Ararat Convalescent Hospital
Inspection Findings
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
or toileting. A review of Resident 5's Progress notes dated 8/15/2025, indicated Resident 5 was tested for COVID- 19 on 8/15/2025 and had a positive test result. During a review of the facility provided document titled, Covid - 19 Contact information form for long -Term Care Facilities Resident, dated 8/13/2025, the Form indicated a total of three residents were positive for Covid - 19. The Form indicated the following:Resident 3 was confirmed COVID -19 positive on 8/13/2025Resident 4 was confirmed COVID-19 positive on : 8/16/2025Resident 5 was confirmed COVID-19 positive on: 8/15/2025 During an interview on 9/11/2025 at 11:15 AM with infection preventionist nurse (IP) 1, IP 1 stated since Residents 1, 4, and 5 were symptomatic and were positive for COVID-19, the facility should have reported the positive COVID- 19 residents to the California Department of Public Health. During an interview on 9/11/2025 at 12:35 with the Administrator (ADM) , the ADM stated the facility had a COVID-19 outbreak and stated that CDPH should have been notified regarding the COVID-19 outbreak. During a concurrent interview and record review on 9/11/2025 at 12:35 with the ADM, the ADM, the undated facility's policy and procedure (P&P) titled, Communicable diseases - outbreak was reviewed. The P&P indicated, the administrator will be responsible for reporting to the Department of Public Health and local public health officer a single case of a communicable disease requiring immediate reporting and epidemiology investigation. The Administrator stated not reporting to CDPH since she thought the facility's IP had reported the COVID-19 positive residents to CDPH. During an interview on 9/11/2025 at 12:45PM with Infection Preventionist (IP) 1, IP 1 stated not notifying CDPH because IP 1 thought IP 2 had notified CDPH regarding Resident 1,4, and 5's positive COVID-19 status. During an interview on 9/11/2025 at 12:50PM with the Director of Nursing ( DON) , the DON stated that the Department of Public health and the Public Health Nurse had been notified.
Stating the Covid Outbreak consisted of three people. No document could be provided by DON indicating
the Department of Public Health had been notified. During an interview on 9/11/2025 at 1:30PM with IP 2, IP 2 not reporting the COVID-19 outbreak to the California Department of Public Health. IP 2 stated not knowing that the facility had to report the COVID-19 cases to CDPH, and by not reporting the COVID-19 cases there would be a lack of outbreak support. During a review of the facility's undated policy and procedure ( P&P) titled, Communicable Diseases - Outbreak,, the P&P indicated the purpose of Policy was to ensure that outbreaks of communicable disease are identified, handled, and reported as required. The P&P indicated outbreaks of communicable diseases within the Facility was promptly identified an appropriated treated and reported. The P&P indicated that the Administrator was responsible for reporting to the Department of Public Health, which included facility outbreak of COVID-19. The P&P indicated outbreak definition was one or more facility acquired COVID-19 case in a resident and/or three or more suspect, probable or confirmed COVID-19 cases. The Policy indicated reporting outbreaks related to a communicable disease, the facility must report the communicable disease data to CDPH.
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ARARAT CONVALESCENT HOSPITAL in LOS ANGELES, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ARARAT CONVALESCENT HOSPITAL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.