Ararat Nursing: Critical Brain Monitoring Failures - CA
The breakdown occurred at Ararat Nursing Facility when staff failed to complete neurological assessments for Resident 1, who had fallen on August 25. Federal inspectors found that nurses resumed the monitoring when he returned from the hospital on August 26 at 1:05 a.m., but stopped checking his neurological status after 4:05 a.m.
The facility's Director of Nursing acknowledged the failure during an August 29 interview with inspectors. "Resident 1's neuro checks should have been done for 72 hours," she said, reviewing the incomplete Neurological Assessment Flowsheet.
The DON explained why the monitoring matters: "We don't know if they hit their head or not, and two days later we could have a bleed [in the brain]. If something did happen, we can catch it right away by performing neurological checks."
The facility's own policy, dating to August 2014, requires nurses to perform neurological assessments "following an unwitnessed fall for a combined total of 72 hours." The protocol calls for checking the resident's neurological status every 15 minutes for one hour, then every 30 minutes for another hour, followed by hourly checks for two hours, then every four hours until the 72-hour period ends.
RN 1, who was interviewed while reviewing Resident 1's medical record, confirmed the requirements. The nurse explained that for any unwitnessed fall, staff must assess the resident's neurological status for the full 72 hours to monitor for signs of brain injury that might not appear immediately.
Records show the neurological assessments began properly on August 25 at 2:20 p.m. and 2:35 p.m. after the fall occurred. But when Resident 1 returned from his hospital stay, the monitoring that resumed at 1:05 a.m. on August 26 lasted only three hours.
The inspection also revealed a second critical failure in Resident 1's care. When he returned from the hospital on August 26, staff failed to complete a required admission assessment, according to the DON's review of his electronic medical record.
"An admission assessment is important because a baseline status is needed since the facility don't know what was done to the patient in the hospital," the DON told inspectors. She could not locate any completed admission assessment related to Resident 1's return.
The facility's admission policy, updated in August 2019, states that "upon admission, a Licensed Nurse will conduct an admission assessment of the resident using NP - 102 - Form A - Resident admission Assessment or alternate form available on the electronic health record platform."
The DON explained that when any resident leaves for the hospital and returns to the facility, both an admission assessment and a progress note from the assigned nurse are required. Neither was completed for Resident 1.
These assessment failures occurred during a critical period when Resident 1 needed close monitoring. Unwitnessed falls pose particular risks because staff cannot determine whether the resident struck their head or sustained other injuries during the incident.
Brain bleeds can develop hours or days after a fall, making the 72-hour neurological monitoring protocol essential for early detection. Signs of neurological deterioration that nurses watch for include changes in consciousness, pupil response, speech patterns, and motor function.
The incomplete monitoring left a dangerous gap in Resident 1's care. Had he developed a delayed brain bleed or other neurological complication between August 26 at 4:05 a.m. and August 28, when inspectors arrived, staff would have missed critical warning signs.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to few residents. But the DON's own words underscore the serious risks involved when neurological monitoring protocols are abandoned.
The facility's failures highlight how quickly safety systems can break down when staff don't follow established protocols. A resident who had already experienced one fall was left without the monitoring designed to protect him from life-threatening complications that could emerge days later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Ararat Nursing Facility in MISSION HILLS, CA was cited for violations during a health inspection on August 29, 2025.
The breakdown occurred at Ararat Nursing Facility when staff failed to complete neurological assessments for Resident 1, who had fallen on August 25.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.