Complaint Investigation

Ararat Nursing Facility

Inspection Date: June 14, 2024

Total Violations 2

Facility ID 555579

Location MISSION HILLS, CA

Inspection Findings

F-Tag F600

Harm Level: Immediate further treatment and evaluation status post (after) fall.

Residents Affected: Few forehead extending to glabella (area of skin between the eyebrows and above the nose) and nasal bridge

F-F600.

Findings:

A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 7/9/2021 with diagnoses including parkinsonism, Alzheimer's disease (a brain disorder affecting memory and thinking skills that worsens over time), dementia (loss of thinking or remembering affecting daily life), and age-related osteoporosis (loss of bone mass with increasing risk for bone breakage).

A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/14/2024, indicated that Resident 1's cognitive skills (ability to think and process information) for daily decision-making tasks were severely impaired. The MDS indicated Resident 1 was dependent (helper does ALL the effort and resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene (cleaning teeth), toileting hygiene, shower or bathing, upper and lower body dressing, putting on or removing footwear, and personal hygiene needs (combing hair and washing or drying face or hands).

A review of Resident 1's record titled, Progress Notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1's assigned CNA (CNA 1) was about to weigh Resident 1 with a lift machine (mechanical lift, a lift device with a weighing scale designed to lift and transfer patients from a bed to a wheelchair or vice versa). CNA 1 then left Resident 1 unattended to ask for assistance from another staff member (unidentified). CNA 1 was then quoted as stating, I was almost at the door when I heard a loud sound. I turned my back, opened the curtain and I saw my resident (Resident 1) on the floor on the legs of the lifting machine. The record indicated CNA 1 noted blood around Resident 1's head.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of Resident 1's record titled, Physician's Order Sheet, dated 6/1/2024 at 12 p.m., indicated the order to Transfer the resident to hospital via 911 (a phone number to contact the emergency services) for Level of Harm - Immediate further treatment and evaluation status post (after) fall. jeopardy to resident health or safety A Review of Resident 1's GACH Emergency Department (ED) records, dated 6/1/2024 at 7:09 p.m., indicated Resident 1 was noted with a V-shaped laceration (a deep cut or tear on the skin) across the Residents Affected - Few forehead extending to glabella (area of skin between the eyebrows and above the nose) and nasal bridge (the bony part of the nose), a laceration to the right infraorbital (below the right eye) region, and bilateral periorbital ecchymosis (discoloration to the left and right surrounding eye area due to trauma). Per ED records, a Computed Tomography scan (CT scan - medical imaging used to obtain detailed internal images of the body) was done on 6/1/2024 at 12:47 p.m. revealing Resident 1 to have a Type lll Odontoid Fracture (bone breakage located in the neck area of the spine) and multiple maxillofacial (affecting the mouth, face, and jaw) bone fractures resulting in Resident 1 passing away in the ED in the afternoon (time not determined).

On 6/6/2024 at 1:45 p.m., during an interview, CNA 4 stated she had been assigned with Resident 1 in the past, and that Resident 1 was not alert and was fully dependent on staff for care. CNA 4 stated that Resident 1 needed a lift machine for transferring from the bed to the wheelchair, or from the wheelchair back to the bed. CNA 4 stated, For use of a lift machine, it is always with two staff because it's dangerous if done by self. CNA 4 stated, If it is just one person, it's dangerous because the sling (mechanical lift sling, a flexible strap or belt used in the form of a loop to support or raise a weight) moves, or the resident can move. CNA 4 stated, having only one staff cannot hold the lift machine and keep the resident steady on the sling all at the same time.

On 6/6/2024 at 2:47 p.m., during an interview, LVN 1 stated that on 6/1/2024 at approximately between 11 a. m. to 11:20 a.m., LVN 1 was called to Resident 1's room with Resident 1 found on the floor with blood coming out from Resident 1's forehead. LVN 1 stated CNA 1's explanation was CNA 1 placed the mechanical lift sling underneath Resident 1, then CNA 1 left to call for assistance, and that was when Resident 1 rolled off the bed hitting Resident 1's head against the metal legs of the mechanical lift machine.

On 6/6/2024 at 3:22 p.m., during an interview, Registered Nurse 1 (RN 1) stated (on 6/1/2024 at around 11 a. m.) RN 1 rushing to Resident 1's room and saw Resident 1 on the floor with the nursing staff (unidentified) attempting to stop the bleeding from Resident 1's head. RN 1 asked what CNA 1 should have done differently for Resident 1's safety, RN 1 stated, I would not have left the resident (Resident 1) alone.

