Ararat Nursing Facility

F-F658

Findings:

a. During a review of Resident 43's Admission Record, the admission record indicated the facility admitted Resident 43 on 3/17/2021 and readmitted on [DATE REDACTED] with diagnoses that included congestive heart failure (CHF - a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and aphasia (a language disorder that makes it hard for a person to read, write, and say what you mean to say).

During a review of Resident 43's Order Summary Report indicated the following physician's order dated 6/13/2024:

-Insulin lispro-aabc injection solution 100 unit per milliliter (unit/ml - a unit of measurement). Inject as per sliding scale: if 150-200 = 2 unit; 201-250 = 4 unit; 251-300 = 6 unit; 301-350 = 8 unit; 351-400 = 10 unit, SQ

before meals related to DM 2. Call physician if fingerstick blood sugar is above 400 or below 70.

During a review of Resident 43's History and Physical (H&P) dated 6/14/2024, the H & P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 211's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/8/2024, indicated the resident had rarely to never had the ability to make self-understood and sometimes understand others. The MDS indicated the resident had highly impaired vision and was on a high-risk drug class hypoglycemic (occurs when the level of glucose in the blood drops below normal) medication insulin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0760 During a review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/1/2024 indicated the resident had moderately impaired cognition (mental action or process of Level of Harm - Minimal harm or acquiring knowledge and understanding) and required supervision or touching assistance with eating, partial potential for actual harm to moderate assistance with walking, was dependent with toileting, bathing, and lower body dressing and required substantial to maximal assistance with all other activities of daily living (ADLs - basic tasks that must Residents Affected - Some be accomplished every day for an individual to thrive). The MDS further indicated Resident 43 received insulin.

During a review of Resident 43's Medication Administration Record (MAR) from 6/2024 to 7/2024, indicated insulin lispro injection solution was administered as follows on the following dates:

06/23/24 11:30 subcutaneously Right Upper Arm (RUA)

06/23/24 17:00 subcutaneously - RUA

06/25/24 11:30 subcutaneously Left Upper Arm (LUA)

06/25/24 17:00 subcutaneously - LUA

06/27/24 17:00 subcutaneously - Left Deltoid (LD)

06/28/24 07:00 subcutaneously - LD

06/30/24 07:00 subcutaneously - RUA

06/30/24 11:30 subcutaneously - RUA

07/02/24 11:30 subcutaneously - RUA

07/02/24 17:00 subcutaneously - RUA

07/03/24 11:30 subcutaneously - LUA

07/03/24 17:00 subcutaneously - LUA

07/10/24 11:30 subcutaneously - LUA

07/10/24 17:00 subcutaneously - LUA

07/13/24 11:30 subcutaneously - RUA

07/13/24 17:00 subcutaneously - RUA

07/19/24 17:00 subcutaneously - RUA

07/20/24 17:00 subcutaneously - RUA

07/20/24 11:30 subcutaneously - LUA

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0760 07/20/24 17:00 subcutaneously - LUA

Level of Harm - Minimal harm or 07/23/24 11:30 subcutaneously - RUA potential for actual harm 07/23/24 17:00 subcutaneously - RUA Residents Affected - Some 07/24/24 17:00 subcutaneously - RUA

07/28/24 11:30 subcutaneously - LUA

07/28/24 17:00 subcutaneously - LUA

07/29/24 07:00 subcutaneously - Right & Above Umbilicus

07/29/24 11:30 subcutaneously - Right & Above Umbilicus

07/30/24 11:30 subcutaneously - Right & Below Level of Umbilicus

07/30/24 17:00 subcutaneously - Right & Below Level of Umbilicus

During a concurrent interview and record review on 8/8/24 at 12:04 p.m., Resident 43's MAR for 6/2024 and 7/2024 was reviewed with Registered Nurse 1 (RN 1). RN 1 verified the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the insulin administration sites should have been rotated as the residents could develop irritation on the site, possibly abscess, and lipodystrophy. RN 1 stated it was a standard of practice and considers not rotating insulin administration site as a medication error.

During a review of the facility's policy and procedure titled, Medication- Errors, last reviewed on 1/29/2024, indicated a medication error is the preparation or administration of medications or biologicals which is not in accordance with:

-The prescriber's order.

-Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; and/or

-Accepted professional standards and principles which apply to professionals providing services.

-Accepted professional standards and principles include the various practice regulations in the state, and currently commonly accepted health standards established by national organizations, boards, and councils.

44376

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0760 b. During a review of Resident 211's Admission Record, the admission record indicated the facility admitted

the resident on 8/22/2022, with diagnoses that included type 2 diabetes mellitus (a disease that occurs when Level of Harm - Minimal harm or the blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a type of kidney potential for actual harm disease caused by diabetes) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). Residents Affected - Some

During a review of Resident 211's History and Physical (H&P), dated 8/11/2023, indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 211's Order Summary Report, indicated an order for:

-7/17/2024 Novolin N FlexPen Subcutaneous Suspension Pen-injector 100 unit (the amount of insulin required to reduce the blood glucose)/milliliters (ml, a unit of volume) (Insulin NPH Human [Isophane]). Inject 4 unit subcutaneously in the morning related to type 2 diabetes mellitus with diabetic chronic kidney disease.

-6/14/2024 Novolog Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (varies the dose of insulin based on blood glucose level): if 150-200=2 unit; 201-250=4 unit; 251-300=6 unit; 301-350=8 unit; 351-400=10 unit, subcutaneously before meals related to type 2 diabetes mellitus with diabetic chronic kidney disease. Call MD if fingerstick (a procedure in which a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing) blood sugar (BS) is above 400 or below.

During a review of Medication Administration Record of insulin for 6/2024 to 7/2024 indicated Novolog insulin was administered on as follows on the following dates:

6/22/2024 at 7 am on (20) the left and above the level of umbilicus (navel).

6/22/2024 at 11:30 am on (20) the left and above the level of umbilicus.

7/7/2024 at 7 am on (21) right and below level of umbilicus.

7/7/2024 at 11:30 am on (21) right and below level of umbilicus.

7/10/2024 at 7 am on (22) left and below level of umbilicus.

7/10/2024 at 11:30 am on (22) left and below level of umbilicus.

7/19/2024 at 11:30 am on (19) to right and above umbilicus.

7/20/2024 at 7 am on (19) to right and above umbilicus.

7/22/2024 at 11:30 am on (21) right and below level of umbilicus.

7/22/2024 at 5 pm on (21) right and below level of umbilicus.

7/24/2024 at 5 pm on (12) left upper arm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0760 7/25/2024 at 7 am on (12) left upper arm.

Level of Harm - Minimal harm or 7/29/2024 at 7 am on (21) right and below level of umbilicus. potential for actual harm 7/29/2024 at 11:30 am (21) right and below level of umbilicus. Residents Affected - Some

During a concurrent interview and record review on 8/8/2024, at 12:04 p.m., with Registered Nurse 1 (RN 1), Resident 211's Order Summary Report and the Medication Administration Record for 6/2024 to 7/2024 was reviewed. RN 1 stated there was an order for Novolin insulin for the resident and the MAR from 6/2024 to 7/2024 indicated there were multiple instances where the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the failure of the licensed nurse to rotate insulin administration sites could cause skin irritations such as abscess, necrosis, and lipodystrophy. RN 1 stated not rotating insulin administration sites was considered a medication error.

During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated it was common knowledge for licensed nurses to rotate insulin administration sites to prevent tenderness, discomfort, and lipodystrophy to the sites that was frequently administered with insulin. The DON stated not rotating insulin administration sites was considered a medication error.

During a review of the facility's recent policy and procedure titled, Medication- Errors, last reviewed on 1/29/2024, the policy indicated to ensure the prompt reporting of errors in the administration of medications and treatments to residents. Definition- The preparation or administration of medications or biologicals which is not in accordance with:

A. The prescriber's order.

B. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological.

C. Accepted professional standards and principles which apply to professionals providing services.

i. Accepted professional standards and principles include the various practice regulations in the state, and currently commonly accepted health standards established by national organizations, boards, and councils.

During a review of the facility provided undated, Novolog Manufacturer's Recommendation for Novolog (insulin aspart) injection 100 U/ml is an insulin analog indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus, indicated repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia; and a sudden change in the injection site (to an unaffected area) has been reported to result in hypoglycemia. Advise patients who have repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 99 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 43455 Residents Affected - Few Based on observation, interview, and record review the facility failed to:

1.Label one Latanoprost (a medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 122, with an open date in accordance with facility requirements and manufacturer's requirements in one of four inspected medication carts (Medication Cart North Middle East.)

2. Dedicate a refrigerator for medication storage only for one of six inspected medication refrigerators (Medication Refrigerator in ADMIN office hallway.)

3. Remove and discard 7 unopened expired Afluria (an influenza [also known as flu] vaccine [a substance that provides immunity to an infectious disease] used to provide protection against the flu vaccine for the 2023 -2024 flu season) vials, one opened expired Afluria vial, 4 unopened expired Procrit (a medication used to treat anemia [having low red blood cells) vials, and 15 expired COVID-19 prefilled (already loaded with the medication) syringes from facility stock use, in accordance with manufacturer's requirements in one of six inspected medication refrigerators (Medication Refrigerator in Administrator [ADMIN] office.)

4. Remove and discard 3 unopened expired Procrit vials for Resident 335 and 336 from use, in accordance with manufacturer's requirements in one of six inspected medication refrigerators (Medication Refrigerator in Administrator [ADMIN] office.)

These deficient practices increased the risk that Residents 122, 335, 336 and all other residents in the facility could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications such as worsening glaucoma, anemia, and infections potentially requiring hospitalization .

During an observation on 8/5/2024 at 11:26 PM, in Medication Cart North Middle East, in the presence of Licensed Vocational Nurse (LVN) 7, the following medication was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored and labeled contrary to facility policies:

1. One open Latanoprost eye drop bottle for Resident 122 was found stored at room temperature and not labeled with a date on which storage at room temperature began.

According to the manufacturer's product storage and labeling, opened Latanoprost bottles may be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page100of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0761 During a concurrent interview with LVN 7, LVN 7 stated that the Latanoprost eye drop bottle was not labeled with a date when use or storage at room temperature began and should not be used for Resident 122. LVN 7 Level of Harm - Minimal harm or stated that eye drop medications were usually good for 28 days after opening the bottle. LVN 7 stated LVN 7 potential for actual harm was unable to identify the expiration date without knowing the date when use began, and considering pharmacy filled the medication on 6/20/2024 the bottle was considered expired. LVN 7 stated that using Residents Affected - Few expired eye drop medication will not be effective in treating Resident 122's glaucoma and potentially cause eye infections since the dropper of the bottle was no longer sterile beyond the 28-day expiration date. LVN 7 stated the Latanoprost bottle for Resident 122 needed to be immediately removed from the medication cart and replaced with a new one from pharmacy.

During an observation, on 8/6/2024 at 11:55 AM, in the presence of Nurse Consultant (NC) and Director of Nursing (DON), in the Medication Refrigerator located in the ADMIN office hallway, the refrigerator was stored with different food items.

During a concurrent interview in the presence of NC and DON, the DON stated the medication refrigerator was currently being used for staff food storage, even though staff have a dedicated food refrigerator in staff break room, and that during influenza season was used for storing influenza vaccines only. The DON stated that DON understands the risk associated with mixing medications and food together in error.

During an observation, on 8/6/2024 at 12 PM, in the presence of ADMIN, NC and DON, in the Medication Refrigerator located in the ADMIN's office, the following medications were found expired and not discarded and stored contrary to facility policies:

1. Seven (7) unopened vials of Afluria 2023-2024 formula vaccines for facility stock were found stored in the refrigerator.

According to the manufacturer expiration dating, the Afluria vials should be stored in the refrigerator and discarded by 6/30/2024.

2. One (1) opened vial of Afluria 2023-2024 formula vaccine for facility stock was found stored in the refrigerator with and labeled with a date indicating that use of the vial began on 11/15/2023.

According to the manufacturer storage and labeling once the Afluria multi-use vial was opened to discard within 28 days.

3. Fifteen (15) unopened prefilled syringes of COVID-19 vaccine for facility stock were found stored in the refrigerator.

According to the manufacturer expiration dating, the Afluria vials should be stored in the refrigerator and discarded by 7/1/2024.

4. Four (4) unopened vials of Procrit for facility stock were found stored in the refrigerator.

According to the manufacturer expiration dating, the Procrit vials should be stored in the refrigerator and discarded by 1/2024.

5. Two (2) unopened vials of Procrit for Resident 335 were found stored in the refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page101of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0761 According to the manufacturer expiration dating, the Procrit vials should be stored in the refrigerator and discarded by 12/2023. Level of Harm - Minimal harm or potential for actual harm 6. One (1) unopened vial of Procrit for Resident 336 was found stored in the refrigerator.

Residents Affected - Few According to the manufacturer expiration dating, the Procrit vials should be stored in the refrigerator and discarded by 1/2024.

During a concurrent interview in the presence of NC and DON, the DON stated the above medications in the ADMIN office refrigerator were expired and needed to be removed from the refrigerator and discarded to prevent accidental use. The DON stated administering expired vaccines and medications to residents in the facility will not provide protection from the flu, COVID-19 and not help treat anemia. The DON stated several licensed staff failed to remove expired medications from the refrigerator which can potentially lead to the accidental use of expired medications and harm residents.

During an interview on 8/8/2024 at 10:55 AM, in the presence of Administrator (ADMIN), the Director of Nursing (DON) stated that the facility failed to label the Latanoprost eye drop bottle for Resident 122 with a date indicating when use began. DON stated that opened multi-use (used more than once) medications, such as eye drops, should be labeled with a date when use began to know when they should be disposed of, otherwise these medications are considered expired and should be removed from the medication cart. The DON stated this failure can potentially lead to the administration of expired Latanoprost to Resident 122, which will not be effective in treating the resident's Glaucoma and causing eye infections due to the compromised sterility of the medication.

Review of the facility's policy and procedures (P&P), titled Procedures for All Medications, dated 1/29/2024,

the P&P indicated To administer medications in a safe and effective manner.

E. Check expiation date on package/container. When opening a multi-dose container, place the date on the container.

Review of facility's guide, titled Medication Storage, dated 5/3/2023, the guide indicated the following:

Xalatan (Latanoprost) stored at room temperature opened has an expiration date of 42 days.

Review of the facility's P&P, titled Storage of Medications, dated 1/29/2024, the P&P indicated: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

K. Medications requiring refrigeration or temperature between 36 to 46 Fahrenheit are kept in a refrigerator .

L. Refrigerated medications are kept in closed and labeled container, with internal and external medications separated and separate from fruit juices, applesauce, and other foods in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page102of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0761 M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for Level of Harm - Minimal harm or medication disposal, and reordered from the pharmacy if a current order exists. potential for actual harm

Review of the facility's P&P, titled Discontinued Medications, dated 1/29/2024, the P&P indicated: When Residents Affected - Few medications are expired, .the medications are marked as discontinued or stored in a separate location and later destroyed or donated .

A. If a medication expires, .the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose.

B. Medications are removed from the medication cart or storage area prior to expiration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page103of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 47441

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to:

a. Ensure one (1) food item in the walk-in refrigerator and three (3) food items in the reach-in refrigerator had

a label.

b. Ensure the bulk condiment container lid had no chips and scratches.

c. Ensure four (4) dented cans were not stored with non-dented cans.

d. Ensure one storage rack was not six (6) inches ([in.] unit of measurement) above the floor.

e. Ensure [NAME] 1 was not wearing two gold bracelets while scooping food and Dietary Aide 1 (DA 1) was not wearing a watch while scooping soup during lunch trayline.

f. Ensure Yogurts were at 58.5 degrees Fahrenheit ([ F], degree of temperature), 57.2 F and 58.2 F.

g. Ensure eight resident's trays had no cracks and chips.

h. Ensure the Staff checked and monitored the temperature when testing solution for sanitizer.

i. Ensure Staff properly cooled the buckwheat.

These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 239 of 239 medically compromised residents who received food and ice from the kitchen.

Findings:

a. During an initial kitchen tour observation on 8/5/2024 at 8:18 a.m. in the walk-in refrigerator, a pan of food had no name.

During a concurrent observation of the reach in refrigerator and interview with Dietary Supervisor (DS) on 8/5/2024 at 8:37 a.m. DS stated there were 3 pans of meat that had no name and there was no product name printed on the food itself however, everyone in the kitchen knows what the product was. DS stated the three pans of meat was ground beef and regular beef. DS stated staff forgot to label them. DS stated their process of labeling and dating included labeling it with the name of the product, the date when the food was pulled from the freezer and the used by date. DS stated it was important to label the food with name to identify what kind of meat, food and what kind of products were in the refrigerators. DS sated the residents could possibly receive wrong food items causing the residents to have diarrhea, and not catering their dislikes as a potential outcome.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page104of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0812 A review of facility's Policies and Procedures (P&P) titled Food Storage dated 1/29/2024 indicated II. Frozen Meat/Poultry and Food Guidelines. (i). label and date all food items. Level of Harm - Minimal harm or potential for actual harm A review of Food Code 2017 indicated 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety Residents Affected - Many food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

b. During an initial kitchen tour observation of the dry storage area on 8/5/2024 at 9:02 a.m. the bulk container lids for bulgar 1, bulgar 2, sugar, pasta, rice, scalloped potatoes, Calrose, lentil, green lentils, and flour had chips and scratches.

During a concurrent observation of the bulk containers and interview with DS and Administrator (ADM) on 8/5/2024 at 9:17 a.m., DS stated the bulk containers had scratches and physical contaminants could go to

the food. DS stated bacteria could grow in these scratches because the container would be hard to clean. ADM sated the containers were not filled up to touch, but it would be a concern for physical contaminants. DS stated the potential outcome would be cross-contamination.

c. During an initial kitchen tour observation of the dry storage area on 8/5/2024 at 9:09 a.m. one (1) dented can was stored in the non-dented cans section.

During a concurrent observation of the dry storage area and interview with DS on 8/5/2024 at 9:18 a.m., DS stated there was a designated area for dented cans so as not to consume it. DS stated dented cans were not good for consumption as the food inside would be spoil. DS stated the expectation was to separate dented cans from non-dented cans to avoid using them. DS stated there were total of four (4) dented cans stored with the undented cans. Residents could get sick if they consumed food from dented cans as a potential outcome.

A review of facility's P&P titled Receiving Food and Supplies dated 1/29/2024 indicated V. Do not accept and return to the supplier, any items that are: B. Dented, rusted, damaged cans.

A review of facility's P&P titled Food Storage dated 1/29/2024 canned fruits and vegetable storage guidelines C. Dented or bulging cans should be placed in separate storage area and returned for credit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page105of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0812 A review of Food Code 2017 indicated 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Level of Harm - Minimal harm or Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from potential for actual harm approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their Residents Affected - Many safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

d. During a concurrent observation of storage rack in the dry storage area used to store paper supplies and

interview with DS and ADM on 8/5/2024 at 9:10 a.m. one storage rack was not more than six (6) inches above floor. DS stated the expectation for all the dry storage racks would be 6 inches or more. DS stated it was important to have the racks or shelves to be more than 6 inches above he floors for the rodents not to get into the food or paper supplies and for infection control. ADM stated the rack was used for paper supply storage that's why it was not more than 6 inches high from the floor. DS stated all the racks or shelves in the dry storage should be above 6 inches from the floors.

A review of the facility's P&P titled Food Storage dated 1/29/2024 indicated Dry Storage Guidelines H.) Shelving should be mounted at least 6 inches from the floor, preferably on castors for ease of cleaning, and 18 inches from the ceiling.

A review of Food Code 2017 indicated 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above

the floor.

e. During an observation of [NAME] 1 on 8/5/2024 at 11:06 a.m., [NAME] 1 was wearing two gold bracelets while cooking and stirring soup.

During an observation of trayline on 8/5/2024 at 11:44 a.m., [NAME] 1 was wearing gold bracelets while dishing out hot food and DA 1 was wearing a watch while dishing out soup.

During a concurrent observation of the trayline and interview with DS on 8/5/2024 at 11:52 a.m. DS stated [NAME] 1 was wearing gold bracelets while dishing out food in trayline and it was not allowed due to physical hazard and infection control. DS stated they only allowed their employees to wear a plain wedding band and watch.

During an interview with [NAME] 1 on 8/5/2024 at 11:57 a.m. [NAME] 1 sated she did not usually wear bracelets and she just forgot to remove it. [NAME] 1 stated she was aware of the importance for not wearing jewelries during food preparation and it was for infection control.

A review of facility's P&P titled Personal Hygiene dated 1/29/2024 indicated Objective: Participants will learn what guidelines for personal hygiene are needed to promote a safe and sanitary Food and Nutrition Services department. Jewelry is limited to wedding band and post earrings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page106of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0812 A review of Food Code 2022 indicated 2-303.11 Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms Level of Harm - Minimal harm or and hands. potential for actual harm f. During an observation of the yogurt on resident's tray inside the cart waiting outside the kitchen hallway on Residents Affected - Many 8/5/2024 at 11:35 a.m., yogurt 1 was at 58.5 F, and yogurt 2 was at 57.2 F.

During a concurrent observation of the yogurt and interview with DS on 8/5/2024 at 11:37 a.m., DS stated staff started placing the cold items including the yogurt on the resident's tray around 11:10-11:20 a.m. DS stated the yogurt in one of the trays was 58.1 F when she tempted it using the facility thermometer. DS stated it was not okay as it should be at 41 F or below to avoid the danger zone ([temperature between 41 F and 135 F], temperatures where bacteria grow rapidly) where bacteria could grow. DS stated she would change all the yogurts on the trays because it would no longer be good to serve to the residents as they could get sick and have diarrhea.

A review of facility's P&P titled Food Temperatures - Danger Zone dated 1/29/2024 indicated Purpose: To ensure the safety and well-being of residents by maintaining at safe temperatures and preventing the growth of harmful bacteria in compliance with Title 22 regulations of the California Code of Regulations. Danger zone: The temperature range between 41 F (5 C) and 135 F (57 C) where bacteria can grow rapidly. Perishable foods: Food that require time and temperature control for safety, including meats, dairy products, cooked vegetables, and certain prepared foods. Policy: (1) Temperature Control: All perishable must be kept out of the danger zone. Cold food must be maintained at or below 40 F (5 C), and hot food must be maintained at or above 140 F (57 C).

A review of facility's P&P titled Food Temperatures dated 1/29/2024, indicated III. Acceptable Serving Temperatures: Milk, juice <41 F. V. If temperatures are not at acceptable levels and cannot be corrected in time for meal service, and appropriate menu substitution should be implemented. B. Cold food may be put in

a freezer 30 minutes to 45 minutes prior to meal service to obtain serving temperature. (i.) Bring only one tray at a time out of the trayline. Place on ice. Ice down all cold foods on trayline.

A review of Food Code 2017, indicated 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less.

g. During a concurrent observation of the resident's trays and interview with DS on 8/5/2024 at 12:36 p.m. eight (8) resident's trays had chip and cracks. DS stated they needed to change the trays with crack and chips as bacteria could grow in it. DS stated potential outcome would be cross-contamination.

A review of facility's P&P titled Discarding of Chipped/Cracked Dishes and Single Service Items dated 1/29/2024 indicated Policy: The dietary staff will maintain a sanitary environment in the dietary department by discarding compromised service ware and single service items. Procedure: I. The dietary staff will discard chipped or cracked dish or glass ware.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page107of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0812 A review of Food Code 2017 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Level of Harm - Minimal harm or potential for actual harm h. During a demonstration of checking sink and surface cleaner sanitizer concentration by [NAME] 2 and

interview with [NAME] 2 on 8/6/2024 at 9:56 a.m. [NAME] 2 did not check the sanitizer solution when Residents Affected - Many checking the concentration. [NAME] 2 stated she did not check and record the temperature of the solution prior to checking the premix sanitizer solution by the two-compartment sink.

