MISSION HILLS, CA - Federal inspectors have cited Ararat Nursing Facility for multiple violations during an August 2024 inspection, including medication administration errors involving diabetic residents and widespread food safety lapses that placed all 239 residents at risk for foodborne illness.
Insulin Administration Errors Endanger Diabetic Residents
The most serious violations involved improper insulin administration practices that could lead to serious complications for vulnerable diabetic residents. Inspectors found that licensed nurses repeatedly failed to rotate injection sites for residents receiving insulin therapy, a fundamental safety requirement.
For two residents with diabetes and cognitive impairments, medication records revealed a troubling pattern. One resident received insulin injections in the same arm locations multiple times over several weeks in June and July 2024. Documentation showed repeated injections to the right upper arm, left upper arm, and left deltoid area without proper site rotation.
A second diabetic resident experienced similar issues, with insulin administered to the same abdominal areas on consecutive days. Records showed injections given to "right and below level of umbilicus" on multiple occasions within the same time period.
The facility's own nursing staff acknowledged these practices as medication errors during interviews with inspectors. The Registered Nurse confirmed that failure to rotate insulin injection sites could cause skin irritation, abscesses, and lipodystrophy - a condition where fat tissue under the skin breaks down, creating lumps or indentations.
Medical Consequences of Improper Insulin Administration
Proper insulin injection site rotation is a cornerstone of diabetes care. When the same site is used repeatedly, several serious complications can develop. Lipodystrophy occurs when fatty tissue becomes damaged from repeated injections, creating areas where insulin absorption becomes unpredictable. This can lead to dangerous blood sugar fluctuations.
The affected tissue may also develop scar tissue or infections. According to manufacturer guidelines cited in the inspection report, repeated injections into areas with lipodystrophy can result in hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar) when injection sites are suddenly changed to unaffected areas.
For nursing home residents with diabetes, these complications are particularly dangerous. Many residents have limited ability to recognize or communicate symptoms of blood sugar emergencies, making proper injection technique critical for their safety.
Expired Medications Discovered in Storage Areas
The inspection also revealed significant medication storage violations that compromised resident safety. In one medication refrigerator, inspectors found numerous expired vaccines and medications that should have been discarded months earlier.
Seven expired flu vaccine vials from the 2023-2024 season remained in storage despite expiring in June 2024. Fifteen expired COVID-19 vaccine syringes and multiple expired anemia medications were also discovered. One opened flu vaccine vial had been stored since November 2023, far exceeding the 28-day limit for opened multi-dose vials.
Additionally, one eye drop medication for a glaucoma patient lacked proper labeling with an opening date. The facility's own policies require multi-use medications to be labeled with opening dates to ensure they are discarded before becoming ineffective or contaminated.
Food Safety Violations Put All Residents at Risk
The inspection uncovered extensive food safety violations in the facility's kitchen that affected all 239 residents. Multiple issues were identified during the food service review, ranging from improper labeling to temperature control failures.
Kitchen staff failed to properly label food items in refrigerators, with unnamed meat products found in both walk-in and reach-in units. The Dietary Supervisor acknowledged this created risks of serving incorrect foods to residents, potentially causing digestive issues and failing to accommodate dietary restrictions.
Temperature control violations were particularly concerning. Yogurt intended for residents was found at temperatures between 57-58 degrees Fahrenheit, well above the required 41-degree maximum. Food stored in the "danger zone" between 41-135 degrees Fahrenheit allows rapid bacterial growth that can cause foodborne illness.
The facility also failed to properly separate dented cans from regular inventory and stored food containers with chipped lids that could harbor bacteria. Staff members were observed wearing prohibited jewelry while handling food, violating infection control protocols.
Infection Control Lapses Documented Throughout Facility
Inspectors identified multiple infection control violations that increased residents' risk of acquiring infections. Oxygen tubing for residents with respiratory conditions was observed resting on floors, potentially introducing harmful bacteria into the respiratory system.
One resident's urinary catheter drainage bag was found lying flat on the floor instead of being properly secured in a privacy bag. Staff acknowledged this practice violated infection control standards and could lead to urinary tract infections.
The facility also failed to maintain proper water temperatures to prevent Legionella growth. Temperature logs showed multiple instances where water temperatures fell below the 108-degree minimum required to prevent this dangerous bacteria from developing in the facility's water system.
Consent Documentation Issues for Vaccinations
The inspection revealed systematic failures in obtaining proper informed consent for flu and COVID-19 vaccinations. For several residents who received vaccines, no documentation existed showing that consent forms were completed or that residents or their representatives received education about vaccine benefits and risks.
The facility's Administrator had instructed staff to obtain consent only once upon admission rather than before each vaccination, contrary to the facility's own policies. The Director of Nursing confirmed that consent forms should be completed each time vaccines are administered to ensure proper informed consent.
Additional Issues Identified
The inspection documented several other violations including improper electrical equipment use by residents, inadequate coverage for clean linen storage carts, failure to maintain proper food storage policies for items brought by visitors, and poor maintenance of the facility's exterior trash disposal area.
Temperature monitoring procedures for sanitizing solutions were also found to be inadequate, with staff failing to record solution temperatures as required by manufacturer guidelines for effective sanitization.
The facility operates under federal regulations that require nursing homes to maintain the highest standards of resident care and safety. These violations demonstrate systemic issues in medication management, food safety, and infection control that directly impact resident wellbeing and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2024-08-09 including all violations, facility responses, and corrective action plans.
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