clothing or leg.

According to the report, on 7/18/2023 inspectors saw the tubing held only by a stitch at the knee. On 7/20/2023 they saw the tubing caught in the bed frame, the stitches pulling at his skin, and brownish red fluid draining down his knee. A registered nurse who checked the site said it was fine. Inspectors found that on 7/21/2023 the director of nursing measured the drain as pulled out 4.5 centimeters and said the nurse should have reported it to him and the physician the day before. The report states Resident 236 was sent to an acute care hospital that night with knee pain and swelling for an orthopedic consult on drain removal and possible further surgery.

The 2567 report cites F684 (quality of care) at severity G. Inspectors said the failures placed the resident at risk of fluid buildup, a wound that does not heal, and infection. The report also lists F609 (reporting of alleged violations) at severity D, and the full narrative for that tag is in the linked report.

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According to the citation, CDPH received a facility-reported incident on 6/6/2023 alleging that Resident 1 hit Resident 2 on the left eyebrow, and made an unannounced visit the next morning. CDPH determined that Resident 2 had two cuts on his left eyebrow, 3 cm and 5 cm long, and was sent to an acute care hospital, where he was diagnosed with a nondisplaced fracture of the bones around the eye (a crack that stayed in alignment).

The department found the facility did not adequately supervise Resident 1, even though he had already put his hands around another resident's throat and had hit his roommate in the face, causing his lip to bleed. According to the citation, staff did not follow his care plan to monitor and document his aggressive behavior. Inspectors found the social service worker and a social services assistant did not tell the director of nursing that Resident 1 wanted to leave the locked unit he had been moved to, felt agitated, and had said he felt like hitting someone. CDPH also found staff did not give Ativan, an anti-anxiety medication, as the physician ordered for his agitation, and did not follow the facility's abuse prevention and supervision policies.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F600 (freedom from abuse and neglect) at severity G for the same events.

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The federal 2567 report states that Resident 1, who had chronic pain, nerve damage and several Stage 4 pressure ulcers (deep bed sores that reach muscle, tendon or bone) on both heels and the base of the spine, was readmitted to the facility on 6/26/2023. Inspectors found the facility did not give him prompt pain relief after he arrived complaining of severe pain, and did not promptly notify his physician to get an order for pain medication.

According to the report, on 6/27/2023 inspectors saw Resident 1 in bed with stiff limbs, grimacing and twitching. He told them he had pain all over, that the nurse had given him only Tylenol, and that he had been waiting since morning for his narcotic pain medication. Inspectors found a licensed vocational nurse gave Tylenol, which was ordered for mild pain, at 10:30 a.m. and did not document a pain reassessment. Nursing notes show that in the afternoon a supervisor learned there was no order to continue his hospital pain medications, and the physician was then called. The report states that on 6/28/2023 he still described pain of 10 out of 10 with spasms after a dose of hydromorphone, an opioid.

Inspectors determined these failures caused Resident 1 unnecessary severe pain over almost 40 hours, with great distress and discomfort. The 2567 report cites F697 (pain management) at severity G.

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According to the citation, CDPH received a facility-reported incident on 3/6/2023 that Resident 1, a 35-year-old man, had gone missing, and visited the facility on 3/7/2023. CDPH found he had been admitted to the facility's locked unit at about 11:30 a.m. on 3/4/2023 with diagnoses including high blood pressure, and was assessed that day as a moderate risk for elopement (leaving without supervision or permission). He was last seen around 8:30 p.m. and was reported missing to the sheriff's department at 10:45 p.m.

The department determined the facility did not supervise Resident 1 to keep him from leaving the locked unit and did not follow its safety and supervision policy. According to the citation, a licensed vocational nurse told inspectors new admissions on that unit were to be closely watched for 72 hours, and a registered nurse said a CNA was stationed in each hallway and the patio and staff should have seen him leave. The registered nurse also said there was no photograph of him in his record. At the time of the investigation, CDPH stated he remained missing, at risk of cold exposure, traffic accidents, dehydration and complications from missing his routine medications, including blood pressure medication.