During concurrent interview with DS and review of sink and surface cleaner manufacturer's guidelines on 8/6/2024 at 10:16 a.m. the sink and surface sanitizer indicated Sanitation range testing - 1. Testing solution should be at or above room temperature: 65 F (18.3 C). DS stated she tested the water temperature for testing solution for sanitizer however, she was not recording it anywhere. DS stated the staff were also not recording the temperature of the solution prior to testing the sanitizer. DS stated they did not follow manufacturer's guidelines for the sanitizer, and it was important to follow the manufacturer's guidelines of the sanitizer to ensure the strength of the sanitizing solution for it to sanitize the dishes for infection control. DS stated she had to include the temperature check in the form.

A review of facility's log titled Food and Nutrition: Sanitizer Test Strips Log dated May 2024 and August 2024, indicated there was no solution temperature recorded when testing the sanitizer concentration.

A review of the facility's chemical manufacturer's guidelines titled Sink and Surface Cleaner Sanitizer not dated, indicated Sink and Surface Test Strips. Measurement can be taken at any temperature above 65 F.

A review of the facility's P&P dated Cleaning and Sanitation Solution dated 1/29/2024 indicated Policy: The dietary department is responsible for following the manufacturer's guidelines for cleaning and sanitation solution concentration and use, as well as proper use of buckets. II. Red buckets will be used for sanitizer solution. A. Test concentration range of sanitizer solution prior to use and adhere to minimum water temperature.

i. During concurrent interview with DS and review of cooling log in 8/6/2024 at 1:30 p.m. DS stated the buckwheat was made from scratch on 8/4/2024 and was cooled following the cooling process. DS stated the process of cooling were as followed:

After cooking the food, temperature is recorded on the cooling log.

Temperature of the food needed to go down in the refrigerator at 70 F in two (2) hours. If it did not go down to 70 F, the food needed to be thrown away or reheated to 165 F.

Overall cooling process was 6 hours. Four (4) hours to go down from 70 F to 40 F.

DS stated the weekend cook did not record the initial time and temperature of the buckwheat as it was not reflected in the cooling log. DS stated it was important to monitor time and temperature when cooling of foods to prevent foodborne illnesses and temperature abuse. DS stated diarrhea and foodborne illnesses were the potential outcome for the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page108of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0812 A review of facility's P&P titled Food Temperatures - Danger Zone dated 1/29/2024 indicated 6. Cool hot foods from 135 F (57 F) to 70 F (21 C) within 2 hours, and from 70 F (21 C) to 41 F (5 C) or below within an Level of Harm - Minimal harm or additional 4 hours. 8. Monitoring and Record-keeping. Record temperatures during receiving, storage, potential for actual harm cooking, holding, cooling, and reheating in designated logs. Procedure: 7. Monitoring and Documentation: Conduct temperature checks at each critical point: receiving, storage, preparation, cooking, holding, cooling, Residents Affected - Many and reheating. Maintain accurate and up-to-date logs for review during inspections.

A review of Food Code 2017 indicated 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified

in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above.

A review of Food Code 2017 indicated 3-501.14 Cooked time/temperature for safety shall be cooled (1) Within 2 hours from 57 F (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 F (135 F) to 5 C (41 F) or less.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page109of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to have an updated policy regarding the Residents Affected - Many use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought

in by family and other visitors.

This deficient practice had the potential to cause a decrease food intake resulting in unintentional (without trying) weight loss, frustrations, and psychosocial harm to 239 of 239 facility residents.

Findings:

A review of the facility's Policies and Procedures (P&P) titled Food Brought in by Visitors dated 6/6/2024, indicated Policy: Food may be brought to a resident by the family members, the resident's responsible party, or friends (visitors) if the food is compatible with the Attending Physician's diet order. Procedure: (B) Food from outside sources should be stored in a sealable container with the resident's name and date it was bought to the facility. The P&P did not indicate a procedure for safe storage of food and where to store the foods.

During an interview with Dietary Supervisor (DS) on 8/6/2024 at 10:19 a.m., the DS stated they have a food from home policy for the resident's visitor who brought food for the residents and nursing staff implemented it. The DS stated they did not have a refrigerator in the resident's room, nursing station and in the kitchen designated as resident's refrigerator. The DS stated family and visitors were only allowed to bring pastries or ice cream and residents had to eat it right away.

During an interview with Licensed Vocational Nurse 1 (LVN 1) on 12:51 a.m. at the [NAME] Station, LVN 1 stated resident's family and visitors were allowed to bring food from the outside and they must sign a paper for bringing food from the outside. LVN 1 stated, they were not allowed to keep resident's leftover food as

they did not have any refrigerator in the nursing stations or inside the resident's room. LVN 1 stated they were not allowed to store frozen prepared food items from the resident's visitors because they prepare foods for the residents every day in the facility's kitchen. LVN 1 stated they could only keep food at room temperature for two (2) hours but was not sure if that was the exact time, because it would not be fresh anymore. LVN 1 stated the potential outcome for the residents would be upset stomach, nausea, vomiting and diarrhea if the food was not refrigerated. LVN 1 stated it would not be good for resident's health. LVN 1 stated she told the families that they could not bring food from the outside beyond one meal. LVN 1 stated

she educated families regarding the reason why they could not store food from the outside beyond one (1) meal unless it was cookies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page110of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0813 During an interview with Licensed Vocational Nurse 2 (LVN 2) at 8/6/2024 at 1:12 p.m. at [NAME] one station, LVN 2 stated resident's visitors could always bring food from the outside however, residents could Level of Harm - Minimal harm or not save the food or later consumption and must eat it right away because the food would spoil without potential for actual harm refrigeration. LVN 2 stated they did not have refrigerators in the resident's room and nursing unit. LVN 2 stated food like cookies were stored in the resident's drawers and they labeled it with name and date. LVN 2 Residents Affected - Many stated they educated residents to bring enough food they could consume right away and if there were other foods brought in, they tell the visitors that they could not bring the food in. LVN 2 stated she would maybe take the food in the kitchen and keep it there or ask the supervisors if she could do that. LVN 2 stated residents could get mad as a potential outcome for not allowing them to bring food for later consumption.

During an interview with Director of Nursing on 8/6/2024 at 2:07 p.m., the DON stated they do not have refrigerators in resident's room and nursing stations for resident's food storage and resident's family were aware that they could only bring food for one time use only. The DON stated they store crackers and cookies from visitors in the resident's drawer but denied other perishable foods and discarded them as they could not store them. The DON stated it was the resident's right to bring food from the outside, but they were never allowed to store it for safety reasons. The DON stated as a potential outcome, residents would not be able to eat and could upset the residents if they were not allowed to store food from the outside.

During an interview with the Administrator (ADM) on 8/6/2024 at 2:28 p.m., the ADM stated residents were allowed to bring food from the outside and any perishable items needed to be consumed within two hours.

The ADM stated they could only eat the food for the day they brought the food in, and it needed to be discarded if not consumed as there were no refrigerators in the resident's room and nurse's station. The ADM stated there were refrigerators in her office and nursing office that they could use if resident's visitor brought food from the outside. The ADM stated there was no significant potential outcome from not storing food from the outside for more than one day consumption.

During an interview with the ADM on 8/6/2024 at 2:40 p.m., the ADM stated the food storage guidelines for food brought by visitors fell off when they updated the policy on 6/6/2024 and the original policy dated 5/1/2024 indicated storage guidelines for food brought from the outside.

A review of P&P titled Food Brought in by Visitors dated 5/1/2024 indicated VI. Perishable food requiring refrigeration will be discarded two (2) hours at bedside, and if refrigerated, it will be labeled, dated, and discarded after 48 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page111of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly Residents Affected - Many by not maintaining the trash area free from trash, soiled gloves, soiled tissue papers, a plastic bag of trash

on the floor and other dirt debris.

This deficient practice had a potential to attract birds, flies, insects, pests and possibly spread infection to 239 of 239 facility residents.

Findings:

During a concurrent observation of the dumpster (a large metal trash container designed to be emptied into a truck) area outside of the facility and interview with the Dietary Supervisor (DS) on 8/6/2024 at 9:33 a.m., there were soiled gloves, tissue papers and a pile of trash around the dumpster area. The DS stated the trash surroundings were not clean. The DS stated the trash on the ground was not good, not sanitized, and cleaned. The DS stated it was important to maintain the cleanliness of trash surroundings to prevent pest in

the area that could end up going in the facility and for infection control.

During concurrent observation of the trash area and interview with the Environmental Service Staff (EVSS)

on 8/6/2024 at 9:35 a.m., the EVSS stated the truck driver who picked up the trash comes everyday around 6-6:30 a.m. and trash would fall from the transfer of the trash from the dumpster to the truck. The EVSS stated their vendor would tell the EVSS that the vendor did not have time for the facility to wait to clean the surroundings. The EVSS stated they must call their vendor to prevent this issue. The EVSS stated it was important to maintain the cleanliness of the trash area for infection control for the residents.

A review of facility's policies and procedures (P&P) titled Pest Control dated 1/29/2024, indicated General Practices B. Garbage and trash are not permitted to accumulate in any part of the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page112of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain and infection prevention Residents Affected - Some and control program to help prevent the development and transmission of communicable diseases and infections by failing to:

1. Ensure the nasal cannula (NC - tubing connected to a device that gives additional oxygen [O2] through the nose) was not resting on the floor for four of four sampled residents (Resident 217, 164, 221, and 13) reviewed under the Respiratory care area.

2. Ensure urinary drainage bag was inside the privacy bag and not laying flat touching the floor mat for one of five sampled residents (Residents 204) observed during a random observation.

3. Ensure nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can bebreathed directly into the lungs through a face mask or mouthpiece) tubing and mask was labeled with the last date it was changed for one of four sampled residents (Resident 13) reviewed under the respiratory care area.

4. Ensure the linen in the nursing stations were protected from external contaminants such as dust, viruses, and bacteria by using a permeable (having pores or openings that permit liquids or gasses to pass through)/ loosely woven material to cover the mobile linen carts to two out of two linen carts (Carts A and B) observed

during infection control facility task.

5. Ensure the water temperature in the entire facility was above 108 degrees Fahrenheit (a scale for measuring temperature) per Centers for Disease Control and Prevention (CDC, a United States federal agency that works to protect the public's health) guidelines to prevent growth of Legionella (a severe form of pneumonia- lung inflammation usually caused by infection) in the water system.

These deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed the residents at risk for acquiring infections.

Findings:

1. During a review of Resident 217's Admission Record, it indicated the facility admitted the resident on 8/26/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and respiratory failure (serious condition when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues).

During a review of Resident 217's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/23/2024, it indicated the resident was dependent on staff for oral hygiene, toileting, bathing, personal hygiene, and mobility. The MDS further indicated the resident used oxygen therapy intermittently.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page113of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 During a review of Resident 217's physician orders, it indicated and order for 2 three liter per minute (LPM, a unit of measurement) via nasal canula as needed for shortness of breath (SOB), dated 11/14/2022. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 217's Care Plans titled, COPD with wheezing: At Risk for Shortness of Breath, initiated 8/29/2022, it indicated to monitor for episodes of shortness of breath and administer oxygen at three Residents Affected - Some LPM via NC as needed for SOB.

was

During an observation on 8/5/2024 at 10:05 a.m., Resident 217 was awake and lying in bed, the resident did not respond to questions. Oxygen was infusing and administered to Resident 217 at 3 LPM via a NC. The NC tubing was resting on the floor.

During a concurrent observation and interview on 8/5/2024 at 12:15 a.m., Certified Nursing Assistant 11 (CNA 11) entered Resident 217's room while the surveyor was present. CNA 11 removed the NC tubing off

the floor and placed the tubing on top of the blanket covering the resident. CNA 11 stated the NC tubing was

on the floor and she placed it on the resident's bed.

During a concurrent observation and interview on 8/5/2024 at 10:20 a.m., Licensed Vocational Nurse 4 (LVN 4) entered Resident 217's room and stated the NC tubing should be off the floor. The surveyor informed LVN 4 that the CNA had placed the NC tubing from the floor onto the bed. LVN 4 stated the NC should be off the floor. LVN 4 exited the room.

During a follow up interview on 8/5/2024 at 10:30 p.m., LVN 4 stated the NC tubing should never be on the floor because of infection control. LVN 4 stated bacteria could go from the floor up the tubing to the resident and cause an infection. LVN 4 stated she did not understand the surveyor stated the NC tubing was moved from the floor to the bed. LVN 4 stated the NC tubing should be changed if it was on the floor.

During an interview on 8/8/2024 at 11:31 a.m., Registered Nurse 2 (RN 2) stated NCs are changed weekly and kept in bags at the bedside because NCs can get dirty from germs. RN 2 stated it was not okay for the NC tubing be touching the floor. RN 2 stated if the NC tubing was touching the floor, it should be removed, and a new NC provided. RN 2 stated CNA 11 should have notified the charge nurse to change the NC immediately because it could potentially lead to germs from the floor, like from dirty shoes, causing cross contamination resulting in an infection in the resident.

During a review of the facility policy and procedure titled, Infection Prevention and Control Program, last reviewed 1/29/2024, it indicated the purpose of the policy was to ensure the facility establishes and maintains an Infection Control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection

43418

2 .During a review of Resident 164's Admission Record, the admission record indicated the facility admitted

the resident on 8/8/2018 with diagnoses including, but not limited to, respiratory failure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page114of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 During a review of Resident 164's MDS, dated [DATE REDACTED], the MDS indicated Resident 164 sometimes makes herself understood and sometimes understands others, was dependent on facility staff for activities of daily Level of Harm - Minimal harm or living such as eating, dressing, hygiene, bathing or showering, and surface-to-surface transfers, and was potential for actual harm receiving oxygen therapy.

Residents Affected - Some During a review of Resident 164's History and Physical (H&P), dated 4/23/2024, the H&P indicated the resident does not have the capacity to understand and make decisions.

During a review of Resident 164's Order Summary Report, dated 8/23/2023, the order summary report indicated the resident was ordered oxygen three liters (a unit of measure for capacity) per minute via nasal cannula as needed for shortness of breath.

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 12, on 8/5/2024, at 10:51 a.m., while inside Resident 164's room, CNA 12 confirmed Resident 164 was wearing a nasal cannula around her nose and the nasal cannula tubing was touching the floor. CNA 12 stated Resident 164's nasal cannula tubing should not be touching the floor due to possible contamination and can be a potential source for infection.

During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated no tubing should touch the floor because of the risk for contamination. The DON further stated when tubing touches

the floor there is a potential for a break in infection control.

A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, last reviewed 1/29/2024,

the P&P indicated oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen are for single resident use only and will be changed weekly and when visibly soiled. The P&P further indicated oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

43988

c. During a review of Resident 204's Admission Record indicated the facility admitted the resident on 1/24/2023 and readmitted on [DATE REDACTED] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), neuromuscular dysfunction of bladder (a condition in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), and generalized muscle weakness.

During a review of Resident 204's History and Physical (H&P) dated 4/27/2024, indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 204's MDS, dated [DATE REDACTED] indicated Resident 204 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance from staff with mobility, was dependent with toileting hygiene, and substantial maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 204 had an indwelling catheter (a catheter drains urine from the bladder into a bag outside the body) and diagnoses of neurogenic bladder and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page115of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 During a review of Resident 204's Order Summary Report indicated the following physician's order:

Level of Harm - Minimal harm or o2/5/2023: Foley Catheter (FC - a thin, flexible tube placed into the bladder to allow urine to drain into a potential for actual harm collection bag) to gravity drain Q shift every shift.

Residents Affected - Some During a review of Resident 204's care plan for FC indicated:

oPotential for infection /At risk for dehydration initiated 2/6/2023 target date 10/23/2024, indicated resident will have no signs and symptoms of infection and/or complications of FC. The care plan indicated the following interventions but not limited to:

1. Provide catheter care per protocol.

2. Always keep catheter tubing placed below level of bladder.

3. Observe resident's FC, tubing, and bag frequently during the shift.

4. Report to physician any changes in urine appearance, amount, odor and clarity.

During a concurrent observation and interview on 8/6/2024 at 8:05 a.m. while inside Resident 204's room with Registered Nurse 1 (RN 1), Resident 204 was sitting at the edge of the bed in the lowest position with

the urinary drainage bag not inside the privacy bag and laying flat on the floor mat. RN 1 stated the urinary drainage bag should not be touching the floor. RN 1 stated it was an infection control issue and the bag should be changed.

During an interview on 8/9/2024 at 10:45 a.m., the Resident Assessment Coordinator (RAC) stated Resident 204's urinary drainage bags should inside the privacy bag and should not be lying flat and touching the floor mat. The RAC stated it was an infection control issue and had the potential for the resident to acquire infection.

During a review of the facility's policy and procedure titled, Catheter - Care of, last reviewed 1/29/2024, indicated:

o A resident, with or without catheter receives the appropriate care and services to prevent infections to the extent possible.

o Ensure the collection bag should always be kept below the level of the bladder, avoiding contact with the floor.

o Catheters and drainage bags will be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised.

o The resident's privacy and dignity will be protected by placing a cover over the drainage bag when the resident is out of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page116of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 A review of the facility's policy and procedure titled, Infection Prevention and Control Program, last reviewed 1/29/2024, indicated the facility establishes and maintains an Infection Control Program designed to provide Level of Harm - Minimal harm or a safe, sanitary, and comfortable environment and to help prevent the development and transmission of potential for actual harm disease and infection in accordance with Federal and State requirements. The policy indicated the facility has an Infection Control Committee (ICC) to provide oversight of all infection control practices in the delivery Residents Affected - Some of resident care.

d. A review of Resident 221's Admission Record indicated the facility admitted the resident on 1/23/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung conditions that make it hard to breathe and get worse over time.), congestive heart failure (CHF - a condition that develops when the heart doesn't pump enough blood for the body's needs), and difficulty walking.

During a review of Resident 221's History and Physical (H&P) dated 1/25/2024, the H & P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 221's MDS, dated [DATE REDACTED] indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance from staff with eating, was dependent with toileting/hygiene, showers/bath, and transfers; and substantial maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 221 had a diagnosis of COPD and on oxygen (O2) therapy.

During a review of Resident 221's Order Summary Report indicated the following physician's order:

o1/23/2023: O2 three (3) liters per minute (L/Min - a unit of measurement) via nasal cannula (NC - a device that delivers extra oxygen through a tube and into the nose) as needed for shortness of breath (SOB).

During a review of Resident 221's care plan indicated:

1. Heart failure: At risk for SOB, chest pain, edema, elevated blood pressure initiated 2/3/2023 with a goal that all signs and symptoms will be addressed thoroughly thru 10/4/2024. The care plan indicated the following interventions but not limited to, have O2 available for use as needed and monitor pulse oximetry as needed and administer O2 per protocol.

2. At risk for SOB and wheezing initiated 5/3/2024 target date 10/4/2024 with a goal to relieve episodes of SOB within 5 minutes interventions. The care plan indicated to monitor for episodes of SOB and administer O2 as needed per protocol and notify physician if ineffective.

During a concurrent observation and interview on 8/6/2024 at 8:02 a.m. inside Resident 221's room with Restorative Nursing Assistant 2 (RNA 2). Resident 221 was receiving O2 at 3 L/Min via NC with the tubing touching the floor. RNA 1 stated Resident 221's oxygen tubing was not really touching the floor at the same time anchoring the tubing on the resident's grab bar. When asked again, RNA 2 stated the tubing was touching the floor.

During an interview on 8/6/2024 at 8:00 a.m., RN 1 stated she just changed the O2 tubing. RN 1 stated the tubing should not be touching as it was an infection control issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page117of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 During an interview on 8/9/2025 at 10:37 a.m., the Minimum Data Set Coordinator (MDSC) stated the O2 tubing should not be touching the floor as it was already contaminated and placed the resident at risk for Level of Harm - Minimal harm or acquiring infection. potential for actual harm

During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed 1/29/2024 Residents Affected - Some indicated, all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled. The policy indicated oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt.

During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, last reviewed 1/29/2024, indicated the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. The policy indicated the facility has an Infection Control Committee (ICC) to provide oversight of all infection control practices in the delivery of resident care.

44376

e. During a review of Resident 13's Admission Record indicated the facility admitted the resident on 3/28/2020, with diagnoses that included paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts

a few hours or days) and history of malignant neoplasm of the brain (a cancerous growth in the brain that grows quickly and invades healthy brain tissue).

During a review of Resident 13's History and Physical (H&P), dated 4/27/2024, the H & P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 13's MDS, dated [DATE REDACTED], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and was totally dependent on mobility and activities of daily living (ADLs).

During a review of Resident 13's Order Summary Report, dated 7/31/2024, indicated an order of Duoneb Inhalation Solution 0.5-2.5 (3) milligrams (mg, a unit of weight)/3 milliliters (ml, a unit of volume) (Ipratropium-Albuterol). 1 unit inhale orally every 8 hours as needed for wheezing (a high-pitched whistling sound made while breathing) for 2 weeks.

During a concurrent observation and interview on 8/6/2024, at 8:32 a.m., inside Resident 13's room, with Licensed Vocational Nurse 3 (LVN 3), the nebulizer mask and tubing was not labeled with the date it was last changed. LVN 3 stated the nebulizer mask and tubing should be changed weekly and labeled with the date it was last changed. LVN 3 stated the failure of the staff to label the nebulizer mask and tubing with the date it was last changed can predispose the resident to infection because they will not be able to know if the tubing was old and bacteria could have grown in the mask and tubing making the residents sick.

During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated the nebulizer mask and tubing should be labeled with the date it was last changed to have a reference of when to change them again. The DON stated the tubing, and the mask should be changed weekly. The DON added if the mask were used for a longer time, there was a potential for contamination/development of infection caused by bacteria that can make the residents sick.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page118of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 During A review of the facility's recent policy and procedure titled, Oxygen Administration, last reviewed on 1/29/2024, indicated all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen: Level of Harm - Minimal harm or potential for actual harm i. Are for single resident use only.

Residents Affected - Some ii. Will be changed weekly and when visibly soiled.

F. During a concurrent observation and interview on 8/7/2023, at 10:35 a.m., with Certified Nursing Assistant 9 (CNA 9), observed Cart A covered with loosely woven/permeable material to protect the clean linens inside

the cart. CNA 9 stated the cover was not totally protecting the clean linens as the covering lets air and water

in that could allow external environmental contaminants in the clean linen. CNA 9 stated it was important to ensure that the linens were protected from environmental contaminants to prevent spread of infection to residents.

During a concurrent observation and interview on 8/7/2024, at 11:05 a.m., with Registered Nurse 1 (RN 1), observed Cart B covered with loosely woven/permeable material to protect the clean linens inside the cart. RN 1 stated the covers can allow air and water to come in contact with the linen and can transmit infection to

the residents.

During a review of the facility's recent policy and procedure titled, Clean Linen Carts, last reviewed on 1/29/2024, indicated the purpose of this policy is to establish standardized procedures for the handling, storage, and transportation of clean linen carts to prevent contamination and ensure compliance with Title 22 regulations thereby maintaining high standards of hygiene and resident care.

G. During a concurrent interview and record review on 8/7/2024, at 3:01 p.m., with the Administrator (ADM),

the Water Management System Binder of the facility was reviewed. The ADM stated they were following the CDC Guidelines for Legionella Water Management System. The ADM stated they have identified areas of water stagnation in the facility in the water heaters, water fountains, dead ends of the main water lines. The DON stated they intervened by flushing the system regularly monthly, draining water heaters quarterly, checking for water sedimentation and non-disturbing the dead ends of the waterlines. The DON stated they did in-service for staff for signs and symptoms of legionnaires disease, and they do water temperature monitoring daily. The DON stated they maintain the water temperature above 108 degrees to prevent Legionella.

During a review of Temperature Log for 5/7/2024 to 8/6/2024 indicated temperatures were below 108 degrees Fahrenheit on the following dates:

5/7/2024 Rm 207- 77 degrees

5/9/2024 Rm 218- 75 degrees

5/14/2024 Rm 215- 75 degrees

5/15/2024 Rm 218- 75 degrees

5/16/2024 Rm 218- not measured.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page119of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0880 5/21/2024 Rm 214- 75 degrees

Level of Harm - Minimal harm or 6/12/2024 Rm 218- 77 degrees potential for actual harm 7/26/2024 Rm 215- 75 degrees Residents Affected - Some

During a concurrent interview and record review on 8/7/2024, at 4:37 p.m., with the ADM, the ADM reviewed and confirmed the dates the water in the facility was below 108 degrees Fahrenheit on the Temperature Log.