On 6/7/2024 at 11:26 a.m. during a phone interview, CNA 1 stated on 6/1/2024, at around 11 a.m., CNA 1 went to Resident 1's room to weigh Resident 1. CNA 1 stated she used the mechanical lift machine. CNA 1 stated the rules for using a lift machine is with two staff members. CNA 1 described the procedure as, I put

the sling under the resident (while in bed), the sling is what carries the resident. I turned around towards the door, then I heard a loud noise and saw the resident face down on the leg of the lift machine. CNA 1 stated, From the start of this, I would have walked in with the second person already from the beginning so they can assist with the care needed for the resident (Resident 1). CNA 1 was asked if there was a floor mat beside

the bed, CNA 1 stated, There was no floor mat where the patient (Resident 1) had landed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 6/7/2024 at 3:05 p.m., during a concurrent interview and a review of Resident 1's care plans for fall and functional abilities, RN 4 stated Resident 1's fall risk score was 16. RN 4 stated a score of 10 and above Level of Harm - Immediate represented high risk for falls. Resident 1's Fall Risk Care Plan initiated on 3/3/2024 indicated the care plan jeopardy to resident health or interventions included placing a floor mat next to resident's bed to prevent the resident from injuries. RN 4 safety stated a floor mat allowed the resident (in general) to fall on the cushion. RN 4 stated, Having a fall is not desirable, but it is better to land on a soft surface than a hard surface. Resident 1's care plan titled, Residents Affected - Few Functional Abilities of Everyday Activities, initiated on 3/3/2024, indicated the intervention was to have two or more persons physical assist for all activities as needed. RN 4 stated the care plan indicated when transferred Resident 1 in and out of bed or wheelchair daily, staff needed to provide two or more persons physical assist when using mechanical lift.

On 6/13/2024 at 11:56 a.m., during a phone interview, CNA 1 stated two staff (in general) are needed to use

the lift machine. CNA 1 stated one staff needed to stand next to the lift machine and the other staff needed to attend to the resident. CNA 1 stated, I should not have left the resident (Resident 1) alone and should not have left the machine with the resident.

On 6/14/2024 at 12:04 p.m., during a concurrent interview and record review of Resident 1's physician orders for 6/2024, and Resident 1's Progress Notes, dated 6/1/2024, RN 4 stated that Resident 1 did not have a Physician's Order for use of a mechanical lift device RN 4 stated, I would not have left the resident (Resident 1) alone RN 4 stated I would not leave the lift machine unattended because we always make sure

the residents' environment needs to be free from hazards. RN 4 stated this lifting machine for this case was

a hazard because it is made of metal. RN 4 stated, because CNA 1 left Resident 1 alone, and because the mechanical lift was left unattended at Resident 1's bedside, Resident 1 ended up having a fall with a sustained injury. A concurrent record review of Resident 1's Progress notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1 had a skin tear on the forehead, and was bleeding from the left eye and nose.

On 6/14/2024 at 1:05 p.m., during an interview, LVN 5 stated CNA 1 left Resident 1 alone with the lift machine (mechanical lift) in the room, and CNA 1 was supposed to keep Resident 1 safe. LVN 3 stated, The machine should not be there, and it should have been the floormat as per care plan. LVN 3 stated CNA 1 could lower the bed, replace the floormat, and remove the machine. LVN 3 stated, Because this was not done, the resident fell off the bed. LVN 3 stated Resident 1 sustained a skin tear on the forehead, and bleeding from the left eye and nose.

A review of the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicated, The resident will have a physician's order for the use of a mechanical lift.

A review of the current facility-provided policy and procedure titled, Resident Rooms and Environment, with last revised date of 11/1/2017, indicated, Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 A review of the current facility-provided policy and procedure titled, Care Planning, with last revised date of 10/24/2022, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each Level of Harm - Immediate resident based on their individual assessed needs. The policy indicated, The resident has the right to receive jeopardy to resident health or the services and/or items included in the plan of care. safety

A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised Residents Affected - Few date of 5/1/2023, indicated the purpose, To provide a safe environment for residents and Facility staff.

A review of the current facility-provided policy and procedure titled, Fall Management Program, with last revised date of 2/29/2024, indicated, It is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 555579

F-Tag F689

Harm Level: Immediate with a weighing scale designed to lift and transfer patients from a bed to a wheelchair or vice versa). CNA 1

Residents Affected: Few indicated CNA 1 noted blood around Resident 1's head.