CDPH issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689 (accident hazards and supervision) at severity J. Inspectors called an immediate jeopardy on 3/8/2023, and according to the report it was removed on 3/9/2023 after the facility's removal plan, which included staff in-services on keeping exit doors secured.

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According to the citation, CDPH received a facility-reported incident on 5/3/2021 alleging that a male certified nursing assistant, CNA 1, hit Resident 1 in the left eye in late March 2021 and tried to close the resident's mouth. CDPH investigated at the facility on 5/13/2021. Resident 1 was a 79-year-old man who was described as confused.

CDPH found that on 3/28/2021 Resident 1 told staff CNA 1 had hit him in the face two days earlier, and nurses noted a fading black discoloration under his left eye measuring about 3.5 by 2.0 centimeters. According to the citation, CNA 1 told the facility the resident had been cursing, that he held the resident's chin and closed his mouth to get him to stop, and that he may have held him down too hard and caused the bruising. The citation states the incident was reported to police, CDPH and the ombudsman, and a police officer who saw the eye called 911; paramedics evaluated the resident and said he needed no further care from them.

The department determined the facility did not ensure CNA 1 did not physically assault Resident 1, and did not make sure staff followed its abuse prohibition policy, including a prompt and thorough, documented investigation of the allegation. CDPH found Resident 1's right to be free from physical abuse was violated, and he had a black eye. CDPH issued a Class A citation with a $20,000 penalty.

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The federal 2567 report states that on 3/2/2023 at about 9:30 a.m., Resident 1, who used a wheelchair and had a known history of wandering into other residents' rooms and of hitting and yelling at others, went into Resident 2's room and threw a lotion bottle that struck her on the left forehead. Inspectors found Resident 2 had pain and a bluish bruise about 3 by 2 centimeters. A licensed vocational nurse told inspectors she heard Resident 2 yelling for help and met Resident 1 leaving the room.

According to the report, the facility did not make sure CNA 1, who was assigned to Resident 1, knew about his wandering behavior or kept track of where he was. CNA 1 told inspectors he was in another resident's room at the time and did not know who was assigned to watch the hallway. A registered nurse supervisor said a CNA was supposed to monitor the hallway hourly and keep residents in sight. Inspectors found the director of nursing said the staff assignment sheet, including the hallway assignment, was not created for that day and that more than likely no CNA was assigned to watch the hallway.

The 2567 report cites F600 (freedom from abuse and neglect) at severity G, finding the facility did not ensure a resident with wandering and aggressive behavior did not physically abuse another resident.

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The federal 2567 report states that inspectors watched medication passes for six residents and found 17 errors out of 44 opportunities, a medication error rate of 38.64%. Federal rules require the rate to be under 5%. The errors affected three residents, Residents 51, 200 and 257.

According to the report, most errors were omitted or late doses, including metoprolol for blood pressure, tamsulosin for prostate problems, two psychiatric medications, an inhaler for breathing problems, clopidogrel to prevent stroke, and Admelog insulin. Two vitamin doses were wrong. Inspectors found that on the morning of 1/25/2023 a licensed vocational nurse said several of Resident 51's 9 a.m. medications were out of stock and she did not know why the pharmacy had not sent refills. Empty pharmacy packs showed some had last been filled in December 2022 for a 14-day supply. The report states these errors raised the risk of stroke, poor blood sugar or blood pressure control, hospitalization, death, or a psychiatric emergency.

The 2567 report cites F759 (medication error rate of 5% or more) at severity K. Inspectors declared an immediate jeopardy on 1/25/2023. According to the report, the facility's removal plan included monitoring the three residents for 72 hours, ordering their missing medications, auditing medication carts, nurse in-services and medication pass skills checks, education on documentation and ordering, and on-site pharmacy training. The immediate jeopardy was removed on 1/28/2023.

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