The DON stated it was important to ensure the temperatures were above 108 degrees to ensure Legionella doesn't grow in their water system that can cause the residents to get sick.

During a review of the facility's recent policy and procedure titled, Legionella, last reviewed on 1/29/2024, the policy indicated its purpose is to inhibit microbial growth in the facility's water systems to reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. The facility will follow guidance issued by the Centers for Disease Control (CDC) as outlined in IC-03- Form A - Developing Water Management Program to Reduce Legionella.

A review of the facility provided Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, last reviewed on 1/29/2024, indicated factors internal to buildings that can lead to Legionella growth, water temperature fluctuations provide conditions where Legionella grows best (77 degrees to 108 degrees Fahrenheit); Legionella can still grow outside this range.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page120of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on interview and record review the facility failed to implement its policy and procedure on influenza Residents Affected - Few (an infection of the nose, throat and lungs, which are a part of the respiratory system) and pneumonia (an infection that affects one or both lungs) vaccine (a substance that stimulates the body's immune system to fight disease) administration by failing to provide documentation an informed consent was obtained from the resident or the resident representative and education was provided to the resident or the resident's representative regarding the benefits and potential side effects of the vaccine for two of five sampled residents (Residents 174 and 98) investigated under infection control task.

This deficient practice violated the resident or responsible party's right to make an informed decision.

Findings:

a. During a review of Resident 174's Admission Record, it indicated the facility admitted the resident on 7/25/2019, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (a loss of brain function that occurs with certain diseases).

During a review of Resident 174's History and Physical (H&P), dated 7/2/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/24/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others.

During a review of Resident 174's Physician's Order Sheet, dated 9/18/2023, it indicated an order for influenza vaccine 0.5 milliliters (ml, a unit of volume) intramuscular injection (IM, into a muscle) injection.

During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the Resident Assessment Coordinator (RAC), reviewed Resident 174's Influenza Vaccination Informed Consent/Refusal forms on file.

The RAC stated there was no Influenza Vaccination Informed Consent/Refusal completed for the 9/8/2023 vaccine administration.

During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 (a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccines.

During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page121of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0883 During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the Influenza Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to Level of Harm - Minimal harm or ensure informed consent and honor the resident or the resident representative's right to refuse the vaccine if potential for actual harm desired.

Residents Affected - Few During a review of the facility's recent policy and procedure titled, Influenza Prevention & Control, last reviewed on 1/29/2024, indicated before offering the influenza vaccine, each resident or the resident representative receives education regarding the benefits and potential side effects of the vaccination. Residents are offered an influenza vaccine during flu season annually, unless the vaccination is medically contraindicated, or the resident has already been vaccinated during this time period. That the resident was given a copy of IC-14-Form A-Influenza Vaccination-Informed Consent/refusal which is to be placed in the resident's medical record.

b. During a review of Resident 98's Admission Record, it indicated the facility admitted the resident on 3/3/2022, with diagnoses including Alzheimer's disease and dementia.

During a review of Resident 98's H&P, dated 3/27/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 98's MDS, dated [DATE REDACTED], the MDS indicated the resident usually makes self-understood and understand others.

During a review of Resident 98's Physician's Order Sheet, dated 9/20/2023, it indicated an order of may have influenza vaccine 0.5 ml IM injection.

During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the RAC, reviewed Resident 98's Influenza Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no Influenza Vaccination Informed Consent/Refusal completed for the 9/20/2023 vaccine administration.

During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 (a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccines.

During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.

During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the Influenza Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or the resident representative's right to refuse the vaccine if desired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page122of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0883 During a review of the facility's recent policy and procedure titled, Influenza Prevention & Control, last reviewed on 1/29/2024, indicated before offering the influenza vaccine, each resident or the resident Level of Harm - Minimal harm or representative receives education regarding the benefits and potential side effects of the vaccination. potential for actual harm Residents are offered an influenza vaccine during flu season annually, unless the vaccination is medically contraindicated, or the resident has already been vaccinated during this time period. That the resident was Residents Affected - Few given a copy of IC-14-Form A-Influenza Vaccination-Informed Consent/Refusal which is to be placed in the resident's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page123of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Some Based on interview and record review the facility failed to implement its policy and procedure on Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccination (the act of introducing a vaccine [a substance that stimulates the body's immune system to fight disease]) by failing to provide documentation an informed consent was obtained from the residents or the resident's representative and education was provided on the risk and benefits of the vaccine prior to vaccination for three of five sampled residents (Residents 174, 80, and 98) investigated under the infection control task.

This deficient practice violated the resident or resident representative's right to make an informed decision.

Findings:

a. During a review of Resident 174's Admission Record indicated the facility admitted the resident on 7/25/2019, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (a loss of brain function that occurs with certain diseases).

During a review of Resident 174's History and Physical (H&P), dated 7/2/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/24/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others.

During a review of Resident 174's Physician's Order Sheet, it indicated the following orders:

-On 5/9/2022, may have COVID-19 vaccine booster (am extra dose of a vaccine) # 2 per family request.

-On 10/6/2022, may have COVID-19 vaccine bivalent (contains both the original vaccine strain) X 1.

-On 7/2/2024, may have Moderna Spikevax COVID-19 vaccine X 1.

During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the Resident Assessment Coordinator (RAC), reviewed Resident 174's COVID-19 Vaccination Informed Consent/Refusal forms on file.

The RAC stated there was no COVID-19 Vaccination Informed Consent/Refusal form completed for the 5/9/2022, 10/6/2022, and 7/2/2024 vaccine administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page124of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0887 During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that Level of Harm - Minimal harm or inflames air sacs, and COVID-19 vaccines. potential for actual harm

During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the Residents Affected - Some resident or representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19.

During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or resident representative's right to refuse the vaccine if desired.

During a review of the facility's recent policy and procedure titled, COVID-19 Vaccination, last reviewed on 1/29/2024, indicated the infection preventionist, or designee, will ensure that the resident's medical record includes documentation that, at a minimum, the resident and/or resident representative was provided education regarding the vaccine they were offered, if they accepted and received the vaccine or refused, and each dose of the COVID-19 vaccine if administered.

i. Such documentation should include the date the education was offered.

b.During a review of Resident 80's Admission record, it indicated the facility admitted the resident on 2/20/2024, with diagnoses including Alzheimer's disease and dementia.

During a review of Resident 80's H&P, dated 6/10/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 80's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others.

During a review of Resident 80's Physician's Order Sheet, dated 7/2/2024, it indicated an order for Moderna Spikevax COVID-19 vaccine X 1.

During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the RAC, reviewed Resident 80's COVID-19 Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no COVID-19 Vaccination Informed Consent/Refusal form completed for the vaccine administration on 7/2/2024.

During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 vaccine.

During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page125of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0887 During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to Level of Harm - Minimal harm or ensure informed consent and honor the resident or resident representative's right to refuse the vaccine if potential for actual harm desired.

Residents Affected - Some During a review of the facility's recent policy and procedure titled, COVID-19 Vaccination, last reviewed on 1/29/2024, indicated the infection preventionist, or designee, will ensure that the resident's medical record includes documentation that, at a minimum, the resident and/or resident representative was provided education regarding the vaccine they were offered, if they accepted and received the vaccine or refused, and each dose of the COVID-19 vaccine if administered.

i. Such documentation should include the date the education was offered.

c.During a review of Resident 98's Admission Record, it indicated the facility admitted the resident on 3/3/2022, with diagnoses including Alzheimer's disease and dementia.

During a review of Resident 98's H&P, dated 3/27/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 98's MDS, dated [DATE REDACTED], the MDS indicated the resident usually makes self-understood and understand others.

During a review of Resident 98's Physician's Order Sheet, it indicated the following orders:

-On 6/16/2022, may have COVID-19 vaccine booster # 2 per family request.

-On 10/11/2022, may have COVID-19 vaccine bivalent X 1.

-On 7/2/2024 may have Moderna Spikevax COVID-19 vaccine X 1.

During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the RAC, reviewed Resident 98's COVID-19 Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no COVID-19 Vaccination Informed Consent/Refusal completed for the for 6/16/2022, 10/11/2022, and 7/2/2024 vaccine administration.

During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 vaccines.

During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.

During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or resident representative's right to refuse the vaccine if desired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page126of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0887 During a review of the facility's recent policy and procedure titled, COVID-19 Vaccination, last reviewed on 1/29/2024, indicated the infection preventionist, or designee, will ensure that the resident's medical record Level of Harm - Minimal harm or includes documentation that, at a minimum, the resident and/or resident representative was provided potential for actual harm education regarding the vaccine they were offered, if they accepted and received the vaccine or refused, and each dose of the COVID-19 vaccine if administered. Residents Affected - Some ii. Such documentation should include the date the education was offered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page127of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 44376

Residents Affected - Few Based on observation, interview, and record review the facility failed to provide a safe environment for one of two sampled residents (Resident 41) investigated during review of the environment task by failing to ensure Resident 41 did not plug an extension cord (an electrical outlet that contains two wires: a neutral wire and a hot wire) into a two-prong wall outlet to charge Resident 41's cellphone.

This deficient practice had the potential to result in safety hazards including electrical shock and fire.

Findings:

During a review of Resident 41's Admission Record, it indicated the facility admitted the resident on 10/3/2018, with diagnoses including atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls) and heart failure (occurs when the heart muscle does not pump blood as well as it should).

During a review of Resident 41's History and Physical (H&P) dated 6/5/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/16/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision.

During a review of Resident 41's Care Plan (CP) titled, Psychosocial: Home like environment, initiated on 2/11/2019, the CP indicated an intervention the facility will rearrange room as per resident's request permitting that new arrangement of the room does not create life safety and/or fire hazards.

During a concurrent observation and interview on 8/5/2024, at 11:32 a.m., inside Resident 41's room, with Licensed Vocational Nurse 5 (LVN 5), observed Resident 41 plug a two-prong extension cord into the wall outlet to charge the resident's cellphone. LVN 5 stated the resident should not use an extension cord that was not underwriter laboratories (UL, the product or service meets local and federal environmental and safety regulations) certified and not inspected by the Maintenance Staff (MS) to prevent fires.

During an interview on 8/9/2024, at 4:24 p.m., with the MS, the MS stated residents are not allowed to use a non-UL approved electrical extension cords without a ground. The MS stated the residents should use three prong extension cords (the third prong and grounded outlet were designed to help reduce the risk of electrical shocks and fires) to prevent electrical shocks and fire in the facility.

During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated two-prong extension cords should not be used in the resident's room because it could cause electrical accidents to residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page128of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0921 During a review of the facility's recent policy and procedure titled, Electrical Equipment- Power Strips, last reviewed on 1/29/2024, indicated to ensure that power strips are used minimally and with general precaution. Level of Harm - Minimal harm or The facility will ensure safe usage of power strips within the resident care environment. Power strips will be potential for actual harm used with general precaution and should not be utilized unless absolutely necessary. Power strips shall meet

the UL 1363A or UL60601-1 standards. Staff will ensure personal electronics will not be plugged in to power Residents Affected - Few strips in resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page129of129 555579

F-F688.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During an interview on 8/6/2024 at 9:34 a.m. with the Director of Rehabilitation (DOR) in the therapy gym,

the DOR stated the RNA program was a maintenance program to maintain a resident's ROM and mobility. Level of Harm - Actual harm The DOR stated limitations in ROM could lead to limitations in function and the development of contractures, which could cause pain. The DOR stated ROM exercises and application of splints can assist in maintaining Residents Affected - Few ROM and preventing contractures. The DOR stated Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) did not complete the residents' JMA quarterly or annually.

During an interview on 8/8/2024 at 9:41 a.m. with Registered Nurse Supervisor 2 (RN 2), RN 2 stated the RN Supervisor and the RNA assigned to the nursing station completed the JMAs for each resident upon admission and quarterly. RN 2 stated the facility did not provide any training on how to perform the JMA.

During an interview on 8/8/2024 at 10:40 a.m. with the Director of Nursing (DON), RN 1, Registered Nurse Supervisor 1 (RN 1) Performance Improvement Quality Improvement Licensed Vocational Nurse 1 (PIQI 1), and PIQI 2, RN 1 stated the RN, PIQI, and RNA assigned to each nursing station performed the JMA for each resident upon admission, quarterly, change of condition, and annually. The DON stated the previous DOR provided a training on how to perform the JMA to the DON, RN Supervisors, PIQI LVNs, and RNAs approximately five years ago. The DON stated there has not been any recent training on how to complete

the JMAs. PIQI 2 stated the JMA assessed a resident's active or passive joint limitations depending on if the resident can move.

During an interview on 8/8/2024 at 1:15 p.m. with PIQI 1, PIQI 1 stated the JMA needed to be accurate because a change in a resident's ROM could be missed if the JMA was not accurate.

During an interview on 8/8/2024 at 1:47 p.m. with DOR and PT 1, the DOR stated the nursing staff were not provided with any recent in-service training for the completion of JMAs.

During an interview on 8/8/2024 at 3:21 p.m. with the DON, the DON stated the Supervising RN, PIQI, and RNA assigned to the nursing station were supposed to perform each resident's JMA. The DON stated the Supervising RN assessed the resident, the PIQI was present to gather information about each resident, and

the RNA provided the ROM for the assessment. The DON stated competency evaluations ensured the nurse was knowledgeable in providing care. The DON stated the RNs, including the DON, did not have competency evaluations to perform the JMA. The DON stated she did not know the reason the facility did not have competency evaluations for RNs to perform the JMA. The DON stated the RNs should have a competency evaluation especially since ROM and joint mobility was not a nursing specialty. The DON stated there was no way to ensure the JMAs for all residents were accurate since the RNs did not have the competence to perform the JMA.

During an interview on 8/8/2024 at 3:43 p.m. with the DON, the DON stated the DON was provided education on performing the JMAs but stated RN 1, RN 2, RN 3, RN 4, and RN 5 performed the residents' JMAs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During an interview on 8/9/2024 at 8:37 a.m. with PIQI 1 and PIQI 2, PIQI 1 and PIQI 2 stated the Supervising RN, PIQI, and the RNA assigned to the nursing station were supposed to be present during Level of Harm - Actual harm each resident's JMA. PIQI 1 and PIQI 2 stated the RNA moved the resident and applied the splints (if applicable), the RN assessed the resident's ROM and splints, and the PIQI recorded the resident's joint Residents Affected - Few mobility limitations based on the RN's assessment.

During a review of the employee files for the DON, RN 1, RN 2, RN 3, RN 4, and RN 5, the employee files,

the employee files included a performance appraisal (process that evaluates and records how well an employee performed their job) for the DON, dated 12/2023, and for RN 4, dated 4/14/2023. The employee files for the DON and RN 4 did not include a competency skills checklist. A review of the employee files included a competency skills checklist for RN 1, dated 5/2024, for RN 2, dated 1/22/2024, for RN 3 dated 7/2023, and for RN 5, dated 3/2024. The competency skills checklist did not include a competency for assessment of splints and performing the JMA.

During a concurrent interview and record review on 8/9/2024 at 3:24 p.m. with the DON, the DON, RN 1, RN 2, RN 3, RN 4, and RN 5's employee files on skill competency evaluations were reviewed. The DON stated skill competency evaluations were completed annually to ensure the RNs were knowledgeable in the necessary and appropriate care provided to the residents. The DON stated she evaluated the RNs for their annual skills competency but stated the facility never performed a skills competency for the DON. The DON stated RN 1, RN 2, RN 3, and RN 5, had skill competency evaluations for the provision of ROM exercises but did not have any competencies to assess ROM to perform the JMA. The DON stated RN 4 was a PIQI RN and did not have an annual competency evaluation since RN 4 did not provide any direct resident care. The DON stated the skills competency evaluations for the DON, RN 1, RN 2, RN 3, RN 4, and RN 5 did not include splint assessment and JMA assessment. The DON stated the JMAs for all residents would be inaccurate since the RNs did not have any competency skills to assess splints and perform the JMA.

During a review of the employee files for the RNAs, the employee files included a Restorative Nursing Skills Evaluation which included but was not limited to the provision of ROM, application of splints, transfers, and walking for RNA 1, dated 5/2024, for RNA 2, dated 6/1/2024, for RNA 6, dated 6/10/2024, for RNA 8, dated 7/26/2024, for RNA 10, dated 7/26/2024, and for RNA 12, dated 7/16/2024. A review of the employee files did not include a Restorative Nursing Skills Evaluation for RNA 3, RNA 4, RNA 5, RNA 7, RNA 9, RNA 11, RNA 13.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During a concurrent interview and record review on 8/9/2024 at 3:49 p.m. with the DON, 13 RNA employee files on competency skills evaluations were reviewed, including RNA 1, RNA 2, RNA 3, RNA 4, RNA 5, RNA Level of Harm - Actual harm 6, RNA 7, RNA 8, RNA 9, RNA 10, RNA 11, RNA 12, and RNA 13. The DON stated RNAs were important to maintain, improve, and prevent any decline in a resident's ROM, mobility, and overall physical condition. The Residents Affected - Few DON stated seven of 13 RNAs, including RNA 3, RNA 4, RNA 5, RNA 7, RNA 9, RNA 11, and RNA 13, did not have any competency skills evaluations to determine appropriate provision of RNA services, including providing ROM, splint application, and mobility. The DON stated six of 13 RNAs, including RNA 1, RNA 2, RNA 6, RNA 8, RNA 10, and RNA 12, had Restorative Nursing Skills Evaluations completed by the Director of Staff Development (DSD) who was not competent in the provision of RNA services. The DON did not know why the skills competency evaluations for the RNAs were not provided by a facility staff member with knowledge of ROM, splint application, and mobility. The DON stated 13 of 13 RNAs did not have appropriate competency skills evaluations to determine whether the RNAs accurately performed their duties. The DON stated the residents could develop ROM limitations and contractures if the RNAs were not competent in the application of splints and provision of ROM and mobility. The DON stated the resident could develop undetected changes and declines in ROM since the RNAs were not competent in the provision of services and the RNs were not competent in performing the JMAs.

During an interview on 8/9/2024 at 4:30 p.m. with the DON, the DON stated contractures develop due to immobility and could be prevented with ROM exercises and application of splints. The DON stated contractures result in limited movement, and could cause discomfort, and pain, and increased a resident's risk of skin impairments. The DON stated contracture prevention was important for a resident's quality of life to prevent any restrictions in movement.

During a review of the facility's policy and procedures (P&P) titled, Staff Competency Evaluations, revised on 7/12/2018 and reviewed on 1/29/2024, the P&P indicated annual competency evaluations for all nursing and clinical staff ensured the facility maintained the highest standards of care and resident safety. The P&P indicated annual competency evaluations will be conducted by qualified personnel who have the appropriate knowledge and experience to assess staff competency.

During a review of the facility's job description titled, Restorative Nursing Assistant, revised 10/2011, the job description indicated RNAs performed restorative nursing procedures that maximized the resident's abilities and minimized the negative effects of disability. The RNA job description also indicated duties and responsibilities included providing restorative nursing care as directed and ordered, including ROM, ambulation, and transfers.

During a review of the facility's P&P titled, Restorative Nursing Program Guidelines, revised on 3/1/2015 and reviewed on 1/29/2024, the P&P indicated RNAs provide interventions to achieve or maintain optimal physical functioning, including providing ROM exercises, applying splints, transfer training, and walking.

During a review of the facility's P&P titled, Range of Motion Exercise Guidelines, revised on 3/1/2015 and revised reviewed on 1/29/2024, the P&P indicated the purpose of the policy included maintaining or increasing ROM of a joint and to prevent or reduce contractures. The P&P indicated ROM should be delivered by staff trained in the procedures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 1. During a review of Resident 119's Admission Record, the Admission Record indicated the facility admitted Resident 119 on 5/11/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration Level of Harm - Actual harm that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline

in mental ability severe enough to interfere with daily life), age-related osteoporosis (medical condition in Residents Affected - Few which the bones become brittle and fragile from loss of tissue), and dysphagia (difficulty swallowing).

During a review of Resident 119's census (record of hospitalization s, room changes, and payor source changes), the census indicated Resident 119 resided at the facility since 5/11/2017 without any hospitalization s.

During a review of Resident 119's Minimum Data Set ([MDS], a comprehensive assessment and care planning tool), dated 5/13/2024, the MDS indicated Resident 119 had unclear speech, rarely expressed ideas and wants, rarely understood verbal content, and was severely impaired (never/rarely made decisions) for daily decision making. The MDS indicated Resident 119 had ROM impairments in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, toileting, showering/bathing, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.

During a review of Resident 119's physician orders, dated 11/9/2020, the physician orders indicated for Resident 119 to receive passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both arms and legs, every day.

During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 6/8/2022, the OT Evaluation indicated Resident 119 was referred to OT due to a decline in ROM, decreased balance, and increased need for assistance from others. The OT Evaluation indicated Resident 119's ROM to the right elbow, both wrists, and both hands were within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 119's impaired ROM included right shoulder flexion (lifting the arm upward) 0 to 80 degrees (0 to 80 degrees, normal 0 to180 degrees), right shoulder abduction (lifting the arm up and away from the body) 0 to 75 degrees (normal 0 to 180 degrees), left shoulder flexion 0 to 40 degrees, left shoulder abduction 0 to 40 degrees, and left elbow extension (straightened) was limited to 80 degrees (normal 0 degrees, positioned in 80 degrees of elbow flexion [bend]).

During a review of Resident 119's OT Treatment Encounter Notes, dated 8/19/2022, the OT Treatment Encounter Notes indicated Resident 119's ROM included right shoulder flexion 0 to 90 degrees (shoulder height), right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees (elbow positioned in 20 degrees of flexion), left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees (elbow positioned in 30 degrees of elbow flexion).

During a review of Resident 119's OT Discharge Summary, dated 8/19/2022, the OT Discharge Summary indicated Resident 119 safely wore splints to both elbows for two hours without signs of redness, swelling, discomfort, or pain. The OT Discharge Summary recommendations included a Restorative Nursing Program ([RNP], nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) to provide Resident 119 with PROM and to apply both elbow splints for two hours daily as tolerated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During a review of Resident 119's RNP Referral/Care Plan, dated 8/19/2022, the RNP Referral/Care Plan indicated Occupational Therapist 2 (OT 2) reviewed Resident 119's program with Restorative Nursing Level of Harm - Actual harm Assistant 5 (RNA 5) to apply both elbow splints for two hours.

Residents Affected - Few During a review of Resident 119's Joint Mobility Screening (JMA completed by OT and PT), dated 10/6/2022,

the Joint Mobility Screening indicated Resident 119's ROM included severe ROM limitation (more than 50 percent [%] loss of motion) in the left shoulder, moderate ROM limitation (25 to 50% loss of motion ) in the right shoulder, minimum ROM limitation (less than 25% loss of motion) in both elbows and knees, and full ROM in both hands, hips, and ankles. The Joint Mobility Screening indicated recommendations for Resident 119 to receive PT and OT Evaluations and to continue with the RNA program.

During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 10/6/2022, the OT Evaluation indicated Resident 119 was seen for an Evaluation Only (no intervention recommended). The OT Evaluation Only indicated Resident 119's ROM was WFL in both wrists and hands but had impairment in both shoulders and elbows, including right shoulder flexion 0 to 90 degrees (shoulder height), right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, and left elbow extension to 30 degrees. The OT Evaluation Only indicated Resident 119 was already provided with both elbow splints and did not have any significant change in condition requiring OT intervention.

During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 10/6/2022, the PT Evaluation indicated Resident 119 was referred to PT due to a new onset of decreased ROM, decreased postural alignment when sitting up in the wheelchair, and was at-risk for contracture development. The PT Evaluation indicated Resident 119's ROM in both hips and ankles were WFL but had impaired ROM to both knees. The PT Evaluation indicated Resident 119's right knee extension was limited to 30 degrees (normal 0 degrees, knee positioned in 30 degrees of knee flexion) and left knee extension was limited to 15 degrees (knee positioned in 15 degrees of knee flexion).