F-F689.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 A review of Resident 1's record titled, Progress Notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1's assigned CNA (CNA 1) was about to weigh Resident 1 with a lift machine (mechanical lift, a lift device Level of Harm - Immediate with a weighing scale designed to lift and transfer patients from a bed to a wheelchair or vice versa). CNA 1 jeopardy to resident health or then left Resident 1 unattended to ask for assistance from another staff member (unidentified). CNA 1 was safety then quoted as stating, I was almost at the door when I heard a loud sound. I turned my back, opened the curtain and I saw my resident (Resident 1) on the floor on the legs of the lifting machine. The record Residents Affected - Few indicated CNA 1 noted blood around Resident 1's head.

A review of Resident 1's record titled, Physician's Order Sheet, dated 6/1/2024 at 12 p.m., indicated the order to Transfer the resident to hospital via 911 (a phone number to contact the emergency services) for further treatment and evaluation status post (after) fall.

A Review of Resident 1's GACH Emergency Department (ED) records, dated 6/1/2024 at 7:09 p.m., indicated Resident 1 was noted with a V-shaped laceration (a deep cut or tear on the skin) across the forehead extending to glabella (area of skin between the eyebrows and above the nose) and nasal bridge (the bony part of the nose), a laceration to the right infraorbital (below the right eye) region, and bilateral periorbital ecchymosis (discoloration to the left and right surrounding eye area due to trauma). Per ED records, a Computed Tomography scan (CT scan - medical imaging used to obtain detailed internal images of the body) was done on 6/1/2024 at 12:47 p.m. revealing Resident 1 to have a Type lll Odontoid Fracture (bone breakage located in the neck area of the spine) and multiple maxillofacial (affecting the mouth, face, and jaw) bone fractures resulting in Resident 1 passing away in the ED in the afternoon (time not determined).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 6/7/2024 at 11:26 a.m. during a phone interview, CNA 1 stated on 6/1/2024, at around 11 a.m., CNA 1 went to Resident 1's room to weigh Resident 1. CNA 1 stated she used the mechanical lift machine. CNA 1 Level of Harm - Immediate stated the rules for using a lift machine is with two staff members. CNA 1 described the procedure as, I put jeopardy to resident health or the sling under the resident (while in bed), the sling is what carries the resident. I turned around towards the safety door, then I heard a loud noise and saw the resident face down on the leg of the lift machine. CNA 1 stated, From the start of this, I would have walked in with the second person already from the beginning so they can Residents Affected - Few assist with the care needed for the resident (Resident 1). CNA 1 was asked if there was a floor mat beside

the bed, CNA 1 stated, There was no floor mat where the patient (Resident 1) had landed.

On 6/7/2024 at 3:05 p.m., during a concurrent interview and a review of Resident 1's care plans for fall and functional abilities, RN 4 stated Resident 1's fall risk score was 16. RN 4 stated a score of 10 and above represented high risk for falls. Resident 1's Fall Risk Care Plan initiated on 3/3/2024 indicated the care plan interventions included placing a floor mat next to resident's bed to prevent the resident from injuries. RN 4 stated a floor mat allowed the resident (in general) to fall on the cushion. RN 4 stated, Having a fall is not desirable, but it is better to land on a soft surface than a hard surface. Resident 1's care plan titled, Functional Abilities of Everyday Activities, initiated on 3/3/2024, indicated the intervention was to have two or more persons physical assist for all activities as needed. RN 4 stated the care plan indicated when transferred Resident 1 in and out of bed or wheelchair daily, staff needed to provide two or more persons physical assist when using mechanical lift.

On 6/13/2024 at 11:56 a.m., during a phone interview, CNA 1 stated two staff (in general) are needed to use

the residents' environment needs to be free from hazards. RN 4 stated this lifting machine for this case was

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 A review of the current facility-provided policy and procedure titled, Resident Rooms and Environment, with last revised date of 11/1/2017, indicated, Facility Staff will provide residents with a pleasant environment and Level of Harm - Immediate person-centered care that emphasizes the residents' comfort, independence, and personal needs and jeopardy to resident health or preferences. This shall include ensuring that residents can receive care and services safely and that the safety physical layout of the Facility maximizes resident independence and does not pose a safety risk.

Residents Affected - Few A review of the current facility-provided policy and procedure titled, Care Planning, with last revised date of 10/24/2022, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The policy indicated, The resident has the right to receive

the services and/or items included in the plan of care.

A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of 5/1/2023, indicated the purpose, To provide a safe environment for residents and Facility staff.

A review of the current facility-provided policy and procedure titled, Abuse Prevention and Prohibition Program, with last revised dated 8/1/2023, indicated, 1. Each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property (illegal use of another person's property of funds).