During a review of Resident 119's PT Discharge Summary, dated 10/28/2022, the PT Discharge Summary indicated Resident 119 tolerated sitting up in a standard wheelchair with a cushioned seat for four hours, had right knee extension to 20 degrees, and tolerated a right knee extension splint for two hours. The PT Discharge recommendations included a RNP to provide Resident 119 with PROM and to apply the right knee extension splint.

During a review of Resident 119's RNP Referral/Care Plan, dated 10/28/2022, the RNP Referral/Care Plan indicated the Physical Therapist 3 (PT 3) reviewed Resident 119's program with RNA 5 to provide PROM to both legs and to apply the right knee splint for two hours.

During a review of Resident 119's JMA, dated 12/7/2022 and 3/3/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs as tolerated. The JMA did not indicate the RNA applied both elbow splints and the right knee splint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During a review of Resident 119's JMA, dated 6/1/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum Level of Harm - Actual harm ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs and application of both elbow splints and the right knee splint. Residents Affected - Few

During a review of Resident 119's JMA, dated 8/23/2023 and 11/24/2023, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs. The JMA did not indicate the RNA applied both elbow splints and the right knee splint.

During a review of Resident 119's JMA, dated 2/16/2024, 5/11/2024, and 8/4/2024, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs and application of both elbow splints and the right knee splint.

During an observation on 8/7/2024 at 12:40 p.m. with Restorative Nursing Assistant 2 (RNA 2) RNA 2 in the bedroom, RNA 2 stated Resident 119's primary (routinely assigned) RNA was RNA 5 who was off today that day (8/7/2024) but will return the next day tomorrow. RNA 2 stood on the right side of Resident 119's bed and performed ROM exercises on Resident 119's right shoulder. RNA 2 could not lift the right arm to shoulder height. RNA 2 bent and extended the right elbow to perform ROM exercises but could not fully extend the right elbow, which remained in a bent position. RNA 2 performed wrist flexion (bent down) and wrist extension (bent up) exercises but did not perform any exercises to Resident 119's right hand. RNA 2 massaged Resident 119's right arm into extension prior to applying the right elbow splint upside down. RNA 2 bent and extended Resident 119's right hip and knee at the same time, causing Resident 119 to moan with

a facial grimace (expression of pain or strong dislike). RNA 2 could not extend the right knee, which continued to have a bend of approximately 90 degrees. RNA 2 performed exercises to the right ankle into rotation, dorsiflexion (ankle bent with toes pointing toward the body), and plantarflexion (ankle bent with toes pointing away from the body). RNA 2 applied Resident 119's right knee splint, which was fixed in a nearly straight position, and fastened a strap over the right kneecap. RNA 2 stood on the left side of Resident 119's bed and performed ROM exercises on the left shoulder. RNA 2 lifted the left arm higher than the right shoulder joint but could not lift the left arm to shoulder height. RNA 2 bent and extended the left elbow to perform ROM exercises but could not fully extend the left elbow, which remained in a bent position. RNA 2 performed wrist flexion and extension exercises but did not perform any exercise to Resident 119's left hand. RNA 2 applied the left elbow splint. RNA 2 bent and extended Resident 119's left hip and knee at the same time. RNA 2 could not fully extend Resident 119's left hip and knee. RNA 2 then performed ankle exercises to Resident 119's left ankle into rotation, dorsiflexion, and plantarflexion.

During an interview on 8/7/2024 at 1:04 p.m. with RNA 2, RNA 2 stated the splints will be checked every 30 minutes and will be removed remove the splints after 2 hours. RNA 2 stated ROM was not performed to Resident 119's hands because both hands were good and stated Resident 119 could straighten the fingers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During a concurrent observation and interview on 8/7/2024 at 1:09 p.m. with the DOR and Physical Therapy Assistant 1 (PTA 1) in Resident 119's the bedroom, Resident 119 was observed lying in bed while wearing Level of Harm - Actual harm both elbow splints and the right knee splint. PTA 1 stated Resident 119's right knee splint was applied lower than the knee. PTA 1 checked the right knee splint and stated Resident 119's knee splint was set to 30 Residents Affected - Few degrees of extension but Resident 119's right knee was bent to approximately 90 degrees. PTA 1 stated the right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee. PTA 1 stated an inappropriately fitted splint could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores (localized damage to the skin and underlying soft tissues over a bony prominence) and dislocation (injury caused when the normal position of a joint is disturbed) of the right knee.

During a concurrent observation and interview on 8/7/2024 at 1:19 p.m. with the DOR and PTA 1 in the bedroom, the DOR removed Resident 119's right knee splint. The skin on Resident 119's right knee, which was directly under the strap of the knee splint, was observed with redness. PTA 1 stated Resident 119 had redness to the pressure sensitive area of the right kneecap. The DOR observed Resident 119's elbow splints, stated the right elbow splint was applied upside down, and adjusted both of Resident 119's elbow splints.

During a concurrent interview and record review on 8/7/2024 at 1:45 p.m. with the DOR, Resident 119's census, OT Discharge Summary, dated 8/19/2022, OT Evaluation Only, dated 10/6/2022, PT Evaluation, dated 10/6/2022, and PT Discharge Summary, dated 10/28/2022, were reviewed. The DOR reviewed Resident 119's census and stated Resident 119 was admitted to the facility on [DATE REDACTED] and did not leave the facility for any reason. The DOR stated Resident 119's ROM upon discharge from OT on 8/19/2022 was right shoulder flexion 0-90 degrees, right shoulder abduction 0-80 degrees, right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees. The DOR stated OT 2 discharged Resident 119 on 8/19/2022 with recommendations for RNA to provide PROM to both arms and apply both elbow splints for two hours. The DOR stated Resident 119 received an OT Evaluation Only on 10/6/2022 but treatment was not Provided since Resident 119's ROM did not change from OT discharge on 8/19/2022. The DOR stated the OT Evaluation Only, dated 10/6/2022, indicated to continue RNA for PROM to both arms and application of both elbow splints. The DOR reviewed

the PT Evaluation, dated 10/6/2022, and stated Resident 119's ROM in both hips and ankles were WFL but had ROM limitation in both knees, including right knee extension to 30 and left knee extension to 15 degrees.

The DOR stated Resident 119 was discharged from PT on 10/28/2022 with right knee extension to 20 degrees. The DOR stated PT 3 (no longer works at the facility) discharged Resident 119 on 10/28/2022 with recommendations for RNA to provide PROM to both legs and apply the right knee extension splint. The DOR stated OT has not performed any treatment to Resident 119 since 10/6/2022 and PT has not performed any treatment to Resident 119 since 10/28/2022 (approximately 22 months ago).

During a concurrent observation and interview on 8/8/2024 at 8:30 a.m. in Resident 119's the bedroom with RNA 5, Resident 119 was lying in bed awake with the head-of-bed (HOB) fully elevated and the elbow splint applied to the right arm. RNA 5 stated Resident 119 was usually nonverbal and that RNA 5 was Resident 119's primary RNA. The skin on Resident 119's right kneecap was observed with pink areas. RNA 5 stated Resident 119's splints were applied this morning at approximately 7:00 a.m. but the right knee and left elbow splints were removed after 15 minutes due to skin redness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During a concurrent observation and interview on 8/8/2024 at 9:05 a.m. with PT 1 Physical Therapist 1 (PT 1) in Resident 119's the bedroom, Resident 119's ROM in both knees and the right knee extension splint Level of Harm - Actual harm were observed. Resident 119 was lying in bed with the HOB fully elevated and both knees were in bent positions. PT 1 extended both knees and stated Resident 119 had contractures to both knees. PT 1 stated Residents Affected - Few the right knee extended to 90 degrees (right knee positioned in 90 degrees of flexion) and the left knee extended to 55 degrees (left knee positioned in 55 degrees of flexion). PT 1 observed Resident 119's right knee extension splint, which was set to 30 degrees, and stated the right knee splint was not an appropriate fit because Resident 119's right knee was bent more than 30 degrees. PT 1 stated the right knee extension splint could cause injury to Resident 119's right leg if applied to the right knee.

During a concurrent observation and interview on 8/8/2024 at 9:16 a.m. with PT 1 and RNA 5 in Resident 119's the bedroom, RNA 5 applied Resident 119's knee extension splint. RNA 5 stated Resident 119's right knee extension splint did not fit because Resident 119's right knee ROM had worsened. PT 1 stated he was not notified of Resident 119's worsening ROM in the right knee and the inability to apply the right knee splint appropriately.

During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 8/8/2024, completed by OT 2, the OT Evaluation indicated Resident 119 had ROM impairments in both shoulders, both elbows, and both hands. The OT Evaluation indicated Resident 119's ROM limitations included right shoulder flexion 0 to 50 degrees, right shoulder abduction 0 to 61 degrees, right elbow extension to 26 degrees, right hand with less than 25% loss of motion, left shoulder flexion 0 to 66 degrees, left shoulder abduction 0 to 61 degrees, left elbow extension to 43 degrees, and left hand with 25 to 50% loss of motion.

During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 8/8/2024, completed by PT 2, Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 119 had ROM impairments in both hips, both knees, and the left ankle. The PT Evaluation indicated Resident 119's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 30 to 96 degrees (normal 0 to 120 degrees), right hip abduction (moving the leg away from the body) 0 to 13 degrees (normal 0 to 45 degrees), right knee extension to 73 degrees, left hip flexion 26 to 70 degrees, left hip abduction 0 to 11 degrees, left knee extension to 17 degrees, and left ankle dorsiflexion 0 to 4 degrees (normal 0 to 20 degrees).

During an interview on 8/9/2024 at 10:36 AM with the DOR, the DOR stated contractures developed over time. The DOR stated performing ROM exercises, positioning and applying splints assisted in preventing contractures, which could cause pain, limited function, increased skin issues, and increased the potential for injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 During a concurrent interview and record review on 8/9/2024 at 11:16 a.m. with the DOR and PT 2, Resident 119's PT Discharge Summary, dated 10/28/2022, and PT Evaluation, dated 8/8/2024, were reviewed. PT 2 Level of Harm - Actual harm stated Resident 119 did not have any ROM limitations in both hips per the PT Discharge Summary. PT 2 stated Resident 119 developed flexion contractures on both hips since both hips could not be extended to Residents Affected - Few neutral (0 degrees) and were significantly limited in hip abduction. PT 2 stated Resident 119's right knee extended to 20 degrees per PT Discharge Summary but currently had 73 degrees of right knee extension per PT Evaluation which was a significant decline in ROM. PT 2 stated Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). The DOR and PT 2 stated Resident 119's decline in ROM on both legs from the PT Evaluation were not reported to the therapy department.

During a concurrent interview and record review on 8/9/2024 at 11:37 a.m. with OT 2, Resident 119's OT Evaluation Only, dated 10/6/2022, and OT Evaluation, dated 8/8/2024, were reviewed. OT 2 stated Resident 119 had 0-90 degrees of right shoulder flexion and 0-80 degrees of left shoulder flexion during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently had 0-50 degrees of right shoulder flexion and 0-61 degrees of left shoulder flexion per OT Evaluation on 8/8/2024, which was a significant decline in ROM. OT 2 stated Resident 119's ROM in both hands were WFL during the OT Evaluation on 10/6/2022. OT 2 stated both [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43418

Residents Affected - Few Based on observation, interview, and record review, the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine medications, for two of two sampled residents reviewed during a general observation and investigated under residents' rights (Resident 177 and Resident 227) by failing to:

1. Obtain a physician's order for Resident 177's bottle of saline spray (a mixture of salt and water that is sprayed into the nose) present on the resident's bedside table.

2. Obtain a physician's order for the use of Areds 2 (supplement for age-related macular degeneration [an eye disease that can blur the central vision]) observed at the bed side taken by Resident 227 on 8/6/2024.

These deficient practices had the potential to result in residents taking medications not authorized for administration by the physician, result in unsafe access of medications by residents, staff, and visitors, and can lead to adverse reactions (an undesired effect of a drug or other type of treatment) due to accidental ingestion of unnecessary medication.

Additionally, based on interview and record review, the facility failed to:

3. Account for two doses of Controlled Medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 25 and 30 in one of four inspected medication carts (Medication Cart North Middle East.)

4. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled Drug Record accountability logs for four of four sampled records.

5. Include the verifying signatures of two LVN's on the Drug Destruction Log for nine of nine sampled records.

As a result, these failures resulted in a lack of control and accountability of discontinued medications and CM awaiting final disposition (process of returning and/or destroying unused medications).

These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use), which had the potential to result in the risk that Resident 25 and 30 could have delayed medication treatment and continuity of care due to lack of availability of the CM, and had the potential to result in accidental exposure to harmful medications to all residents, possibly leading to physical and psychosocial harm.

Cross-reference

F-F689.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0755 Findings:

Level of Harm - Minimal harm or 1. During a review of Resident 177's Admission Record, the admission record indicated Resident 177 was potential for actual harm admitted to the facility on [DATE REDACTED] with diagnoses that included, but not limited to, hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than the normal), Residents Affected - Few hyponatremia (a condition that occurs when the level of sodium in the blood is too low), and allergic rhinitis (also known as seasonal allergies, a response causing itchy, watery eyes, sneezing, and other similar symptoms).

During a review Resident 177's History and Physical (H&P), dated 7/2/2023, the H&P indicated Resident 177 had fluctuating capacity to understand and make decisions.

During a review of Resident 177's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/26/2024, the MDS indicated Resident 177 was able to understand and make decisions, required setup assistance with eating, required touching assistance or supervision with walking up to 150 feet (a unit of measure for length), and required moderate assistance to total dependence on facility staff for surface-to-surface transfers, hygiene, bathing or showering, and dressing.

During a review of Resident 177's Order Summary Report, the order summary report did not indicate an order for saline solution nasal spray.

During a concurrent observation and interview with Resident 177, on 8/5/2024, at 10:26 a.m., inside Resident 177's room, Resident 177's bedside table contained saline spray bottle. Resident 177 further stated

she uses the saline spray as needed to help her breathe.

During a concurrent interview and record review with LVN 1, on 8/8/2024, at 9:35 a.m., Resident 177's Order Summary Report was reviewed and LVN 1 confirmed Resident 177 did not have an order saline spray. LVN 1 stated without physician orders, the facility cannot administer medications. LVN 1 further stated for any diagnosis and condition, the physician should be aware in order to prescribe medications.

During an interview with Resident 177, on 8/8/2024, at 10:15 a.m., Resident 177 stated when she was admitted to the general acute care hospital (GACH), her physician ordered a saline spray for her. Resident 177 further stated when she returned to the facility from the GACH, she brought the saline spray with her to

the facility.

During an interview with the DON, on 8/9/2024, at 8:55 a.m., the DON stated any medications the resident takes, there should be a physician's order. The DON further stated without a physician's order the facility would not be able to give resident's their medication and would not be able to provide care for the residents.

During a review of the facility's policy and procedure (P&P) titled, Medication - Errors, last reviewed on 1/29/2024, the P&P indicated a medication error may be administration or omission of medication which is not currently prescribed.

44376

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0755 2. During a review of Resident 227's Admission Record indicated the facility admitted the resident to the facility on [DATE REDACTED], with diagnoses including glaucoma (a group of eye diseases that can cause vision loss Level of Harm - Minimal harm or and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia (difficulty potential for actual harm swallowing).

Residents Affected - Few During a review of Resident 227's Care Plan titled, Family Education related to resident's safe feeding/eating precautions, initiated on 5/16/2024, indicated to instruct visitors that either feeding or resident eating with visitor should be under close supervision of staff.

During a review of Resident 227's H&P, dated 5/22/2024, indicated the resident had the capacity to understand and make decisions.

During a review of Resident 227's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had intact cognition (gaining of knowledge and understanding).

During a review of Resident 227's Order Summary Report, the report did not indicate a physician's order for Areds 2.

During a review of Resident 227's Interdisciplinary Team (IDT - a group of people from different disciplines or fields of knowledge who work together to address a common problem or goal), dated 6/26/2024, indicated

the resident was alert and oriented times three (alert and oriented to person, place, and time). Knows his vitamins and supplements, wanted to keep his medications at the bedside.

During an observation on 8/6/2024, at 8:45 a.m., while inside Resident 227's room, Resident 227 was taking one tablet from a medication bottle labeled Areds 2.

During a concurrent interview and record review on 8/6/2024, at 8:47 a.m., with LVN 3, Resident 227's Order Summary Report and Medication Administration Record (MAR - a record of mediations administered to residents) were reviewed. LVN 3 stated there was no order for the resident to self-administer medications and that it was okay to keep the medications at the bedside on the Order Summary Report. LVN 3 also stated there was no order for the medication Areds 2. LVN 3 stated she does not know how the bottle of Areds 2 was left at the resident's bedside. LVN 3 stated it must be the family member that gave the medication Areds 2 to the resident.

During a concurrent interview and record review on 8/6/2024, at 9:05 a.m., with the Minimum Data Set Coordinator (MDSC), the Order Summary Report, Assessment for Self-Administration of Medication, and IDTs done for the resident was reviewed. The MDSC stated there was no order for Areds 2 and that it was okay to self-Administer medications on the Order Summary Report. The MDSC also stated there was no Medication Self-Administration Assessment done on admission for the resident. The MDSC confirmed there was a desire from the resident to keep supplements and vitamins at the bedside of the resident during an Interdisciplinary done on 6/26/2024, and they failed to assess the resident for self-administration of medications. The MDSC stated it was important to assess the resident for their ability to self-administer their medications to honor the resident's rights. The MDSC stated after assessing the resident for their ability to self-administer medication they should get an order from the physician for the resident to self-administer medication to ensure safe use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0755 During an interview on 8/9/2024, at 4:52 p.m., with the DON, the DON stated a self-administration medication assessment should be done on admission. The DON stated they should honor the resident's right Level of Harm - Minimal harm or to self-administer medications. The DON stated the resident was a researcher and was alert and oriented potential for actual harm very much capable of taking his own medications. The DON stated the failure of the staff to do an assessment for medication self-administration for the resident deprived the resident of his right to Residents Affected - Few self-determination and the failure of the staff to ensure there was an order for the medication Areds 2 had predisposed the resident to taking unnecessary medications and the adverse effect of the medication that can cause harm to the resident.

During a review of the facility's recent P&P titled, Physician Orders, last reviewed on 1/29/2024, indicated the purpose of the policy was to ensure all physician orders are complete and accurate. Medication orders will include the following:

A. Name of the medication;

B. Dosage;

C. Frequency; and

D. Duration of order

E. The route and the condition/diagnosis for which the medication is ordered, if applicable.

Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline.

During a review of the facility's recent P&P titled, Medication- Self Administration, last reviewed on 1/29/2024, indicated Residents who request to perform medication self-administration will be assessed for capacity. During the admission process, residents will be asked if they wish to self-administer medications. Those residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications.

A. Additional assessments will be completed at least quarterly based on OBRA timeframes.

If the resident is assessed as clinically appropriate for medication self-administration, by the IDT, the Licensed Nurse obtains a physician's order for self-administration of selected medications.

A. The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate.

The IDT develops and implements a care plan for medication self-administration. The care plan will identify:

i. Where the medications are stored;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0755 ii. Education for resident/family regarding medication self-administration process; specific medication information and safe, effective use of medications; Level of Harm - Minimal harm or potential for actual harm a. Obtaining medication;

Residents Affected - Few b. Administering medication according to physician order;

iii. How Licensed Nurses will validate that medications are taken as ordered by the attending physician; and;

iv. How non-compliance and/or refusal to take medications will be managed.

43455

3. During an observation on 8/5/2024 at 11:26 AM, with LVN 7, of Medication Cart North Middle East, there was a discrepancy in the count between the Controlled Drug Record accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents:

a. One dose of clonazepam (a CM used for anxiety) 0.25 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug

Record accountability log for Resident 25. The Controlled Drug Record accountability log for clonazepam indicated the medication bubble pack should have contained a total of 11 clonazepam 0.25 mg tablets, after

the last administration of clonazepam 0.25 mg tablet documented/signed-off on 8/4/2024 at 9 AM, however

the medication bottle contained 10 clonazepam 0.25 mg tablets and contained no other documentation of subsequent administrations.

b. One dose of diphenoxylate with atropine (a combination CM used for functional diarrhea [where 75% of stools are mushy and watery) 2.5/0.025 mg tablet was missing from the medication bubble pack compared to

the count indicated on the Controlled Drug Record accountability log for Resident 30. The Controlled Drug

Record accountability log for diphenoxylate with atropine indicated the medication bubble pack should have contained a total of 10 diphenoxylate with atropine 2.5/0.025 mg tablets, after the last administration of diphenoxylate with atropine 2.5/0.025 mg tablet documented/signed-off on 8/1/2024 at 9 AM, however the medication bottle contained nine (9) diphenoxylate with atropine 2.5/0.025 mg tablets and contained no other documentation of subsequent administrations.

During a concurrent interview, LVN 7 stated LVN 7 administered clonazepam 0.25 mg tablet to Resident 25 and diphenoxylate with atropine 2.5/0.025 mg tablet to Resident 30 that morning at 9 AM and forgot to sign

the Controlled Drug Record accountability logs. LVN 7 stated LVN 7 failed to follow the facility's policy of signing each CM dose on the Controlled Drug Record accountability log after preparing the dose for the resident. LVN 7 stated LVN 7 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 7 stated if documentation was not accurate then it can lead to medication error if overdosed (administering more than the prescribed dose) leading to stoppage of breathing, hospitalization and possibly death for Resident 25 and 30.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0755 During a record review on 8/6/2024 at 12:04 PM, with the DON, in the presence of the Nurse Consultant (NC), four (4) Controlled Drug Record accountability logs for CM's and 9 Drug Destruction Logs for Level of Harm - Minimal harm or discontinued medications awaiting final disposition did not contain verifying signatures. potential for actual harm

During a concurrent interview, in the presence of the NC, the DON stated the DON was unable to locate the Residents Affected - Few verifying signatures of LVNs and Registered Nurse (RN)/DON on the 4 Controlled Drug Record accountability logs and was unable to locate the verifying signatures of LVNs on the 9 Drug Destruction Logs. The DON stated the DON failed to sign the Controlled Drug Record logs upon receipt of the CM's and

the LVN's failed to sign upon handing the CMs to the DON. The DON stated the DON counts the CMs with

the LVN's upon receipt of the accountability logs, however there was no consistent process to sign the logs.

The DON stated there was also no consistent process of the LVN's signing the Drug Destruction Logs. The DON stated the DON needed to immediately implement a process for including verifying signatures of the LVN's and RN/DON on the Controlled Drug Record and Drug Destruction Logs forms. The DON stated the DON understood the importance of CM accountability to ensure each CM dose was accounted for until disposed. The DON stated it was also important to verify and sign these logs to prevent medication diversions and accidental exposure of harmful substances to residents.

During an interview on 8/8/2024 at 10:55 AM, in the presence of the ADMIN, the DON stated LVN 7 failed to follow facility the policy for documenting the preparation of CM immediately on the Controlled Drug Record accountability log for Resident 25 and 30. The DON stated not documenting the Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use of harmful substances for residents.

During a review of Resident 25's Admission Record (a document containing demographic and diagnostic information,) dated 5/21/2024, the Admission Record indicated Resident 25 was originally admitted to the facility on [DATE REDACTED] with a diagnosis including anxiety.

During a review of Resident 25's Order Summary Report, dated 8/1/2024, the report indicated Resident 25 was prescribed clonazepam 0.25 mg to give by mouth twice a day as needed for anxiety manifested by agitation/irritability (yelling/screaming for no apparent reason) and constant pacing in the hallways with repetitive questions where do I go, what do I do, starting 6/6/2024.

During a review of Resident 25' s MAR, for August 2024, the MAR indicated Resident 25 was prescribed clonazepam 0.25 mg twice a day Pro Re Nata ([PRN] - as needed) and was administered a dose on 8/8/2024 at 9 AM.

During a review of Resident 30's Admission Record, dated 2/15/2024, the Admission Record indicated Resident 30 was originally admitted to the facility on [DATE REDACTED] with a diagnosis including functional diarrhea.

During a review of Resident 30's Order Summary Report, dated 8/1/2024, the report indicated Resident 30 was prescribed diphenoxylate with atropine 2.5/0.025 mg to give by mouth three times a day for functional diarrhea, starting 11/4/2022.

During a review of Resident 30's MAR for August 2024, the MAR indicated Resident 30 was prescribed diphenoxylate with atropine 2.5/0.025 mg for functional diarrhea three times a day, at 9 AM, 1 PM and 5 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0755 During a review of the P&P titled, Controlled Medications, dated 1/29/2024, the P&P indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances Level of Harm - Minimal harm or are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with potential for actual harm federal and state laws and regulations.

Residents Affected - Few A. The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.

C. When a controlled mediation is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR:

a. Date and time of administration

b .Amount administered

c. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.

D. When a dose of a CM is removed from the container for administration but refused by the resident or not given for any reason .It must be destroyed according to facility policy in the presence of 2 licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules.

During a review of the P&P titled, Controlled Medication Storage, dated 1/29/2024, the P&P indicated that At each shift change, a physical inventory of all CM, including the emergency supply is conducted by 2 licensed nurses and is documented on the CM accountability record.

During a review of the P&P titled, Controlled Medication Disposal, dated 1/29/2024, the P&P indicated that When a dose of a CM is removed from the container for administration but refused by the resident or not given for any reason .It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of CS wasted for any reason.

During a review of the P&P titled, Medication Destruction, dated 1/29/2024, the P&P indicated that:

C. Non-controlled medication destruction occurs in the presence of two licensed nurses.

D. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered

on the medication disposition form.

6) Signature of witnesses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455

Residents Affected - Few Based on interview and record review, the facility failed to ensure the Consultant Pharmacist's (CP) recommendation for July 2024's Medication Regimen Review (MRR) (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was reviewed, addressed or carried out as per facility policy and procedure for one of five sampled residents (Resident 79).

The deficient practice had the potential to result in the increased risk of receiving medication that was not optimal for Resident 79's medical condition, that would not maintain the resident's highest level of physical, mental and psychosocial well-being and/or increase the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy.

Cross reference to

F-F726.

Level of Harm - Actual harm Findings:

Residents Affected - Few a. During a review of Resident 119's Admission Record, the facility admitted Resident 119 on 5/11/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), age-related osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), and dysphagia (difficulty swallowing).

During a review of Resident 119's census (record of hospitalization s, room changes, and payor source changes), the census indicated Resident 119 resided at the facility since 5/11/2017 without any hospitalization s.

During a review of Resident 119's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 5/13/2024, the MDS indicated Resident 119 had unclear speech, rarely expressed ideas and wants, rarely understood verbal content, and was severely impaired (never/rarely made decisions) for daily decision making. The MDS indicated Resident 119 had ROM impairments in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with eating, toileting, showering/bathing, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.

During a review of Resident 119's physician orders, dated 11/9/2020, the physician orders indicated for Resident 119 to receive PROM exercises to both arms and legs, every day.

During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 6/8/2022, the OT Evaluation indicated Resident 119 was referred to OT due to a decline in ROM, decreased balance, and increased need for assistance from others. The OT Evaluation indicated Resident 119's ROM to the right elbow, both wrists, and both hands were within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 119's impaired ROM included right shoulder flexion (lifting the arm upward) 0 to 80 degrees (0 to 80 degrees, normal 0 to 180 degrees), right shoulder abduction (lifting the arm up and away from the body) 0 to 75 degrees (normal 0 to 180 degrees), left shoulder flexion 0 to 40 degrees, left shoulder abduction 0 to 40 degrees, and left elbow extension (straightened) was limited to 80 degrees (normal 0 degrees, positioned in 80 degrees of elbow flexion [bend]).

During a review of Resident 119's OT Treatment Encounter Notes, dated 8/19/2022, the OT Treatment Encounter Notes indicated Resident 119's ROM included right shoulder flexion 0 to 90 degrees (shoulder height), right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees (elbow positioned in 20 degrees of flexion), left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees (elbow positioned in 30 degrees of elbow flexion).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a review of Resident 119's OT Discharge Summary, dated 8/19/2022, the OT Discharge Summary indicated Resident 119 safely wore splints to both elbows for two hours without signs of redness, swelling, Level of Harm - Actual harm discomfort, or pain. The OT Discharge Summary recommendations included a Restorative Nursing Program ([RNP] nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function Residents Affected - Few and mobility) to provide Resident 119 with PROM and to apply both elbow splints for two hours daily as tolerated.

During a review of Resident 119's Restorative Nursing Program (RNP) Referral/Care Plan, dated 8/19/2022,

the RNP Referral/Care Plan indicated Occupational Therapist 2 (OT 2) reviewed Resident 119's program with Restorative Nursing Assistant 5 (RNA 5) to apply both elbow splints for two hours.

During a review of Resident 119's physician orders, dated 8/19/2022, the physician orders indicated for RNA to apply both elbow splints for two hours daily as tolerated.

During a review of Resident 119's Registered Nurse (RN)/Licensed Vocational Nurse (LVN) Progress Notes, dated 10/4/2022, the RN/LVN Progress Notes indicated Resident 119 was on RNA program for PROM exercises to both arms and both legs and application of both elbow splints for two hours as tolerated. The RN/LVN Progress Notes indicated Resident 119 was noted with abnormal posture (position in which someone holds their body) while sitting up in the wheelchair and/or lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated Resident 119 will continue to be monitored.

During a review of Resident 119's RN/LVN Progress Notes, dated 10/5/2022, the RN/LVN Progress Notes indicated Resident 119 continued to have abnormal posture while sitting up in the wheelchair and lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated a discussion with family included providing Resident 119 with PT and OT Evaluations to ensure correct body alignment, positioning, and prevention of contractures.

During a review of Resident 119's Joint Mobility Screening (JMA completed by PT and OT), dated 10/6/2022,

the Joint Mobility Screening indicated Resident 119's ROM included severe ROM limitation (more than 50 percent [%] loss of motion) in the left shoulder, moderate ROM limitation (25 to 50% loss of motion ) in the right shoulder, minimum ROM limitation (less than 25% loss of motion) in both elbows and knees, and full ROM in both hands, hips, and ankles. The Joint Mobility Screening indicated recommendations for Resident 119 to receive PT and OT Evaluations and to continue with the RNA program.

During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 10/6/2022, the OT Evaluation indicated Resident 119 was seen for an Evaluation Only (no intervention recommended). The OT Evaluation Only indicated Resident 119's ROM was WFL in both wrists and hands but had impairment in both shoulders and elbows, including right shoulder flexion 0 to 90 degrees (shoulder height), right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, and left elbow extension to 30 degrees. The OT Evaluation Only indicated Resident 119 was already provided with both elbow splints and did not have any significant change in condition requiring OT intervention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 10/6/2022, the PT Evaluation indicated Resident 119 was referred to PT due to a new onset of decreased ROM, decreased postural Level of Harm - Actual harm alignment when sitting up in the wheelchair, and at-risk for contracture development. The PT Evaluation indicated Resident 119's ROM in both hips and ankles were WFL but had impaired ROM to both knees. The Residents Affected - Few PT Evaluation indicated Resident 119's right knee extension was limited to 30 degrees (normal 0 degrees, knee positioned in 30 degrees of knee flexion) and left knee extension was limited to 15 degrees (knee positioned in 15 degrees of knee flexion).

During a review of Resident 119's PT Discharge Summary, dated 10/28/2022, the PT Discharge Summary indicated Resident 119 tolerated sitting up in a standard wheelchair with a cushioned seat for four hours, had right knee extension to 20 degrees, and tolerated a right knee extension splint for two hours. The PT Discharge recommendations included a RNP to provide Resident 119 with PROM and to apply the right knee extension splint.

During a review of Resident 119's RNP Referral/Care Plan, dated 10/28/2022, the RNP Referral/Care Plan indicated the Physical Therapist 3 (PT 3) reviewed Resident 119's program with RNA 5 to provide PROM to both legs and to apply the right knee splint for two hours.

During a review of Resident 119's physician orders, dated 10/28/2022, the physician orders indicated for the RNA to apply the right knee splint for two hours with skin checks every 30 minutes daily as tolerated.

During a review of Resident 119's JMAs, dated 12/7/2022 and 3/3/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs as tolerated. The JMAs did not indicate the RNA applied both elbow splints and the right knee splint.

During a review of Resident 119's JMAs, dated 8/23/2023 and 11/24/2023, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs. The JMAs did not indicate the RNA applied both elbow splints and the right knee splint.

During an interview on 8/6/2024 at 9:34 a.m. with the Director of Rehabilitation (DOR) in the therapy gym,

the DOR stated RNA was a maintenance program to maintain a resident's ROM and mobility. The DOR stated the DOR, RNA Team Lead (RNA 1), and the RNA assigned to each station had weekly meetings to discuss new admissions and any changes with residents. The DOR stated limitations in ROM (in general) can lead to limitations in function and the development of contractures, which could cause pain. The DOR stated ROM exercises and application of splints can assist in maintaining ROM and preventing contractures.

The DOR stated PT and OT did not complete the JMA quarterly or annually.

During an observation on 8/6/2024 at 3:45 p.m. in the bedroom, Resident 119 was being transferred from the bed to a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) using a mechanical lift (used to transfer residents between surfaces). Resident 119 was fully dressed, did not have any splints applied to either arm or leg, but did have cushioned heel protectors (minimizes risk of injury to the heels) applied to both feet. Resident 119's both knees were bent while sitting up in the Geri chair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a concurrent observation and interview on 8/7/2024 at 9:10 a.m. in the dining room with Restorative Nursing Assistant 2 (RNA 2), Resident 119 was sitting upright in the Geri chair without any splints applied to Level of Harm - Actual harm either arm or leg but had cushioned heels protectors applied to both feet. RNA 2 stated Resident 119 was seen by RNA 2 for ROM exercises to both arms and both legs and the splints were applied this morning. Residents Affected - Few RNA 2 stated Resident 119's Certified Nursing Assistant (CNA) may have removed the splints.

During an observation on 8/7/2024 at 12:40 p.m. in the bedroom, RNA 2 stated Resident 119's primary (routinely assigned) RNA was RNA 5. RNA 2 stood on the right side of Resident 119's bed and performed ROM exercises on Resident 119's right shoulder. RNA 2 could not lift the right arm to shoulder height. RNA 2 bent and extended the right elbow to perform ROM exercises but could not fully extend the right elbow, which remained in a bent position. RNA 2 performed wrist flexion (bent down) and wrist extension (bent up) exercises but did not perform any exercises to Resident 119's right hand. RNA 2 massaged Resident 119's right arm into extension prior to applying the right elbow splint upside down. RNA 2 bent and extended Resident 119's right hip and knee at the same time, causing Resident 119 to moan with a facial grimace (expression of pain or strong dislike). RNA 2 could not extend the right knee, which continued to have a bend of approximately 90 degrees. RNA 2 performed exercises to the right ankle into rotation, dorsiflexion (ankle bent with toes pointing toward the body), and plantarflexion (ankle bent with toes pointing away from the body), and then applied the cushioned heel protector. RNA 2 applied Resident 119's right knee splint, which was fixed in a nearly straight position, and fastened a strap over the right kneecap. Resident 119's knee splint was not applied directly on the right knee but toward the right ankle. RNA 2 stood on the left side of Resident 119's bed and performed ROM exercises on the left shoulder. RNA 2 lifted the left arm higher than

the right shoulder joint but could not lift the left arm to shoulder height. RNA 2 bent and extended the left elbow to perform ROM exercises but could not fully extend the left elbow, which remained in a bent position. RNA 2 performed wrist flexion and extension exercises but did not perform any exercise to Resident 119's left hand. RNA 2 applied the left elbow splint. RNA 2 bent and extended Resident 119's left hip and knee at

the same time. RNA 2 could not fully extend Resident 119's left hip and knee. RNA 2 then performed ankle exercises to Resident 119's left ankle into rotation, dorsiflexion, and plantarflexion and then applied the left cushioned heel protector.

During an interview on 8/7/2024 at 1:04 p.m. with RNA 2, RNA 2 stated the splints will be checked every 30 minutes and will remove the splints after 2 hours. RNA 2 stated ROM was not performed to Resident 119's hands because both hands were good and stated Resident 119 could straighten the fingers.

During a concurrent observation and interview on 8/7/2024 at 1:09 p.m. with the DOR and Physical Therapy Assistant 1 (PTA 1) in the bedroom, Resident 119 was observed lying in bed while wearing both elbow splints and the right knee splint. PTA 1 stated Resident 119's right knee splint was applied lower than the knee. PTA 1 checked the right knee splint and stated Resident 119's knee splint was set to 30 degrees of extension but Resident 119's right knee was bent to approximately 90 degrees. PTA 1 stated the right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee. PTA 1 stated an inappropriately fitted splint could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores (localized damage to the skin and underlying soft tissues over a bony prominence) and dislocation (injury caused when the normal position of a joint is disturbed) of the right knee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a concurrent observation and interview on 8/7/2024 at 1:19 p.m. with the DOR and PTA 1 in the bedroom, the DOR removed Resident 119's right knee splint. The skin on Resident 119's right knee, which Level of Harm - Actual harm was directly under the strap of the knee splint, was observed with redness. PTA 1 stated Resident 119 had redness to the pressure sensitive area of the right kneecap. The DOR observed Resident 119's elbow Residents Affected - Few splints, stated the right elbow splint was applied upside down, and adjusted both of Resident 119's elbow splints.

During a concurrent interview and record review on 8/7/2024 at 1:45 p.m. with the DOR, Resident 119's census, OT Evaluation, dated 6/8/2022, OT Discharge Summary, dated 8/19/2022, OT Evaluation Only, dated 10/6/2022, PT Evaluation, dated 10/6/2022, and PT Discharge Summary, dated 10/28/2022, were reviewed. The DOR reviewed Resident 119's census and stated Resident 119 was admitted to the facility on [DATE REDACTED] and did not leave the facility for any reason. The DOR stated Resident 119 received an OT Evaluation on 6/8/2022 due to a change of condition ([COC] major decline or improvement in a resident's status that will not resolve itself without intervention), including declining ROM, reduced balance, and increased need for assistance from others, but did not receive a PT Evaluation (unknown reason). The DOR stated Resident 119's ROM in both wrists and hands were WFL but had ROM limitations in both shoulders and elbows. The DOR stated Resident 119's ROM upon discharge from OT on 8/19/2022 was right shoulder flexion 0 to 90 degrees, right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees. The DOR stated OT 2 discharged Resident 119 on 8/19/2022 with recommendations for RNA to provide PROM to both arms and apply both elbow splints for two hours. The DOR stated Resident 119 received an OT Evaluation Only on 10/6/2022 but treatment was not provided since Resident 119's ROM did not change from OT discharge on 8/19/2022. The DOR stated the OT Evaluation Only, dated 10/6/2022, indicated to continue RNA for PROM to both arms and application of both elbow splints. The DOR reviewed

the PT Evaluation, dated 10/6/2022, and stated Resident 119's ROM in both hips and ankles were WFL but had ROM limitation in both knees, including right knee extension to 30 and left knee extension to 15 degrees.

The DOR stated Resident 119 was discharged from PT on 10/28/2022 with right knee extension to 20 degrees. The DOR stated PT 3 (no longer works at the facility) discharged Resident 119 on 10/28/2022 with recommendations for RNA to provide PROM to both legs and apply the right knee extension splint. The DOR stated OT has not performed any treatment to Resident 119 since 10/6/2022 and PT has not performed any treatment to Resident 119 since 10/28/2022 (approximately 22 months ago).

During a concurrent observation and interview on 8/8/2024 at 8:30 a.m. in the bedroom with RNA 5, Resident 119 was lying in bed awake with the head-of-bed (HOB) fully elevated and the elbow splint applied to the right arm. RNA 5 stated Resident 119 was usually nonverbal and that RNA 5 was Resident 119's primary RNA. The skin on Resident 119's right kneecap was observed with pink areas. RNA 5 stated Resident 119's splints were applied this morning at approximately 7:00 a.m. but the right knee and left elbow splints were removed after 15 minutes due to skin redness on both sites.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a concurrent observation and interview on 8/8/2024 at 9:05 a.m. with Physical Therapist 1 (PT 1) in

the bedroom, Resident 119's ROM in both knees and the right knee extension splint were observed. Level of Harm - Actual harm Resident 119 was lying in bed with the HOB fully elevated and both knees were in bent positions. PT 1 extended both knees and stated Resident 119 had contractures to both knees. PT 1 stated the right knee Residents Affected - Few extended to 90 degrees (right knee positioned in 90 degrees of flexion) and the left knee extended to 55 degrees (left knee positioned in 55 degrees of flexion). PT 1 observed Resident 119's right knee extension splint, which was set to 30 degrees, and stated the right knee splint was not an appropriate fit because Resident 119's right knee was bent more than 30 degrees. PT 1 stated the right knee extension splint could cause injury to Resident 119's right leg if applied to the right knee.

During a concurrent observation and interview on 8/8/2024 at 9:16 a.m. with PT 1 and RNA 5 in the bedroom, RNA 5 applied Resident 119's knee extension splint. RNA 5 stated Resident 119's right knee extension splint did not fit because Resident 119's right knee ROM had worsened. PT 1 stated he was not notified of Resident 119's worsening ROM in the right knee and the inability to apply the right knee splint appropriately.

During a review of Resident 119's physician orders, dated 8/8/2024 timed at 9:30 a.m., the physician orders indicated to discontinue the right knee splint and both elbow splints. The physician orders also indicated for OT and PT to evaluate and treat.

During an interview on 8/8/2024 at 10:40 a.m. with the Director of Nursing (DON), Registered Nurse Supervisor 1 (RN 1), Performance Improvement Quality Improvement Licensed Vocational Nurse 1 (PIQI 1), and PIQI 2, RN 1 stated the facility process is that the RN, PIQI, and RNA assigned to each nursing station complete the JMA for each resident upon admission, quarterly, change of condition, and annually. The DON stated the previous DOR provided a training on how to complete the JMA to the DON, RN Supervisors, PIQI LVNs, and RNAs approximately five years ago. The DON stated there has not been any recent training on how to complete the JMAs. PIQI 2 stated the JMA assessed a resident's active or passive joint limitations depending on if the resident can move.

During a concurrent interview and record review on 8/8/2024 at 11:55 a.m. with RN 1, PIQI 1, PIQI 2, Resident 119's quarterly JMAs from 3/3/2023, 6/1/2023, 8/23/2023, 11/24/2023, 2/16/2024, 5/11/2024, and 8/4/2024. RN 1 stated the splints should be assessed for proper fit during the JMAs. RN 1 stated Resident 119's JMAs from 3/3/2023 to 8/4/2024 indicated Resident 119 had severe ROM limitations in both shoulders, moderate ROM limitations in both elbows, hips, knees, and ankles, and minimum ROM limitations in both wrists. RN 1 stated Resident 119's JMAs from 3/3/2023 to 8/4/2024 indicated Resident 119's ROM limitations remained the same and did not change.

During an interview on 8/8/2024 at 3:21 p.m. with the DON, the DON stated the Supervising RN, PIQI LVN, and RNA assigned to the nursing station were supposed to perform each resident's JMA. The DON stated

the Supervising RN assessed the resident, the PIQI LVN was present to gather information about each resident, and the RNA provided the ROM movement as part of the assessment. The DON stated the RNs, including the DON, did not have competency assessments (systematic process that evaluated an individual's skill and knowledge) to perform JMAs. The DON stated there was no way to ensure the JMAs for all residents were accurate since the RNs did not have a competency to perform the JMAs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 8/8/2024 completed by OT 2,

the OT Evaluation indicated Resident 119 had ROM impairments in both shoulders, both elbows, and both Level of Harm - Actual harm hands. The OT Evaluation indicated Resident 119's ROM limitations included right shoulder flexion 0 to 50 degrees, right shoulder abduction 0 to 61 degrees, right elbow extension to 26 degrees, right hand with less Residents Affected - Few than 25% loss of motion, left shoulder flexion 0 to 66 degrees, left shoulder abduction 0 to 61 degrees, left elbow extension to 43 degrees, and left hand with 25 to 50% loss of motion.

During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 8/8/2024 completed by Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 119 had ROM impairments in both hips, both knees, and the left ankle. The PT Evaluation indicated Resident 119's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 30 to 96 degrees (normal 0 to 120 degrees), right hip abduction (moving the leg away from the body) 0 to 13 degrees (normal 0 to 45 degrees), right knee extension to 73 degrees, left hip flexion 26 to 70 degrees, left hip abduction 0 to 11 degrees, left knee extension to 17 degrees, and left ankle dorsiflexion 0 to 4 degrees (normal 0 to 20 degrees).

During an interview and record review on 8/9/2024 at 8:37 a.m. with RNA 5, PIQI 1 and PIQI 2, Resident 119's JMAs, dated 2/16/2024, 5/11/2024, and 8/4/2024, were reviewed. PIQI 1 and PIQI 2 stated the Supervising RN, PIQI LVN, and the RNA assigned to the nursing station were supposed to be present during each resident's JMA (in general). PIQI 1 and PIQI 2 stated the RNA moved the resident and applied the splints (if applicable), the RN assessed the resident's ROM and splints, and the PIQI recorded the resident's joint mobility limitations based on the RN's assessment. PIQI 1 stated PIQI 3 and RN 5 participated in Resident 119's JMA on 8/4/2024. RNA 5 stated she watched but did not move Resident 119 or apply any splints during Resident 119's JMAs on 2/16/2024, 5/11/2024, and 8/4/2024.

During a telephone interview on 8/9/2024 at 8:56 a.m. with PIQI 3, PIQI 3 stated RN 5 and PIQI 3 performed Resident 119's JMA on 8/4/2024 without RNA 5. PIQI 3 stated Resident 119's splints were not applied during

the JMA on 8/4/2024 but should have been applied to assess whether the splints fit.

During an interview on 8/9/2024 at 10:36 AM with the DOR, the DOR stated contractures developed over time. The DOR stated performing ROM exercises, positioning and applying splints assisted in preventing contractures, which could cause pain, limited function, increased skin issues, and increased the potential for injury.

During a concurrent interview and record review on 8/9/2024 at 11:16 a.m. with the DOR and PT 2, Resident 119's PT Discharge Summary, dated 10/28/2022, and PT Evaluation, dated 8/8/2024, were reviewed. PT 2 stated Resident 119 did not have any ROM limitations in both hips upon PT Discharge on 10/28/2022. PT 2 stated Resident 119 developed flexion contractures on both hips since both hips could not be extended to neutral (0 degrees) and were significantly limited in hip abduction. PT 2 stated Resident 119's right knee extended to 20 degrees upon PT Discharge on 10/28/2022 but currently had 73 degrees of right knee extension which was a significant decline in ROM. PT 2 stated Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). The DOR and PT 2 stated Resident 119's decline in ROM on both legs were not reported to the therapy department.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a concurrent interview and record review on 8/9/2024 at 11:37 a.m. with OT 2, Resident 119's OT Evaluation Only, dated 10/6/2022, and OT Evaluation, dated 8/8/2024, were reviewed. OT 2 stated Resident Level of Harm - Actual harm 119 had 0 to 90 degrees of right shoulder flexion and 0 to 80 degrees of left shoulder flexion during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently had 0 to 50 degrees of right shoulder flexion Residents Affected - Few and 0 to 61 degrees of left shoulder flexion which was a significant decline in ROM. OT 2 stated Resident 119's ROM in both hands were WFL during the OT Evaluation on 10/6/2022. OT 2 stated both of Resident 119's hands currently cannot extend completely. OT 2 stated Resident 11 developed flexion contractures on both hands and had worsening contractures on both shoulders and elbows. OT 2 stated contractures could cause discomfort and pain. OT 2 stated Resident 119's decline in ROM on both arms were not reported to

the therapy department.

During an interview on 8/9/2024 at 2:06 p.m. with RNA 5, RNA 5 stated she did not report but was supposed to report to the LVN charge nurse or the RN supervisor that Resident 119's right knee splint did not fit. RNA 5 stated Resident 119 resisted ROM because Resident 119 was in pain and had facial expressions of pain whenever RNA 5 touched Resident 119.