The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of property. 2. The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff The policy also defines neglect as Leaving someone unattended who needs supervision.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Immediate jeopardy to resident health or 37861 safety Based on interview and record review, the facility failed to ensure one of seven residents (Resident 1), who Residents Affected - Few was with impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was high risk for falls, and was diagnosed with parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), was free from accidents, by failing to:

1. Provide Resident 1 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of individuals who require support for mobility) in weighing Resident 1 on 6/1/2024 at around 11 a.m.

2. Ensure Certified Nursing Assistant 1 (CNA 1) did not leave Resident 1 unattended. On 6/1/2024 at around 11 a.m., CNA 1, by herself, brought a mechanical lift inside Resident 1's room to weigh Resident 1. After CNA 1 placed the sling lift (a fabric device used on lift machines to carry patients in a hammock-type position) underneath Resident 1, CNA 1 left Resident 1 unattended to get another staff to assist in weighing Resident 1 using the mechanical lift.

3. Ensure CNA 1 followed Resident 1's care plan (a summary of a person's health condition and current treatment interventions associated with care needs) on Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination), initiated on 7/12/2021, regarding Resident 1's risk for injuries from tremors (condition that includes shaking or trembling movements

in one or more parts of the body) and involuntary (not done intentionally) muscle movements, indicating the goal of Resident 1's safety with interventions including observing environment for safety measures and to keep it free from hazards (any source of potential damage, harm or adverse health effects). When CNA 1 brought the mechanical lift at Resident 1's bedside on 6/1/2024 at around 11 a.m., it (mechanical lift) posed as a hazard to Resident 1 when CNA 1 left Resident 1 unattended.

4. Ensure Resident 1 had a physician's order for the use of the mechanical lift to weigh Resident 1 in accordance with the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicating, The resident will have a physician's order for the use of a mechanical lift.

As a result, on 6/1/2024 at around 11 a.m., Resident 1 sustained a fall resulting in Resident 1's face landing

on the base of the mechanical lift device. Resident 1 sustained a skin tear with bleeding on her forehead and bleeding from the left eye and nose. The facility transferred Resident 1 to a General Acute Care Hospital (GACH) for further evaluation where Resident 1 was identified with multiple facial fractures (bone breakage) and facial laceration (skin tear), and ultimately passing away on the afternoon of 6/1/2024 (time not determined) in the GACH due to the extent of injuries related to the fall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 6/13/2024 at 2:35 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation Level of Harm - Immediate has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of jeopardy to resident health or the Administrator (ADM), Director of Nursing (DON), and the Risk Management Registered Nurse (RM 1) safety due to the facility's failure to ensure Resident 1 was free from accidents under 42 CFR S S483.25 (d) (1) (2) Accidents. Residents Affected - Few

On 6/14/2024 at 4:03 p.m., the ADM submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified and confirmed the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the in the presence of the ADM, DON, and RM 1 on 6/14/2024 at 4:50 p.m.

The acceptable IJ Removal Plan included the following summarized actions:

1) On 6/1/2024 the resident (Resident 1) affected by the deficient practice was immediately transferred to the GACH for treatment. Resident 1 passed away at the GACH.

2) On 6/1/2024, CNA 1 who was involved in the incident was immediately suspended pending investigation.

On 6/7/2024, the employee was terminated upon the completion of the investigation.

3) On 6/1/2024, the facility's Registered Nurse (RN) Supervisors immediately initiated facility rounds to ensure no other residents were affected by the deficient practice.

4) On 6/3/2024, the interdisciplinary team (IDT - comprises of professionals from various disciplines who work in collaboration to address a patient with multiple needs) conducted a root cause analysis (the process of discovering the root causes of problems to identify appropriate solutions) of the incident and identified the potentially affected populations: those with Parkinson's disease and parkinsonism as well as those requiring

the use of a mechanical lift. No other residents were found to be affected.

5. On 6/3/2024 Information Systems Nurse conducted a diagnosis search to identify all residents with diagnosis of Parkinson's Disease or parkinsonism. 17 residents were identified in-house. The list was provided to Care Planner Nurses, who then conducted a chart audit of residents' care plans to ensure that

the care plans are comprehensive, individualized, measurable, realistic, and goal oriented. No additional residents were identified as being affected by the deficient practice.

6. On 6/03/2024, the Director of Staff Development (DSD) initiated in-services (training) for all nursing staff pertaining to: safety, use of mechanical lift device (during weighing and transfers), resident environment by keeping free it of hazards (not leaving any equipment in residents' rooms unattended), ensuring presence of two or more (2+) staff when utilizing lifting machines, and following residents' care plans regarding safety.