During a concurrent interview and record review on 8/9/2024 at 3:49 p.m. with the DON, 13 RNA employee files were reviewed. The DON stated RNAs were important to maintain, improve, and prevent any decline in

a resident's mobility, ROM, and overall physical condition. The DON stated 7 of 13 RNA staff did not have any competency evaluations for the provision of RNA services. The DON Stated 6 of 13 RNA staff were evaluated by the Director of Staff Development (DSD) who were not competent in the provision of RNA services. The DON stated 13 of 13 RNAs did not have the competency to accurately perform their duties, including providing ROM, applying splints, and detecting declines in ROM and mobility.

During a concurrent interview and record review on 8/9/2024 at 4:30 p.m. with the DON, Resident 119's quarterly JMAs from 3/3/2023 to 8/4/2024 were reviewed. The DON stated the JMA (in general) was completed to determine if there were any changes in a resident's joint mobility and ROM. The DON stated Resident 119's JMAs were the same because the RN Supervisors were not competent to assess joint mobility and therefore did not notice any changes in Resident 119's ROM. The DON stated contractures (in general) develop due to immobility and could be prevented with ROM exercises and application of splints.

The DON stated contractures limited movement, could cause discomfort and pain, and increased a resident's risk of skin impairments. The DON stated contracture prevention was important for a resident's quality of life to prevent any restrictions in movement.

During a concurrent interview and record review on 8/9/2024 at 6:19 PM with the DON, Resident 119's JMA, dated 12/7/2022, 3/3/2023, 8/23/2023, and 11/24/2023, were reviewed. The DON stated the JMAs did not indicate Resident 119 had both elbow and the right knee splints. The DON stated the splints were not assessed during the JMAs for fit if the splints were not documented.

During a review of the facility's policy and procedure (P&P) titled, Joint Mobility Assessment, revised 5/1/2018 and reviewed on 1/29/2024, the P&P indicated all residents shall receive a joint mobility assessment upon admission, quarterly, and during a significant change in the resident's condition to identify any limitation in joint mobility and risk of contractures. The P&P indicated the DON or designee will monitor

the completion and accuracy of joint mobility assessments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 During a review of the facility's P&P titled, Range of Motion Exercise Guidelines, revised 3/1/2015 and reviewed on 1/29/2024, the P&P indicated ROM should be delivered by trained staff to maintain or increase Level of Harm - Actual harm ROM of a joint and to prevent or reduce contractures.

Residents Affected - Few b.1. During a review of Resident 139's Admission Record, the facility admitted Resident 139 on 4/28/2021 with d [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for eight of ten sampled residents (Residents 227, 38, 14, 55, 148, 177, 213, and 43) investigated under care area accidents by failing to ensure:

1. Resident 227's Areds 2 (supplement for age related macular degeneration) was not left at the bedside for

the resident to self-administer.

The deficient practice had the potential to place Resident 227 at risk for adverse effect (a harmful or abnormal result) of taking medications.

2. Residents 38 was not left in a wheelchair with a bedside table on top of a fall mat (used to cushion fall impact) to eat breakfast.

The deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the floor mat decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and potential of the residents hitting the hard surfaces of the heavy equipment and furniture causing fractures (break in bone) and even death.

3. Resident 14's wheelchair was not placed on top of floor mats while left unattended by staff.

This deficient practice had the potential to result in the resident's wheelchair becoming unstable and toppling over resulting in injury to the resident.

4. Certified Nursing Assistant 2 (CNA 2) did not leave the sit-to-stand assistive device (helps transfer residents from one seated surface to another) in Resident 55 and 148s shared room while Resident 55 was

in the room unattended by staff.

This deficient practice had the potential to result in residents sustaining injury caused by a trip or fall over the unattended device.

5. Resident 177's two white circular tablets and a bottle of saline spray (a mixture of salt and water that is sprayed into the nose) was not left on the resident's bedside table.

This deficient practice had the potential for other residents to enter the resident's room and take the medication without the facility staff knowing.

6. Resident 213 was assessed for elopement risk quarterly per the facility policy for 7/19/2024.

7. Resident 43 was assessed for elopement risk upon readmission.

These deficient practices had the potential to affect resident safety and minimize injury in the event of elopement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 Findings:

Level of Harm - Minimal harm or 1. During a review of Resident 227's Admission Record, the admission record indicated the facility admitted potential for actual harm the resident on 12/26/2023, with diagnoses that included glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia Residents Affected - Some (difficulty swallowing).

During a review of Resident 227's Care Plan titled, Family Education related to resident's safe feeding/eating precautions, initiated on 5/16/2024, indicated to instruct visitors that either feeding or resident eating with visitor should be under close supervision of staff.

During a review of Resident 227's History and Physical (H&P), dated 5/22/2024, the H & P indicated Resident 227 had the capacity to understand and make decisions.

During a review of Resident 227's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/24/2024, indicated the resident had the ability to make self-understood and understand others.

The MDS indicated the resident had impaired vision and had intact cognition (gaining of knowledge and understanding).

During a review of Resident 227's Order Summary Report, the report did not indicate a physician's order for Areds 2.

During a review of Resident 227's Interdisciplinary Team (IDT, is a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychosocial, and spiritual needs of the residents) note, dated 6/26/2024, indicated the resident was alert and oriented times 3 (alert and oriented to person, place, and time), knows his vitamins and supplements, and wanted to keep his medications at the bedside.

During an observation on 8/6/2024, at 8:45 a.m., while inside Resident 227's room, Resident 227 was observed taking one tablet from a medication bottle labeled Areds 2.

During a concurrent interview and record review on 8/6/2024, at 8:47 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 227's Order Summary Report and Medication Administration Record (MAR) was reviewed. LVN 3 stated there was no order for the resident to self-administer medications or an order that it was okay to keep medications at the bedside on the Order Summary Report. LVN 3 also stated there was no order for

the medication Areds 2. LVN 3 stated she does not know how the bottle of Areds 2 was left at the resident's bedside. LVN 3 stated it must be the family member that gave the medication Areds 2 to the resident. LVN 3 stated leaving a medication at the bedside without a physician order can cause accidental ingestion of medication by other residents and had a potential for the resident to choke due to unsupervised administration of the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 During a concurrent interview and record review on 8/6/2024, at 9:05 a.m., with the Minimum Data Set Coordinator (MDSC), the Order Summary Report, Assessment for Self-Administration of Medication, and Level of Harm - Minimal harm or IDTs done for the resident were reviewed. The MDSC stated there was no order for Areds 2 or an order that potential for actual harm it was okay to self-Administer medications on the Order Summary Report. The MDSC also stated there was no Medication Self-Administration Assessment done on admission for the resident. The MDSC confirmed Residents Affected - Some there was a desire from the resident to keep supplements and vitamins at the bedside of the resident during

an Interdisciplinary Team (IDT, professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) done on 6/26/2024, and they failed to assess the resident for self-administration of medications. The MDSC stated it was important to assess the resident for their ability to self-administer their medications to honor the resident's rights. The MDSC stated after assessing the resident for their ability to self-administer medication they should get an order from the physician for the resident to self-administer medication to ensure safe use.

During an interview on 8/9/2024, at 4:52 p.m., with the Director of Nursing (DON), the DON stated a self-administration medication assessment should be done on admission. The DON stated they should honor

the resident's right to self-administer medications. The DON stated the resident was a researcher and was alert and oriented very much capable of taking his own medications. The DON stated the failure of the staff to do an assessment for medication self-administration to the resident deprived the resident of his right to self-determination and the failure of the staff to ensure there was an order for the medication Areds 2 had predisposed the resident to taking unnecessary medications and the adverse effect of the medication that can cause harm to the resident. The DON also stated some residents may have access to the medication and take the medication accidentally that can cause an accident of ingesting non-prescribed medication.

During a review of the facility's most recent policy and procedure titled, Physician Orders, last reviewed on 1/29/2024, the policy indicated the purpose of the policy was to ensure all physician orders are complete and accurate. Medication orders will include the following:

A. Name of the medication;

B. Dosage;

C. Frequency; and

D. Duration of order

E. The route and the condition/diagnosis for which the medication is ordered, if applicable.

Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 During a review of the facility's most recent policy and procedure titled, Medication- Self Administration, last reviewed on 1/29/2024, indicated Residents who request to perform medication self-administration will be Level of Harm - Minimal harm or assessed for capacity. During the admission process, residents will be asked if they wish to self-administer potential for actual harm medications. Those residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications. Residents Affected - Some A. Additional assessments will be completed at least quarterly based on OBRA timeframes.

If the resident is assessed as clinically appropriate for medication self-administration, by the IDT, the Licensed Nurse obtains a physician's order for self-administration of selected medications.

A. The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate.

The IDT develops and implements a care plan for medication self-administration. The care plan will identify:

i. Where the medications are stored;

ii. Education for resident/family regarding medication self-administration process; specific medication information and safe, effective use of medications;

a. Obtaining medication;

b. Administering medication according to physician order;

iii. How Licensed Nurses will validate that medications are taken as ordered by the attending physician; and

iv. How non-compliance and/or refusal to take medications will be managed.

2. During a review of Resident 38's Admission Record, the admission record indicated the facility admitted

the resident on 2/28/2023, with diagnoses including age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), ataxia (a loss of muscle control), and presence of right artificial shoulder joint (a metal or plastic part that is surgically implanted to replace a natural joint).

During a review of Resident 38's Care Plan titled, At risk for fall secondary to impairment of upper and lower extremities on both sides/presence of artificial shoulder joint, initiated on 3/15/2023, indicated an intervention to keep environment free of hazards such as wet spots or small objects below field of vision and to place a floor mat next to resident's bed to prevent the resident from injuries.

During a review of Resident 38's H&P, dated 1/27/2024, the H & P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 38's Order Summary Report, the report included the following orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 -3/11/2024 Caution for sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs), lethargy (a condition marked by drowsiness and an unusual lack of energy and mental alertness), Level of Harm - Minimal harm or drowsiness, dizziness, respiratory depression, and falls. Every shift. potential for actual harm -2/28/2023 May have floor mat next to bed to prevent injuries. Every shift. Residents Affected - Some

During a review of Resident 38's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and to understand others. The MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident had impaired upper and lower extremity and required substantial to maximal assistance in mobility and activities of daily living (ADLs).

During a review of Resident 38's Fall Risk Assessment, dated 8/1/2024, indicated the resident was a high risk for falls.

During an observation on 8/5/2024, at 8:54 a.m., Resident 38 was eating breakfast at the bedside in a wheelchair with a bedside table on top of a fall mat.

During an interview on 8/5/2024, at 10:18 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated there should be no rolling equipment like a bedside table on top of the floor mat so the resident will not fall on them.

During a concurrent observation and interview on 8/8/2024, at 11:45 a.m., with Performance Improvement Quality Improvement Nurse 1 (PIQI 1), rounded the nursing stations and found multiple rooms with bedside tables and equipment on top of the fall mats. PIQI 1 stated there should be no equipment or furniture on top of fall mats as it forms a permanent dent on the mats decreasing the capability of the mat to lessen the impact of resident's fall on the floor. PIQI 1 also stated leaving equipment and furniture on the fall mat increases the risk of the resident sustaining falls with injury because they could hit the sharp edges and hard surfaces of the equipment or furniture that was left on the fall mat.

During an interview on 8/9/2024, at 5:12 p.m., with the DON, the DON stated the fall mats should be free of any furniture and device so that when residents fall on the mat they will not hit on the sharp edges and hard surfaces of the furniture that was left on top of them. The DON also added leaving equipment or furniture on top of the fall mat will leave a dent on the surface of the mat and will not serve its purpose to lessen the fall impact to the resident.

During a review of the facility provided undated, Manufacturer's Recommendation on the use of Landing Mat 1 (LM 1), indicated when moving equipment across the mat ensure that the wheels are not locked as dragging wheels may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.3. During

a review of Resident 14's Admission Record, the admission record indicated the facility admitted Resident 14

on 6/11/2021 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), age-related osteoporosis (a disease that causes bones to become weak and brittle), and sarcopenia (loss of muscle mass and strength that can affect older adults).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 3. During a review of Resident 14's Admission Record, the admission record indicated the facility admitted Resident 14 on 6/11/2021 with diagnoses that included unspecified dementia (impaired ability to remember, Level of Harm - Minimal harm or think, or make decisions that interferes with doing everyday activities), age-related osteoporosis (a disease potential for actual harm that causes bones to become weak and brittle), and sarcopenia (loss of muscle mass and strength that can affect older adults). Residents Affected - Some

During a review of Resident 14's physician orders indicated the following orders:

-May have floor mat next to bed to prevent injuries, dated 6/11/2021.

During a review of Resident 14's Care Plans titled, At Risk for Fall secondary to Impairment of Upper and Lower Extremities on both sides, initiated on 4/25/2024, indicated the resident's potential for fall/injury will be minimized, to place a floor mat at the resident's bed to prevent injuries, and to keep the environment free from hazards.

During a review of Resident 14's history and physical dated 6/28/2024, indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 14's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/10/2024, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS indicated Resident 14 was dependent on staff for oral hygiene, toileting, bathing, and personal hygiene, and required substantial to maximal assistance with mobility.

During an observation on 8/9/2024 at 12:25 p.m., Resident 14 was sitting in a wheelchair (WC) between the resident's right side of the bed and the wall near the entrance door. The resident's WC with the left wheel was on the wood floor surface and the right wheel was on top of the floor mat.

During an observation and interview on 8/9/2024 at 12:43 p.m., Certified Nursing Assistant 2 (CNA 2) entered Resident 14's room and stated the resident's WC was on top of the floor mat. CNA 2 stated Resident 14 was a total assist resident and was not able to move the WC. CNA 2 stated the resident's WC should not be on top of the floor mat for safety.

During an observation and interview on 8/9/2024 at 12:45 p.m., Licensed Vocation Nurse 4 (LVN 4) entered Resident 14's room and stated residents in WCs should never be left on top of the floor mat for safety. LVN 4 stated the WC could become unstable and fall over.

During an interview on 8/9/2024 at 1:52 p.m., the Director of Nursing (DON) stated WCs should not be on top of the floor mat because the resident must be free from hazards. The DON stated this was a safety issue and if the resident fell it could cause harm like a fracture (broken bone).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 During a review of the facility policy and procedure titled, Safety - Environment, last reviewed on 1/29/2024,

the policy indicated the purpose of the policy was to provide a safe, clean, and hazard free environment for Level of Harm - Minimal harm or all residents promoting their wellbeing, dignity, and quality of life. The facility shall maintain an environment potential for actual harm that ensures the safety and security of all residents. This includes, but is not limited to, the prevention of accidents, hazards, and exposure to harmful conditions. All rooms shall be arranged in a manner that Residents Affected - Some ensures safety. All furniture should be positioned to allow safe movement within the room. All rooms shall be free of clutter and any items that could pose a fall risk.

44244

4.a. During a review of Resident 55's Admission Record, the admission record indicated the facility admitted

the resident on 11/21/2019 with diagnoses that included unspecified dementia, metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination) with dyskinesia (uncontrolled, involuntary muscle movements), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out

the simplest tasks), and muscle weakness.

During a review of Resident 55's physician orders indicated the following orders:

-May use mechanical device for transfers and or weights, dated 6/14/2024.

During a review of Resident 55's MDS dated [DATE REDACTED], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS indicated the resident required substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene; and mobility.

During a review of Resident 55's history and physical dated 7/24/2024, the H & P indicated the resident had

the capacity to understand and make decisions.

During an observation on 8/9/2024 at 12:15 p.m., Resident 55 was lying in bed. A sit-to-stand assistive device was inside the resident's room placed near the door next to Resident 148's bed. No staff were present

in the room or hallway.

During an observation on 8/9/2024 at 12:30 p.m., CNA 2 exited the resident room, walked to the nursing station, and moved Resident 148 in the WC to the shared room with Resident 55 and closed the curtain.

After assisting Resident 148 into bed, CNA 2 walked out of the room with the sit-to-stand assistive device.

During an interview on 8/9/2024 at 12:40 p.m., CNA 2 stated she used the sit-to-stand assistive device to assist Resident 148 into bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 During an interview on 8/9/2024 at 2:02 p.m., the DON stated she was made aware by CNA 2 that the sit-to-stand assistive device was left unattended next to the resident's bed while there was a resident in the Level of Harm - Minimal harm or room. The DON stated equipment should not be left in the resident rooms if there is a resident present in the potential for actual harm room. The DON stated it was an environmental hazard to leave equipment in a resident's room because residents may harm themselves on the equipment. The DON stated the facility CNAs have recently had Residents Affected - Some in-services on not leaving equipment in the resident's room.

During a review of the facility provided In-Service Training Report for Mechanical Lifting Safety, dated 6/14/2024, the Inservice report indicated CNA 2 completed a Mechanical Lifting Post Test that indicated lifting machines may not be stored in the resident's room.

During an interview on 8/9/2024 at 2:40 p.m. the facility Administrator (ADM) stated equipment should not be left in resident rooms because it could create a hazard for residents, especially if they are ambulatory. The ADM stated there was a risk that ambulatory residents could trip and fall over the equipment that could result

in an injury like a fracture.

During an interview on 8/9/2024 at 2:45 p.m., LVN 4 stated CNA 2 told her she brought and left the sit-to-stand assistive device in the residents' room. LVN 4 stated the resident should be brought into the room first, then the sit-to-stand machine should be brought to the room because there are other residents that may walk in the room when the equipment is unattended.

During a review of the facility policy and procedure titled, Resident Rooms and Environment, last reviewed 1/29/2024, the policy indicated its purpose is to provide residents with a safe, clean, comfortable, and homelike environment. The facility shall ensure residents can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk.

During a review of the facility policy and procedure titled, Sit-to-Stand Lift, last reviewed on 1/29/2024, indicated the purpose of the policy was to ensure safety of residents during transfers and to reduce the potential for injuries to residents.

During a review of the facility policy and procedure titled, Safety Environment, last reviewed on 1/29/2024, indicated the purpose of the policy was to provide a safe, clean, and hazard free environment for all residents promoting their wellbeing, dignity, and quality of life. The facility shall maintain an environment that ensures the safety and security of all residents. This includes, but is not limited to, the prevention of accidents, hazards, and exposure to harmful conditions. All rooms shall be arranged in a manner that ensures safety. All rooms shall be free of clutter and any items that could pose a fall risk.

4.b. During a review of Resident 55's Admission Record, the admission record indicated the facility admitted

the resident on 11/21/2019 with diagnoses that included unspecified dementia, metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination) with dyskinesia (uncontrolled, involuntary muscle movements), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out

the simplest tasks), and muscle weakness.

During a review of Resident 55's physician orders indicated the following orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 -May use mechanical device for transfers and or weights, dated 6/14/2024.

Level of Harm - Minimal harm or During a review of Resident 55's MDS dated [DATE REDACTED], the MDS indicated the resident was able to understand potential for actual harm others and was able to make himself understood. The MDS indicated the resident required substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene; and mobility. Residents Affected - Some

During a review of Resident 55's history and physical dated 7/24/2024, the H & P indicated the resident had

the capacity to understand and make decisions.

During an observation on 8/9/2024 at 12:15 p.m., Resident 55 was lying in bed. A sit-to-stand assistive device was inside the resident's room placed near the door next to Resident 148's bed. No staff were present

in the room or hallway.

During an observation on 8/9/2024 at 12:30 p.m., CNA 2 exited the resident room, walked to the nursing station, and moved Resident 148 in the WC to the shared room with Resident 55 and closed the curtain.

After assisting Resident 148 into bed, CNA 2 walked out of the room with the sit-to-stand assistive device.

During an interview on 8/9/2024 at 12:40 p.m., CNA 2 stated she used the sit-to-stand assistive device to assist Resident 148 into bed.

During an interview on 8/9/2024 at 2:02 p.m., the DON stated she was made aware by CNA 2 that the sit-to-stand assistive device was left unattended next to the resident's bed while there was a resident in the room. The DON stated equipment should not be left in the resident rooms if there is a resident present in the room. The DON stated it was an environmental hazard to leave equipment in a resident's room because residents may harm themselves on the equipment. The DON stated the facility CNAs have recently had in-services on not leaving equipment in the resident's room.

During a review of the facility provided In-Service Training Report for Mechanical Lifting Safety, dated 6/14/2024, the Inservice report indicated CNA 2 completed a Mechanical Lifting Post Test that indicated lifting machines may not be stored in the resident's room.

During an interview on 8/9/2024 at 2:40 p.m. the facility Administrator (ADM) stated equipment should not be left in resident rooms because it could create a hazard for residents, especially if they are ambulatory. The ADM stated there was a risk that ambulatory residents could trip and fall over the equipment that could result

in an injury like a fracture.

During an interview on 8/9/2024 at 2:45 p.m., LVN 4 stated CNA 2 told her she brought and left the sit-to-stand assistive device in the residents' room. LVN 4 stated the resident should be brought into the room first, then the sit-to-stand machine should be brought to the room because there are other residents that may walk in the room when the equipment is unattended.

During a review of the facility policy and procedure titled, Resident Rooms and Environment, last reviewed 1/29/2024, the policy indicated its purpose is to provide residents with a safe, clean, comfortable, and homelike environment. The facility shall ensure residents can receive care and services safely and that the physical layout 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 70 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 During a review of the facility policy and procedure titled, Sit-to-Stand Lift, last reviewed on 1/29/2024, indicated the purpose of the policy was to ensure safety of residents during transfers and to reduce the Level of Harm - Minimal harm or potential for injuries to residents. potential for actual harm

During a review of the facility policy and procedure titled, Safety Environment, last reviewed on 1/29/2024, Residents Affected - Some indicated the purpose of the policy was to provide a safe, clean, and hazard free environment for all residents promoting their wellbeing, dignity, and quality of life. The facility shall maintain an environment that ensures the safety and security of all residents. This includes, but is not limited to, the prevention of accidents, hazards, and exposure to harmful conditions. All rooms shall be arranged in a manner that ensures safety. All rooms shall be free of clutter and any items that could pose a fall risk.

43418

5. During a review of Resident 177's Admission Record, the admission record indicated Resident 177 was admitted to the facility on [DATE REDACTED] with diagnoses including, but not limited to, hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than the normal), hyponatremia (a condition that occurs when the level of sodium in the blood is too low), and allergic rhinitis (also known as seasonal allergies, a response causing itchy, watery eyes, sneezing, and other similar symptoms).

During a review of Resident 177's Order Summary Report, dated 6/28/2022, the order summary report indicated Resident 177 was ordered sodium chloride tablet one gram (a unit of measure for mass), two tablets by mouth two times a day related to hypo-osmolality and hyponatremia.

During a review Resident 177's History and Physical (H&P), dated 7/2/2023, the H&P indicated Resident 177 had fluctuating capacity to understand and make decisions.

During a review of Resident 177's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/26/2024, the MDS indicated Resident 177 was able to understand and make decisions, required setup assistance with eating, required touching assistance or supervision with walking up to 150 feet (a unit of measure for length), and required moderate assistance to total dependence on facility staff for surface-to-surface transfers, hygiene, bathing or showering, and dressing.

During a concurrent observation and interview with Resident 177, on 8/5/2024, at 10:26 a.m., inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup containing two white circular tablets and a saline spray bottle. Resident 177 stated the two white circular tablets in the medication cup were her sodium tablets and she takes the medications with food. Resident 177 stated the nurse gave her the tablets in the morning and will take the tablets after eating lunch. Resident 177 further stated she uses the saline spray as needed to help her breathe.

During a review of Resident 177's Order Summary Report, the order summary report did not indicate an order for saline solution nasal spray.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 During an interview with Licensed Vocational Nurse (LVN) 1, on 8/8/2024, at 9:35 a.m., LVN 1 stated she was assigned to Resident 177. LVN 1 stated Resident 177 takes sodium chloride tablets that are scheduled Level of Harm - Minimal harm or for the morning, and she likes to take them around lunch time. LVN 1 stated she reminds Resident 177 that potential for actual harm she could bring the sodium chloride tablets before lunch, but Resident 177 tells her to leave them at the bedside in the morning. Residents Affected - Some

During an observation on 8/8/2024, at 10:15 a.m., while inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup with two white circular tablets.

During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated medications should not be left at the bedside. The DON further stated if medications are left at the bedside, there is a potential for other residents to go into the resident's room, take the medication, and potentially harm themselves.

During a review of the facility's policy and procedure (P&P) titled, Medication - Self Administration, last reviewed on 1/29/2024, the P&P indicated if the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) and attending physician approve self-administration of medications, the medications will be placed in a secure drawer or cabinet that is easily accessible to the resident. The P&P further indicated the Administrator/DON or designee ensures that the resident has access to a secure container for proper medication storage if the medications are not stored in the medication cart.

43988

6. During a review of Resident 213's Admission Record indicated the facility admitted the resident on 9/8/2023 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).

During a review of Resident 213's History and Physical (H&P) dated 9/8/2023, the H & P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 213's Elopement Risk Assessment form for 11/13/2023, 2/1/2024, and 4/25/2024, indicated a score of 8. The form did not indicate that the resident's quarterly assessment, which was due in 7/2024, was done. The form indicated [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36943 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure the facility's Registered Nurses (RNs) and Restorative Nursing Assistants ([RNA], certified nursing aide program that helps residents to maintain their function and joint mobility) were competent in providing assessments and services affecting four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move), by failing to:

1. Ensure the facility's system, which identified six RNs (Director of Nursing [DON], RN 1, RN 2, RN 3, RN 4, RN 5) who performed assessments of joint mobility at each major joint, had competency evaluations (systematic process that evaluated an individual's skill and knowledge) to perform the Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) in accordance with the facility's policy and procedure titled, Staff Competency Evaluations, upon admission, quarterly, annually, and for a change in condition for all 296 residents.

2. Ensure RNs were competent in the assessment of splints (material used to restrict, protect, or immobilize

a part of the body to support function, assist and/or increase range of motion) during the JMAs to ensure proper fit to prevent complications such as skin breakdown and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness).

3. Ensure RNAs 3, 4, 5, 7, 9, 11, and 13 had competency evaluations for RNA duties and responsibilities, including ROM exercises, application of splints, and ambulation (the act of walking) in accordance with the facility's job description titled, Restorative Nursing Assistant, and policy and procedure titled, Range of Motion Exercise Guidelines.

4. Ensure RNAs 1, 2, 6, 8, 10, and 12 had competency evaluations completed by a qualified staff member with knowledge and experience to evaluate staff competency in accordance with the facility's policy and procedure titled, Staff Competency Evaluations.

These failures resulted in Resident 119's decline in ROM due to the facility-identified qualified personnels' (RNs) inability to identify ROM decline during JMAs, the RNAs' inability to correctly apply splints, and the RNAs' inability to identify and report a decline in ROM and mobility during the provision of care, including Resident 119's development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) to both hands and hips and worsening contractures to both shoulders, elbows, and knees while residing at the facility. These failures also had the potential for Residents 139, 141, and 34, to experience a decline in ROM.

Cross reference

F-F755.

Findings:

1. During a review of Resident 177's admission record, the admission record indicated Resident 177 was admitted to the facility on [DATE REDACTED] with diagnoses that included, hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than the normal), hyponatremia (a condition that occurs when the level of sodium in the blood is too low), and allergic rhinitis (also known as seasonal allergies, a response causing itchy, watery eyes, sneezing, and other similar symptoms).

During a review of Resident 177's Order Summary Report, dated 6/28/2022, the order summary report indicated to administer to Resident 177 sodium chloride tablet one gram (a unit of measure for mass), two tablets by mouth two times a day related to hypo-osmolality and hyponatremia.

During a review Resident 177's History and Physical (H&P), dated 7/2/2023, the H&P indicated Resident 177 had fluctuating capacity to understand and make decisions.

During a review of Resident 177's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/26/2024, the MDS indicated Resident 177 was able to understand and make decisions, required setup assistance with eating, required touching assistance or supervision with walking up to 150 feet (a unit of measure for length), and required moderate assistance to total dependence on facility staff for surface-to-surface transfers, hygiene, bathing or showering, and dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0554 During a concurrent observation and interview with Resident 177, on 8/5/2024, at 10:26 a.m., inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup containing two white Level of Harm - Minimal harm or circular tablets and a saline spray bottle. Resident 177 stated the two white circular tablets in the medication potential for actual harm cup were her sodium tablets and she takes the medications with food. Resident 177 stated the nurse gave her the tablets in the morning and she will take the tablets after eating lunch. Resident 177 further stated she Residents Affected - Few uses the saline spray as needed to help her breathe.

During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 8/8/2024, at 9:35 a.m., Resident 177's medical record was reviewed and LVN 1 confirmed Resident 177 did not have a medication self-administration assessment. LVN 1 stated Resident 177 is alert and oriented and told her to leave her sodium chloride tablets at the bedside so she can take it later. LVN 1 stated it is important to perform a medication self-administration assessment for resident safety, to accommodate the resident's needs, and respect the resident's rights. LVN 1 further stated, if a medication self-administration assessment is not performed, it is possible that staff would be unaware if residents are safe to take medications on their own.

During an observation on 8/8/2024, at 10:15 a.m., inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup with two white circular tablets.

During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated for better practices and safety, the facility chooses not to have residents self-administer medications. The DON stated medication self-administration assessments should be done on admission, quarterly, and as needed, such as during a significant change of condition. The DON further stated Resident 177 did not have a medication self-administration assessment performed.

During a review of Resident 177's medical record, the medical record did not indicate a medication self-administration assessment was performed.

During a review of Resident 177's Order Summary Report, (What date?) the order summary report did not indicate an order for saline solution nasal spray (a mixture of salt and water that is sprayed into the nose).

During a review of Resident 177's Order Summary Report, (What was the date of the summary report?) the order summary report did not indicate an order for self-administration for medication.

During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/29/2024,

the P&P indicated state and federal laws guarantee certain basic rights to all residents of the facility which include, but are not limited to, self-administer medication, if the IDT determines it is safe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0554 During a review of the facility's P&P titled, Medication - Self Administration, last reviewed 1/29/2024, the P&P indicated during the admission process, residents will be asked if they wish to self-administer medications. Level of Harm - Minimal harm or The P&P indicated residents who wish to self-administer medications will be assessed during the admission potential for actual harm process to ensure they have the necessary knowledge and skills to safely self-administer medications. The P&P indicated if the resident is assessed as clinically appropriate for medication self-administration by the Residents Affected - Few IDT, the licensed vocational nurse obtains a physician's order for self-administration of selected medications.

The P&P indicated the resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate. The P&P further indicated the IDT develops and implements a care plan for medication self-administration and will identify where medications are stored, education for resident or family regarding medication self-administration process, specific medication information and safe, effective use of medications, obtaining medication, administering medications according to physician's order, how the licensed nurse will validate that medications are taken as ordered by the attending physician, and how non-compliance and/or refusal to take medications will be managed.

During a review of the facility's P&P titled, Medication Labels, last reviewed 1/29/2024, the P&P indicated when medication is ordered for use at the bedside, the medication label contains, in addition to the instruction for use, a notation that it may be self-administered and stored at the bedside.

44376

2. During a review of Resident 227's Admission Record, the admission record indicated the facility admitted Resident 227 on 12/26/2023, with diagnoses that included glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia (difficulty swallowing).

During a review of Resident 227's Care Plan titled, Family Education related to resident's safe feeding/eating precautions, initiated on 5/16/2024, indicated to instruct visitors that either feeding or resident eating with visitor should be under close supervision of staff.

During a review of Resident 227's H&P, dated 5/22/2024, indicated Resident 227 had the capacity to understand and make decisions.

During a review of Resident 227's MDS, dated [DATE REDACTED], indicated Resident 227 had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had intact cognition (gaining of knowledge and understanding).

During a review of Resident 227's IDT, dated 6/26/2024, the IDT indicated Resident 227 was alert and oriented times 3 (alert and oriented to person, place, and time). Knows his vitamins and supplements and wanted to keep his medications at the bedside.

During an observation on 8/6/2024, at 8:45 a.m., inside Resident 227's room, Resident 227 was observed taking one tablet from a medication bottle labeled Areds 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0554 During a review of Resident 227's Order Summary Report, (Date?) the report did not indicate a physician's order for Areds 2 (supplement for age-related macular degeneration [an eye disease that can blur the central Level of Harm - Minimal harm or vision]). potential for actual harm

During a concurrent interview and record review on 8/6/2024, at 8:47 a.m., with LVN 3, a review of Resident Residents Affected - Few 227's Order Summary Report and Medication Administration Record (MAR) was done. LVN 3 stated there was no order for the resident to self-administer medications and there was no okay to keep medications at

the bedside on the Order Summary Report. LVN 3 also stated there was no order for the medication Areds 2 and she does not know how the bottle of Areds 2 was left at the resident's bedside. LVN 3 stated it must be

the family member that gave the medication, Areds 2, to the resident.

During a concurrent interview and record review on 8/6/2024, at 9:05 a.m., with the Minimum Data Set Coordinator (MDSC), a review of Resident 227's Order Summary Report, Assessment for Self-Administration of Medication, and IDTs was done. The MDSC stated there was no order for Areds 2 or an okay to self-administer medications on the Order Summary Report. The MDSC also stated there was no Medication Self-Administration Assessment done on admission for Resident 227. The MDSC confirmed there was a desire from Resident 227 to keep supplements and vitamins at the bedside of the resident during an IDT done on 6/26/2024, but they failed to assess the resident for self-administration of medications. The MDSC stated it was important to assess the resident for their ability to self-administer their medications to honor the resident's rights. The MDSC stated after assessing the resident for their ability to self-administer medication

they should get an order from the physician for the resident to self-administer medication to ensure safe use.

During an interview on 8/9/2024, at 4:52 p.m., with the DON, the DON stated an assessment for medication self-administration should be done on admission. The DON stated they should honor the resident's right to self-administer medications. The DON stated the resident was a researcher and was alert and oriented and was very much capable of taking his own medications. The DON stated the failure of the staff to perform an assessment for medication self-administration to the resident deprived the resident of his right to self-determination and the failure of the staff to ensure there was an order for the medication Areds 2 had predisposed the resident to taking unnecessary medications and to adverse effects of the medication that can cause harm to the resident.

During a review of the facility's most recent policy and procedure titled, Resident Rights, last reviewed on 1/29/2024, indicated to self-administer medication, if the Interdisciplinary Team determines it is safe.

During a review of the facility's recent policy and procedure titled, Medication- Self Administration, last reviewed on 1/29/2024, the policy indicated Residents who request to perform medication self-administration will be assessed for capacity. During the admission process, residents will be asked if they wish to self-administer medications. Those residents who wish to self-administer medications will be assessed

during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications.

A. Additional assessments will be completed at least quarterly based on OBRA timeframes.

If the resident is assessed as clinically appropriate for medication self-administration, by the IDT, the Licensed Nurse obtains a physician's order for self-administration of selected medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0554 A. The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate. Level of Harm - Minimal harm or potential for actual harm The IDT develops and implements a care plan for medication self-administration. The care plan will identify:

Residents Affected - Few i. Where the medications are stored.

ii. Education for resident/family regarding medication self-administration process; specific medication information and safe, effective use of medications.

a. Obtaining medication.

b. Administering medication according to physician order.

iii. How Licensed Nurses will validate that medications are taken as ordered by the attending physician; and

iv. How non-compliance and/or refusal to take medications will be managed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0558 Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43418 potential for actual harm Based on observation, interview, and record review, the facility failed to provide reasonable accommodation Residents Affected - Few of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two of two sampled residents (Resident 159 and 14) reviewed under the Environment task.

This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Findings:

1. During a review of Resident 159's admission record, the admission record indicated the facility originally admitted Resident 159 on 10/14/2021 and readmitted the resident on 12/15/2021 with diagnoses that included generalized muscle weakness and a history of falling.

During a review of Resident 159's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/12/2024, the MDS indicated Resident 159 had mild cognitive impairment (difficulty understanding and making decisions) and was independent or required setup assistance to moderate assistance with activities of daily living, such as eating, hygiene, bathing, toileting, dressing, walking, and surface-to-surface transfers.

During a review of Resident 159's Care Plan, last reviewed 7/16/2024, the care plan indicated Resident 159 was at risk for fall secondary to impaired vision and unsteady balance during transitions and walking, has impairment of upper and lower extremities on both sides. The care plan further indicated interventions included keeping the call light within easy reach and answer promptly.

During a review of Resident 159's History & Physical (H&P), dated 7/20/2024, the H&P indicated Resident 159 had fluctuating capacity to understand and make decisions.

During a concurrent observation and interview with Resident 159, on 8/5/2024, at 9:22 a.m., inside Resident 159's room, Resident 159 was lying down in bed with the head of his bed elevated greater than 40 degrees, and the call light was on the floor, to the left of the resident's bed. Resident 159 stated he was unable to reach for his call light. Resident 159 attempted to get his call light from the floor but was unsuccessful.

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 8/5/2024, at 9:25 a.m., inside Resident 159's room, CNA 1 confirmed Resident 159's call light was on the floor and outside of

the resident's reach. CNA 1 stated she was assigned to Resident 159 and stated Resident 159 has difficulty grabbing items, needs assistance with using the bathroom, and is able to use the call light. CNA 1 stated when call lights are outside of a resident's reach, the resident has the potential to get out of bed on their own when they are not supposed to. CNA 1 further stated when residents are not able to reach the call light and call for help, the residents can potentially injure themselves from falling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0558 During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated call lights should be within easy reach of residents, regardless of whether the resident is in bed, wheelchair, or chair so Level of Harm - Minimal harm or that the facility can attend to the resident's needs. The DON further stated if the call light is not within reach, potential for actual harm the resident's needs will not be met.

Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Communication, last reviewed on 1/29/2024, the P&P indicated to place the call light or call device close to the person.

During a review of the facility's P&P titled, Call Light, last reviewed on 1/29/2024, the P&P indicated all residents shall have immediate access to a functioning call light at all times, ensuring they can easily signal for assistance whenever needed. The P&P further indicated the call light must be within the resident's reach at all times, including when in bed, in a chair, or in the bathroom.

44244

2. During a review of Resident 14's Admission Record, the admission record indicated the facility admitted Resident 14 on 6/11/2021 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), age-related osteoporosis (a disease that causes bones to become weak and brittle), and sarcopenia (loss of muscle mass and strength that can affect older adults).

During a review of Resident 14's Care Plan titled, Minimal Difficulty Hearing: At Risk for Communication Deficit, initiated 5/19/2023, it indicated to keep the call light within easy reach and answer promptly.

During a review of Resident 14's Care Plan titled, Short- and Long-Term Memory/Moderately Impaired Decision Making ., initiated on 5/19/2023, the CP indicated to encourage the resident to use the call light for assistance and to keep the call light within easy reach and answer promptly.

During a review of Resident 14's H&P, dated 6/28/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.

During a review of Resident 14's MDS, dated [DATE REDACTED], the MDS indicated Resident 14 sometimes was able to understand others and sometimes was able to make herself understood. The MDS indicated Resident 14 was dependent on staff for oral hygiene, toileting, bathing, and personal hygiene; and the resident required substantial/maximal assistance with mobility.

During an observation on 8/9/2024 at 12:25 p.m., Resident 14 was observed sitting in a wheelchair (WC) between the resident's right side of the bed and the wall near the entrance door. The call light was resting on top of the resident's bed, not within reach of the resident. Resident 14 did not respond to the surveyor's questions and no staff were present in the room.

During an observation and interview on 8/9/2024 at 12:43 p.m., CNA 2 entered Resident 14's room and stated the resident was in the WC and the call light was on the resident's bed. CNA 2 stated Resident 14 was a total assist resident, and the call light was not within reach. CNA 2 stated the call light did not need to be within reach of the resident. CNA 2 exited the room. The call light remained on the bed out of reach of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0558 During an observation and interview on 8/9/2024 at 12:45 p.m., Licensed Vocational Nurse 4 (LVN 4) entered Resident 14's room and stated all facility resident's need the call light within reach. LVN 4 stated all Level of Harm - Minimal harm or facility residents need to be able to call for help even if the resident is not always able to use the call light. potential for actual harm LVN 4 exited the room and the call light remained on the bed out of reach of the resident.

Residents Affected - Few During an interview on 8/9/2024 at 1:52 p.m., the DON stated all residents need to have the call light within reach and it does not matter if the resident can use it. The DON stated it is not up to the CNA to decide if the resident is able to use the call light or not. The DON stated the importance of the call light is for staff to be able to attend to the resident's needs. The DON stated when the call light is not within reach, there is the possibility that residents would not have their needs met resulting in the resident becoming restless and attempting to get up resulting in a fall.

During a review of the facility's policy and procedure titled, Call Light last reviewed on 1/29/2024, the policy indicated all residents shall have immediate access to a functioning call light at all times, ensuring they can easily signal for assistance whenever needed. The call light must be within the resident's reach at all times, including when in bed, in a chair, or in the bathroom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Minimal harm or potential for actual harm 36943

Residents Affected - Some Based on observation, interview, and record review, the facility failed to report and monitor changes of condition ([COC] major decline or improvement in a resident's status that will not resolve itself without intervention) for two of four sampled residents (Resident 119 and Resident 139) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns by failing to:

1. Report Resident 119's decline in ROM to both arms and legs during Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) sessions in accordance with the facility's job description titled, Restorative Nursing Assistant, revised 10/2011, and policy tilted, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024.

2. Monitor Resident 139's decline in cognition and weakness indicated on the Registered Nurse (RN)/Licensed Vocational Nurse (LVN) Progress Notes, dated 7/24/2024, for 72 hours in accordance with

the facility's policy titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024.

3. Report to Resident 139's physician and responsible party or family and monitor Resident 139's decline in ROM to both arms and legs from minimum ROM limitation (less than 25 percent [%] ROM loss) on the Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/5/2024 and 6/3/2024, to moderate ROM limitation (25-50% ROM loss) on the JMA, dated 8/6/2024, for 72 hours in accordance with the facility's policy titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024.

These failures prevented Resident 119 and 139 from receiving intervention to improve mobility and ROM, including intervention to prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness).

Cross reference

F-F756

Findings:

During a review of Resident 79's Admission Record (a document containing demographic and diagnostic information,) dated 8/7/2024, the Admission Record indicated Resident 79 was originally admitted to the facility on [DATE REDACTED] with a diagnosis including depression (a health condition that causes constant feeling of sadness and loss of interest in activities that one would normally enjoy, and often associated with insomnia [inability to sleep]).

During a review of Resident 79's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 5/29/2024, indicated Resident 79 did not have symptoms of little interest or pleasure in doing things, fell ing down, depressed, or hopeless. The MDS indicated Resident 79 was not marked for having trouble falling or staying asleep. Resident 79's MDS indicated Resident 79 received antidepressant medication on a routine basis.

During a review of Resident 79's Order Summary Report, dated 8/8/2024, the report indicated Resident 79 was prescribed Trazadone (a psychotropic [any medication capable of affecting the mind, emotions, and behavior] medication used for depression and insomnia) 75 milligram ([mg] - a unit of measure of mass) tablet to give by mouth at bedtime for depression manifested by constant health complaints and insomnia, starting 6/18/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0758 During a review of the Medication Regimen Review (MRR) note by the Consultant Pharmacist (CP) for Resident 79 on 8/7/2024, titled Note to Attending Physician/Prescriber and dated 7/4/2024, the note stated Level of Harm - Minimal harm or This resident continues on Trazadone 75 mg qhs (at bedtime) from 6/18/2023. The Federal nursing potential for actual harm regulations require that a gradual dose reduction ([GDR] - lowering dose, frequency or discontinuing medication]) be attempted in two separate quarters (with at least one month between attempts) within the Residents Affected - Few first year in which a resident receives psychopharmacological medication. Please assess if clinically appropriate at this time to consider a GDR. If dose to continue, please include documentation describing a dose reduction as clinically not indicated in your progress notes or on this form. Thank you. The document did not contain a response from a physician and was not signed or dated by a physician.

During a review of Resident 79's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) for July 2024, the MAR indicated Resident 79 had no episodes of insomnia documented between 7/1/2024 and 7/31/2024.

During a review of Resident 79's Psychiatry Progress Note, dated 7/29/2024, the note indicated that staff reports resident having infrequent behaviors but are stable on current dose of Trazadone. The note indicated to continue Trazadone 75 mg qhs, its clinically contraindicated (not recommended) to lower or discontinue medication at this time.

During an interview and concurrent record review of Resident 79's clinical record, MDS, MRR, MAR, Psychiatric notes on 8/7/2024 at 3:10 PM, with Director of Nursing (DON,) the DON stated that Resident 79 did not have documented behaviors of insomnia for July 2024. The DON stated based on Resident 79 not exhibiting behaviors of insomnia for July 2024, there should have been an attempt for a GDR and/or documentation in the psychiatry note, dated 7/29/24, indicating a clinical rationale for continuing the Trazadone at the originally prescribed dose or what clinical contraindications presented for not considering a GDR at that time. The DON stated the DON was unable to find a clinical rationale to continue the Trazodone 75 mg qhs. The DON stated it was important to properly assess the absence of behaviors and consider GDR to ensure Resident 79 was receiving treatment that was optimal for Resident 79's condition and to maintain their highest level of well-being. The DON stated as a result, Resident 79 was placed at risk of continuing unnecessary psychotropic medications that could result in adverse consequences and side effects, negatively impacting the resident's well-being. The DON stated the facility and physician failed to document

a clinical rationale for continuing the Trazadone as originally prescribed for depression manifested by insomnia on 6/18/2023, for Resident 79.

During a review of the facility's Policy and Procedures (P&P,) titled Behavioral - Management, dated 11/1/2017, the P&P indicated: To ensure that Facility Staff performs an appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications.

E. Ensuring pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated.

During a review of the facility's P&P titled Psychotherapeutic Drug Management, dated 5/17/2024, the P&P indicated the following:

Purpose

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0758 II. To help promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, Level of Harm - Minimal harm or potential for actual harm III. To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s). Residents Affected - Few V. To ensure clinically significant adverse consequences are minimized.

Policy

II. The Facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits.

III. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation.

Procedure

I. K. The Attending Physician/LHP will respond to any irregularities reported by the pharmacist .by reviewing

the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it.

A. If no action has been taken, the Attending Physician/LHP must document his/her rationale.

IX. A. Goals of GDR are to achieve the lowest effective dose; to discontinue the mediations that are no longer benefit the resident; and to minimize exposure to increased risk of adverse consequences.

B. GDR is indicated when the resident's clinical condition has improved or stabilized or the underlying causes of symptoms have resolved

X. A. During the first year of receiving an antipsychotic or other psychopharmacological medication, at least one attempt at GDR or dose tapering is attempted.

B. A second attempt, in a subsequent quarter the same year (12-month period) unless the first attempt demonstrated that GDR or tapering was clinically contraindicated.

C. After the first year, GDR or tapering should be attempted once a year.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988 potential for actual harm Based on interview and record review, the facility failed to ensure residents were free of any significant Residents Affected - Some medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two (2) out of 2 sampled residents (Residents 43, and 211) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.

These deficient practices had the potential to result in adverse effects (unwanted, unintended result) and complications of same site subcutaneous administration such as insulin induced lipodystrophy (This complication occurs because of repeated injections at the same site. An abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Cross Reference

F-F758

Findings:

During a review of Resident 79's Admission Record (a document containing demographic and diagnostic information,) dated 8/7/2024, the Admission Record indicated Resident 79 was originally admitted to the facility on [DATE REDACTED], with a diagnosis including depression (a health condition that causes constant feeling of sadness and loss of interest in activities that one would normally enjoy, and often associated with insomnia [inability to sleep]).

During a review of Resident 79's Order Summary Report, dated 8/8/2024, the report indicated Resident 79 was prescribed Trazadone (a psychotropic [any medication capable of affecting the mind, emotions, and behavior] medication used for depression and insomnia) 75 milligram ([mg] - a unit of measure of mass) tablet by mouth at bedtime for depression manifested by constant health complaints and insomnia, starting 6/18/2023.

During a review of Resident 79's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) for July 2024, the MAR indicated Resident 79 had no episodes of insomnia documented between 7/1/2024 and 7/31/2024.