7. On 6/03/2024, RN Supervisors and Risk Management Nurse conducted rounds (to go around and see the residents) throughout the shift (the time assigned for work) to ensure that all residents who required the use of lift machines were transferred appropriately and safely according to facility's policy and procedures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 8. On 6/5/2024 at 1:42 p.m., the ADM informed all nursing staff (CNAs, Restorative Nursing Assistants [RNAs], and Licensed Nurses) via Carefeed (a communication platform that interfaces with facility's Level of Harm - Immediate electronic medical software as well as payroll software) that two persons must be present when utilizing a jeopardy to resident health or mechanical lift. safety 9. On 6/13/2024, RN Supervisors on the shift initiated additional in-services for all CNAs and licensed Residents Affected - Few vocational nurses (LVNs) pertaining to safety, use of mechanical lift (during weighing and transfers), and keeping the environment free of hazards (by not leaving any equipment in the residents' rooms unattended), ensuring presence of 2+ staff when utilizing lifting machines, following residents' care plans regarding safety, and ensuring that all residents who utilize mechanical lifts have physician orders for its use (licensed nurses only).

10. On 6/13/2024, the Regional Mentor (a licensed Occupational Therapist) provided additional training to all nursing staff on all shifts to ensure additional reinforcement of procedures, safety protocols, with one-on-one (person-to-person contact) return demonstrations to verify acknowledgment and demonstrate learning. On 6/14/2024, the Regional Mentor initiated training for all nursing and rehab staff utilizing a mechanical lift and

a mannequin for hands-on demonstrations and return demonstrations to be completed by every employee in attendance.

11. On 6/13/2024, the Minimum Data Set (MDS) Nurses reviewed all 30 residents' charts (medical records) who required the use of mechanical lifts to ensure presence of physician orders for use of mechanical lifts. No additional residents were identified to be affected by the deficient practice.

12. Effective 6/14/2024, an in-service was provided by an outside entity to all current nursing and rehabilitation staff (staff who assist individuals with a disability and/or illness that is continuing for a long time to attain and maintain maximum function) with mandatory (required) return demonstrations (a teaching strategy that involves the learner demonstrating their understanding or mastery of a skill or concept by performing it themselves) for all those present on the use of mechanical lift and safe transfers. Any nursing staff not on duty will receive training upon returning to work.

13. On 6/14/2024, the CNA, RNA, Licensed Nursing, and rehabilitation team skills checklists were updated to include return demonstrations of transfer skills utilizing mechanical lifts.

14. Updated skills checklists were included in the newly hired packets for all nursing staff and rehabilitation department to ensure proper training and return demonstrations of transfer techniques and use of lift machines is correct prior to staff working with residents. Any staff not on duty will receive training upon return to work.

15. All newly admitted and readmitted residents will be assessed by RN Supervisors upon admission/readmission for dependence on use of mechanical lift for transfers.

16. On 6/13/2024, the DON posted a memo notifying all staff that effective immediately, weighing (monthly and/or weekly) will be done on Mondays during morning shift only, in the presence of Risk Management Nurse, DSD, or RN Supervisors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 555579 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555579 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 17. Effective 6/13/2024 MDS nurses will communicate with the DON, RN Supervisors and PIQI (Performance Improvement, Quality Improvement) Nurses regarding residents who suddenly require the use Level of Harm - Immediate of a mechanical lift. The DON, RN Supervisors, and/or PIQI Nurses will then obtain an order from the jeopardy to resident health or physician for resident transfers with the use of mechanical lift. Resident teaching will be provided to resident safety and/or responsible party with updated care plan.

Residents Affected - Few 18. Effective 6/14/2024, the Administrator, DON, Director of Rehab, Information Systems Nurses, and MDS nurses will discuss the residents who are newly admitted /readmitted and those with any changes of condition who may require mechanical lifting machine for transfers as a part of the daily Stand-Up meeting (short meeting to discuss progress and identify blockers) that takes places Mondays through Fridays. Any changes over the weekend will be discussed on the following business day.

19. The DON and/or designee (during the weekends) will review the Shift Monitoring and Reporting Tool daily to gather data on RN Supervisors' visual audits of staff transfer practices on all shifts to monitor adherence and maintain/sustain compliance. Any identified concerns will be reported to the ADM for resolution as warranted.

20. The PIQI Nurses and/or RN Supervisors (on the weekends) will review the Shift Monitoring and Reporting Tool for compliance and report the findings to the ADM and DON. The ADM and DON will then present findings to the PIQI Committee monthly for the first 3 months and quarterly for at least 8 quarters, until substantial compliance of 100 percent (% - one part in every hundred) is achieved.

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Ararat Nursing Facility

Inspection Findings

F-Tag F600

F-Tag F689

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