During a review of the MRR note by the CP for Resident 79 on 8/7/2024, titled Note to Attending Physician/Prescriber and dated 7/4/2024, the note stated This resident continues on Trazadone 75mg qhs (at bedtime) from 6/18/2023. The Federal nursing regulations require that a gradual dose reduction (GDR) be attempted in two separate quarters (with at least one month between attempts) within the first year in which a resident receives psychopharmacological medication. Please assess if clinically appropriate at this time to consider a GDR. If dose to continue, please include documentation describing a dose reduction as clinically not indicated in your progress notes or on this form. Thank you. The document did not contain a response from a physician and was not signed or dated by a physician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0756 During an interview on 8/7/2024 at 3:10 PM, with the DON, the DON stated per facility policy the MRR irregularity notes by the CP needed to be reviewed and documented within 30 days of the written report. The Level of Harm - Minimal harm or DON stated it was important to review the irregularities timely to ensure residents were receiving treatment potential for actual harm that was optimal for their condition and to maintain their highest level of well-being. The DON stated the facility and physician failed to timely review and address the CP MRR note written on 7/4/2024 for the Residents Affected - Few Trazadone 75 mg qhs identified irregularity and failed to document a clinical rationale for continuing the Trazadone as originally prescribed for depression manifested by insomnia on 6/18/2023, for Resident 79.

A Review of the facility policy and procedure (P&P) titled Drug Regimen Review, dated 11/1/2017, the policy indicated that The intent is that the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON).

The policy further indicates the pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications.

The pharmacist will report any irregularities to the attending physician and the facility's medical director and DON, and these reports must be acted upon.

Procedure

II. The pharmacist performing the DRR will review the resident's medical record to appropriately monitor the medication regimen and verify the medication each resident is taking is clinically indicated.

III. B. The consulting Pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the Facility's Medical Director, DON, and the Attending Physician.

i. Irregularities must be addressed in a separate, written report. The report will include the resident's name,

the relevant drug, and the irregularity the pharmacist identified.

IV. The Attending physician will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it.

A. If not action has been taken, the attending physician must document his/her rationale.

B. Documentation by the Attending Physician must occur within 30 days of issuance of the pharmacist's report, unless the irregularity is an emergent issue requiring immediate action.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 Residents Affected - Few Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 79) drug regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to

provide a detailed clinical rationale for continuing Trazadone (a psychotropic medication used for depression [also referred to as antidepressant] and insomnia [inability to sleep]) as originally prescribed on 6/18/2023 for Resident 79.

These deficient practices had the potential to place Resident 79 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medications, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.

Cross refernec to

F-F760

a. During a review of Resident 43's Admission Record, the admission record indicated Resident 43 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included congestive heart failure (CHF - a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and aphasia (a language disorder that makes it hard for a person to read, write, and say what you mean to say).

During a review of Resident 43's History and Physical (H&P) dated 6/14/2024, the H & P indicated Resident 43 did not have the capacity to understand and make decisions.

During a review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/1/2024 indicated Resident 43 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, partial to moderate assistance with walking, was dependent with toileting, bathing, and lower body dressing and required substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 43 received insulin.

During a review of Resident 43's Order Summary Report indicated the following physician's order dated 6/13/2024:

Administer Insulin lispro-aabc injection solution 100 unit per milliliter (unit/ml - a unit of measurement). Inject as per sliding scale: if 150-200 unit; 201-250 = 4 unit; 251-300 = 6 unit; 301-350 = 8 unit; 351-400 = 10 unit, SQ before meals related to DM 2. Call physician if fingerstick blood sugar is above 400 or below 70.

During a review of Resident 43's Medication Administration Record (MAR) from 6/2024 to 7/2024, the MAR indicated insulin lispro injection solution was administered as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0658 06/23/24 11:30 subcutaneously Right Upper Arm (RUA)

Level of Harm - Minimal harm or 06/23/24 17:00 subcutaneously - RUA potential for actual harm 06/25/24 11:30 subcutaneously Left Upper Arm (LUA) Residents Affected - Some 06/25/24 17:00 subcutaneously - LUA

06/27/24 17:00 subcutaneously - Left Deltoid (LD)

06/28/24 07:00 subcutaneously - LD

06/30/24 07:00 subcutaneously - RUA

06/30/24 11:30 subcutaneously - RUA

07/02/24 11:30 subcutaneously - RUA

07/02/24 17:00 subcutaneously - RUA

07/03/24 11:30 subcutaneously - LUA

07/03/24 17:00 subcutaneously - LUA

07/10/24 11:30 subcutaneously - LUA

07/10/24 17:00 subcutaneously - LUA

07/13/24 11:30 subcutaneously - RUA

07/13/24 17:00 subcutaneously - RUA

07/19/24 17:00 subcutaneously - RUA

07/20/24 17:00 subcutaneously - RUA

07/20/24 11:30 subcutaneously - LUA

07/20/24 17:00 subcutaneously - LUA

07/23/24 11:30 subcutaneously - RUA

07/23/24 17:00 subcutaneously - RUA

07/24/24 17:00 subcutaneously - RUA

07/28/24 11:30 subcutaneously - LUA

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0658 07/28/24 17:00 subcutaneously - LUA

Level of Harm - Minimal harm or 07/29/24 07:00 subcutaneously - Right & Above Umbilicus potential for actual harm 07/29/24 11:30 subcutaneously - Right & Above Umbilicus Residents Affected - Some 07/30/24 11:30 subcutaneously - Right & Below Level of Umbilicus

07/30/24 17:00 subcutaneously - Right & Below Level of Umbilicus

During a concurrent interview and record review on 8/8/24 at 12:04 p.m., Resident 43's MAR for 6/2024 and 7/2024 was reviewed with Registered Nurse 1 (RN 1). RN 1 verified the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the insulin administration sites should have been rotated as the residents could develop irritation on the site, possibly abscess, and lipodystrophy. RN 1 stated it was a standard of practice and considers not rotating insulin administration site as a medication error.

During a review of the undated, insulin lispro manufacturer's guideline provided by the facility, the manufacturers guidelines indicated to change (rotate) injection sites within the area you choose for each dose to reduce the risk of getting lipodystrophy and localized cutaneous amyloidosis at the injection sites.

44376

b. During a review of Resident 211's Admission Record, the admission record indicated the facility admitted Resident 211 on 8/22/2022, with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).

During a review of Resident 211's History and Physical (H&P), dated 8/11/2023, indicated Resident 211 did not have the capacity to understand and make decisions.

During a review of Resident 211's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/8/2024, indicated Resident 211 had rarely or never had the ability to make self-understood and sometimes understand others. The MDS indicated the resident had highly impaired vision and was on a high-risk drug class hypoglycemic (occurs when the level of glucose in the blood drops below normal) medication insulin.

During a review of Resident 211's Order Summary Report, indicated an order for the following:

-7/17/2024 Novolin N FlexPen Subcutaneous Suspension Pen-injector 100 unit (the amount of insulin required to reduce the blood glucose)/milliliters (ml, a unit of volume) (Insulin NPH Human [Isophane]). Inject 4 unit subcutaneously in the morning related to type 2 diabetes mellitus with diabetic chronic kidney disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0658 -6/14/2024 Novolog Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (varies the dose of insulin based on blood glucose level): if 150-200=2 unit; 201-250=4 unit; 251-300=6unit; 301-350=8 unit; Level of Harm - Minimal harm or 351-400=10 unit, subcutaneously before meals related to type 2 diabetes mellitus with diabetic chronic potential for actual harm kidney disease. Call MD if fingerstick (a procedure in which a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing) blood sugar (BS) is above 400 or below. Residents Affected - Some

During a review of Medication Administration Record of insulin for 6/2024 to 7/2024 indicated Novolog insulin was administered on:

6/22/2024 at 7 am on (20) the left and above the level of umbilicus (navel).

6/22/204 at 11:30 am on (20) the left and above the level of umbilicus.

7/7/2024 at 7 am on (21) right and below level of umbilicus.

7/7/2024 at 11:30 am on (21) right and below level of umbilicus.

7/10/2024 at 7 am on (22) left and below level of umbilicus.

7/10/2024 at 11:30 am on (22) left and below level of umbilicus.

7/19/2024 at 11:30 am on (19) to right and above umbilicus.

7/20/2024 at 7 am on (19) to right and above umbilicus.

7/22/2024 at 11:30 am on (21) right and below level of umbilicus.

7/22/2024 at 5 pm on (21) right and below level of umbilicus.

7/24/2024 at 5 pm on (12) left upper arm.

7/25/2024 at 7 am on (12) left upper arm.

7/29/2024 at 7 am on (21) right and below level of umbilicus.

7/29/2024 at 11:30 am (21) right and below level of umbilicus.

During a concurrent interview and record review on 8/8/2024, at 12:04 p.m., with Registered Nurse 1 (RN 1), Resident 211's Order Summary Report and the Medication Administration Record for 6/2024 to 7/2024 was reviewed. RN 1 stated there was an order for Novolin insulin for the resident and on the MAR from 6/2024 to 7/2024 there were multiple instances where the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the failure of the licensed nurse to rotate insulin administration sites could cause skin irritations such as abscess, necrosis, and lipodystrophy.

During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated it was common knowledge for licensed nurses to rotate insulin administration sites to prevent tenderness, discomfort, and lipodystrophy to the sites that was frequently administered with insulin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0658 During a review of the facility's undated, Novolog Manufacturer's Recommendation for Novolog (insulin aspart) injection 100 U/ml is an insulin analog indicated to improve glycemic control in adults and pediatric Level of Harm - Minimal harm or patients with diabetes mellitus, indicated repeated insulin injections into areas of lipodystrophy or localized potential for actual harm cutaneous amyloidosis have been reported to result in hyperglycemia; and a sudden change in the injection site (to an unaffected area) has been reported to result in hypoglycemia. Advise patients who have Residents Affected - Some repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure residents received care Residents Affected - Some consistent with professional standards of practice to prevent pressure injuries (PI, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to:

1. Set the Low Air Loss Mattress (LALM or LAL mattress, designed to prevent and treat PIs) in accordance with the resident's weight and manufacturer's instructions for two of three sampled residents (Resident 23, 230) reviewed under the Pressure Ulcer/Injury care area.

2. Reposition a resident on a wheelchair every hour per facility policy for one of three sampled residents (Resident 139) reviewed under the Pressure Ulcer/Injury care area.

These deficient practices had the potential for the reoccurrence or development of new PIs.

Findings:

a. During a review of Resident 23's Admission Record, it indicated the facility admitted the resident on 6/21/2022 with diagnoses that included Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements), Alzheimer disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]), and dementia, and muscle weakness.

During a review of Resident 23's Care Plan titled, Pressure Injury, Stage Two (the skin breaks open, wears away, or forms a wound which is usually tender and painful) Left Buttock and Right Buttock, initiated on 8/3/2023 and resolved on 9/22/2023, the CP indicated the resident had a history of pressure injuries and was placed on a LALM.

During a review of Resident 23's Care Plan titled, Functional Abilities of Everyday Activities Dependent in . bed mobility . At Risk for Skin Breakdown ., initiated on 12/8/2023, the CP indicated to apply a LALM for skin integrity as ordered.

During a review of Resident 23's history and physical dated 6/1/2024, it indicated the resident did not have

the capacity to understand and make decisions.

During a review of Resident 23's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/18/2024, it indicated the resident was unable to complete the brief interview for mental status (BIMS, a brief cognitive screening measure that focuses on orientation and short-term word recall). The MDS indicated the resident was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and mobility.

During a review of Resident 23's Weight Flow Sheet, the flow sheet indicated on 7/29/2024 that the resident weighed 141 pounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0686 During an observation on 8/5/2024 at 9:40 a.m., Resident 23 lay in bed on top of a LALM, no staff were present in the room. The LALM pump was turned on and had the dial set to indicate a weight of 250 pounds Level of Harm - Minimal harm or (lbs). potential for actual harm

During a concurrent observation and interview on 8/5/2024 at 9:45 a.m. Certified Nursing Assistant 10 (CNA Residents Affected - Some 10) stated Resident 23 was on a LALM for preventative reasons because the resident has back pain and prefers to stay lying down. CNA 10 stated the charge nurse sets the LALM and she does not touch the settings. CNA 10 entered Resident 23's room and assessed the LALM settings and stated it was set to a resident weight of 250 lbs.

During a concurrent observation, interview, and record review on 8/5/2024 at 9:50 a.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Resident 23's weights and physician's orders. LVN 2 stated LALM are set according to the resident's weight. LVN 2 stated Resident 23 had an order for a LALM and the resident's weight is 141 lbs. LVN 2 entered Resident 23's room and stated the mattress was set to 250 lbs and it was not the correct weight. LVN 2 adjusted the LALM setting to 180 lbs and stated the setting was the closest to

the resident's weight. RN 2 stated when the LALM is set to a higher weight it makes the mattress harder. RN 2 stated the purpose of the LALM was to provide a softer surface to prevent PIs.

During an interview on 8/7/2024 at 12:53 p.m., Treatment Nurse 1 (TN 1) stated Resident 23's family wanted her to be on a LALM and they were trying to be nice by providing the LALM. TN 1 stated Resident 23 had a physician's order and a care plan for the LALM and if it was provided then it should be set to the correct setting. TN 1 stated it was not okay that the LALM was set to 250 lbs, but things happen. TN 1 stated it was more important to set the LALM so it doesn't have too little air because the resident would then be touching

the bed frame. TN 1 stated she does not look at the LALM manufacture guidelines to set the LALM pumps. TN 1 stated she doesn't work for the manufacture and has never called them. TN 1 stated she knows how to set the LALM settings based on her [AGE] years of experience in the facility. TN 1 stated she did not think there was any harm in setting the LALM setting weight too high.

During an interview on 8/7/2024 at 1:50 p.m., LVN 2 stated if the LALM weight is set too high then the mattress will be harder resulting in the loss of the purpose of the mattress to prevent PIs. LVN 2 stated it was everyone's responsibility to monitor the LALM settings.

During an interview on 8/8/2024 at 9:17 a.m., the Director of Nursing (DON) stated the facility policy includes providing a LALM for PI prevention. The DON stated the LALM should be set to the resident's weight. The DON stated if the LALM mattress was set to a higher weight it would be firmer. The DON stated the LALM is

a piece of equipment, and all equipment comes with manufacture instructions that are available to staff for reference. The DON stated when the LALM is set to too high of a weight and staff are not following the manufacture guidelines, it could potentially harm the resident by causing skin breakdown.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0686 During a review of the facility policy and procedure titled, Support Surface Guidelines, last reviewed on 1/29/2024, the policy indicated pressure reducing support surfaces is a surface designed to prevent or Level of Harm - Minimal harm or promote the healing of pressure ulcers by distributing pressure over a larger surface area of the body in an potential for actual harm effort to reduce or eliminate tissue pressure in a more circumscribed location. The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure Residents Affected - Some ulcer development. LALM are giant air-permeable pillows that are continuously inflated with air, the air flow has a drying effect on tissue. An individual at risk for developing pressure ulcers will be placed on pressure reducing devices as recommended.

During a review of the facility provided LALM 2 Instruction Manual indicated to always read the operating instructions before use. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out, then the pressure in the mattress will slowly increase to the intended value after the air mattress is ready to use. Users can adjust the pressure of air mattress to a desired softness by adjusting the comfort keys. Please consult physician for a suitable setting.

43988

b. During a review of Resident 230's Admission Record, the admission record indicated the facility admitted

the resident on 3/29/2024 with diagnoses that included PU of the sacral region (located below the lumbar spine and above the tailbone) Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle), protein-calorie malnutrition (a range of condition arising from lack of dietary protein and/or energy (calories), and cachexia (a wasting disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat).

During a review of Resident 230's History and Physical (H&P) dated 3/29/2024, the H & P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 230's Order Summary Report dated 3/29/2024, indicated Resident 230 was ordered a pressure redistribution mattress - low air loss mattress for skin integrity every shift.

During a review of Resident 230's care plan initiated on 3/29/2024, the CP indicated Resident 230 had pressure injury Stage 4 to the coccyx area (also known as tailbone, a small bone at the bottom of the spine), with interventions including, but not limited to, place LALM on bed as ordered and use a pressure reducing pad when up in wheelchair.

During a review of Resident 230's Braden Scale - For Predicting Pressure Sore Risk dated 5/28/2024 and 6/26/2024, indicated resident was a high risk with a score of 1

A review of Resident 230's MDS, dated [DATE REDACTED] indicated Resident 230 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance from staff with eating, was dependent with toileting, required partial to moderate assistance with oral hygiene, upper body dressing, sit to lying, lying to sit, and required substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

The MDS indicated Resident 230 had one Stage 4 PU and used pressure reducing devices on the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0686 During a concurrent observation and interview on 8/5/2024 at 12:46 p.m., while inside Resident 230's room, Treatment Nurse 3 (TN 3) verified Resident 230 was lying on a LALM in supine position with the device's Level of Harm - Minimal harm or setting at 120 pounds (lbs. - a unit of measurement). TN 3 stated the LALM setting should be according to potential for actual harm the resident's weight. TN 3 stated Resident 230's current weight was 80 lbs. TN 3 stated the setting should be at 80 lbs. Residents Affected - Some

During an interview on 8/8/2024 at 2:30 p.m. while inside Resident 230's room, Resident 230 stated she felt

a little uncomfortable at the buttock area when the LALM setting was at a little higher setting. Resident 230 stated the bed feels more comfortable and did not hurt the buttock area anymore.

During a concurrent interview and record review on 8/9/2024 at 11:13 a.m., Resident 230's medical records including the physician's orders, care plan, MDS, and weights flow sheet was reviewed with the Resident Assessment Coordinator (RAC). The RAC verified Resident 230's last weight dated 7/8/2024 was at 79 lbs., and a physician's order for LALM every shift for skin integrity. The RAC stated Resident 230's LALM should be set according to weight and the closest weight setting was at 80 lbs. The RAC stated the firmer setting for

the LALM placed the resident at risk for worsening of the PU.

During an interview on 8/9/2024 at 5:23 p.m., the DON stated LALM setting should be set according to weight. The DON stated it can affect and possibly delay wound healing.

During a review of undated, manual provided by the facility for LALM 1 owner's manual, indicated:

Once the pump starts press the plus (+) and minus (-) buttons to input the patient's weight (80-35o lbs.) and

the machine will automatically adjust the pressure to the ideal level of resistances for the person's weight.

The (+) and (-) increases or decreases the patient weight setting for the mattress in lbs. adjust this setting to fine tune the desired mattress firmness, lower weight for a softer setting and higher weight for a firmer setting.

The mattress is rated for a minimum weight of 80 lbs. and a maximum of 350 lbs. exceeding these limitations may result in damage to the product or personal injury.

During a review of the facility's policy and procedure titled, Support Surface Guidelines, last reviewed on 1/29/2024, indicated:

Provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown.

The facility will identify residents at risk for PU and provide care and services to promote the prevention of PU development.

44376

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0686 c. During a review of Resident 139's Admission Record indicated the facility admitted the resident on 4/28/2021, with diagnoses that included pressure-induced deep tissue damage (condition that affects the Level of Harm - Minimal harm or underlying layers of skin, muscle, and other soft tissues) of the left heel, muscle wasting and atrophy (a potential for actual harm wasting away or progressive decline, typically of a body part, organ, or tissue), and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs). Residents Affected - Some

During a review of Resident 139's History and Physical (H&P), dated 4/1/2024, the H & P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 139's MDS, dated [DATE REDACTED], indicated the resident usually makes self-understood and understands others. The MDS indicated the resident had upper and lower extremity impairment and was totally dependent in the area of mobility and activities of daily living (ADLs). The MDS indicated the resident was incontinent (unable to control excretions, to hold urine in the bladder, or to keep feces in the rectum.) of urine and bowel (feces) and was at risk for developing pressure injuries. The MDS also indicated the resident had an unstageable pressure injury and was on a turning/repositioning program.

During a review of Resident 139's Order Summary Report, dated 7/2/2024, indicated an order to cleanse with normal saline (NSS, a mixture of water and salt for washing the wound), the left medial malleolus (the bony protuberance on either side of the ankle) arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), pat dry, apply Santyl ointment (used to help the healing of burns and skin ulcers), cover with dry dressing (DD), and secure with tape. One time a day for one month.

During a review of Resident 139's Braden Scale- For predicting Pressure Sore Risk, dated 8/6/2024, indicated Resident 139 was a high risk for developing or worsening of pressure injuries.

During a concurrent observation and interview on 8/7/2024, at 12:47 p.m., while inside Resident 139's room, with Certified Nursing Assistant 7 (CNA 7), Resident 139 was sitting on a wheelchair. CNA 7 stated the resident was in the wheelchair for four hours now. CNA 7 stated they do not reposition the resident in the wheelchair. CNA 7 stated they use a Hoyer lift (a patient lift used by caregivers to safely transfer patients) to transfer the resident from chair to bed and vice versa.

During an observation on 8/7/2024, at 1:28 p.m., Resident 139 was still in the wheelchair beside the resident's bed.

During an interview on 8/8/2024, at 9 a.m., with Registered Nurse 1 (RN 1), RN 1 stated residents can only sit in a wheelchair for two hours to prevent skin breakdown.

During an interview on 8/8/2024, at 9:15 a.m., with the Performance Improvement Quality Improvement Nurse 1 (PIQI 1), PIQI 1 stated the resident can only be in a wheelchair for a maximum of two hours to prevent pressure injury. PIQI 1 stated if the resident needed to stay in a wheelchair for a longer period, they need to reposition the resident every two hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0686 During a concurrent interview and record review, on 8/8/2024, at 9:43 a.m., with the Administrator (ADM), the ADM stated they were repositioning residents in a wheelchair every two hours to prevent pressure injury. Level of Harm - Minimal harm or The Policy and procedure titled, Support Surface Guidelines, was reviewed with the ADM, the ADM potential for actual harm confirmed they were not following their policy and procedure as it indicated to reposition the resident in a chair every hour and to encourage the resident to change position on their own every 15 minutes. Residents Affected - Some

During a review of the facility's recent policy and procedure titled, Support Surface Guidelines, last reviewed

on 1/29/2024, the policy indicated the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing relieving devices for residents at risk of skin breakdown. Residents placed

in chairs should be repositioned every hour and encouraged to change position on their own every 15 min.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36943 Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) received treatment and services to prevent further decline in ROM, by failing to:

1. Accurately complete Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) for Residents 119, 139, 141, and 34 in accordance with the facility's policy titled, Joint Mobility Assessment, revised on 5/1/2018 and reviewed on 1/29/2024.

2. Assess both of Resident 119's elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for proper fit during the JMAs, dated 12/7/2022, 3/3/2023, 8/23/2023, 11/24/2023, and 8/4/2024, after Resident 119's discharge from Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) on 8/19/2022 and 10/6/2022.

3. Assess Resident 119's right knee splint during JMAs, dated 12/7/2022, 3/3/2023, 8/23/2023, 11/24/2023, and 8/4/2024 for proper fit, after Resident 119's discharge from Physical Therapy ([PT] profession aimed in

the restoration, maintenance, and promotion of optimal physical function) on 10/28/2022.

4. Identify and report Resident 119's significant decline in ROM to both arms and legs on the JMA, dated 8/4/2024.

5. Provide passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both of Resident 119's hands on 8/7/2024. The physician's order is to PROM to both arms every day.

6. Apply Resident 119's right elbow splint properly by applying the splint right-side up (not upside down) on 8/7/2024.

7. Identify and report Resident 119's right knee splint was not aligned with the right knee for at least two weeks, including on 8/7/2024 and 8/8/2024.

8. Identify and replace Resident 139's loose left hand compressive glove (worn after a burn or skin injury to provide consistent and even pressure to the healed skin to decrease the severity of scarring).

These failures resulted in Resident 119's undetected worsening contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both elbows and knees and

the development of contractures to both hips and hands. These failures resulted in inaccurate monitoring of ROM in both arms and legs for Resident 119, 34, 139, and 141. These failures had the potential for Resident 139 to experience a decline in ROM to the left hand.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of129 555579 Department of Health & Human Services Printed: 09/13/2025 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 08/09/2024

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 0688 Cross reference