Ararat Nursing Facility

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.

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.

The P&P indicated residents who wish to self-administer medications will be assessed during the admission 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 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.

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

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.

555579 08/09/2024

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

During a review of Resident 139's JMA, dated 3/5/2024 and 6/3/2024, the JMA indicated Resident 139 had minimum ROM limitations (less than 25% ROM loss) in both shoulders, elbows, wrists, hips, knees, and ankles and full ROM in both hands.

During a review of Resident 139's JMA for a significant change of condition, dated 8/6/2024, the JMA indicated Resident 139 had moderate ROM limitations (25-50% ROM loss) in both shoulders, elbow, wrists, hips, knees, and ankles, full ROM in the right hand, and stiffness in the left hand.

During an interview on 8/8/2024 at 11:25 a.m. with the RN 1, PIQI 1, and PIQI 2, Resident 139's JMA, dated 3/5/2024, 6/3/2024, and 8/6/2024, and RN/LVN Progress Notes were reviewed. PIQI 1 stated the pink-colored RN/LVN Progress Notes (in general) indicated any changes of condition (COCs) for the resident. RN 1 stated Resident 139's JMAs indicated Resident 139 had a decline in ROM on 8/6/2024 compared to the JMAs dated 3/5/2024 and 6/3/2024. RN 1 stated Resident 139's COC for ROM decline was not documented and monitored on the RN/LVN Progress Notes.

During a concurrent interview and record review on 8/9/2024 at 4:40 p.m. with the Director of Nursing (DON), the DON reviewed Resident 139's JMA, dated 3/5/2024, 6/3/2024, and 8/6/2024 and RN/LVN Progress Notes were reviewed.

The DON stated Resident 139 had a decline of ROM which should have been but was not documented and monitored for 72 hours after identification.

The DON stated the COC was not completed; therefore, Resident 139's physician and family were not notified.

During a review of the P&P titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024, the P&P indicated the licensed nurse will assess the resident's change of condition and document observations and symptoms.

The P&P indicated the physician will be notified timely and the resident's responsible party or family will be notified as soon as possible.

The P&P also indicated the licensed nurse will document the resident's change in condition each shift for at least 72 hours.

Cross reference F-F688 and F-F726.

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

1/29/2024, the P&P indicated the facility respects the resident's right to make an informed decision

and prolonged use of a device that may lead to inability to regain use of a normal bodily function.

incapacitated resident) to accept a treatment or procedure after receiving the following information: the nature of the proposed treatment; material information concerning the risks, and complications and expected benefits or effects of the treatment.

The informed consent will be documented and placed in the resident's medical record.

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

During an observation on 8/7/2024 at 9:59 a.m. in the bedroom with Restorative Nursing Assistant 3 (RNA 3), Resident 34 was seated in a wheelchair. RNA 3 pushed Resident 34's wheelchair to the hallway to perform exercises. RNA 3 verbally and visually cued Resident 34 to perform AROM on the right leg and performed AAROM on Resident 34's left leg. RNA 3 verbally and visually cued Resident 34 to perform AROM on the right arm and performed AAROM on the left arm.

During an observation on 8/7/2024 at 10:10 a.m. in the hallway, RNA 3 placed a cloth gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 34's waist while Resident 34 sat in the wheelchair. RNA 3 placed a hemi-walker on Resident 34's right side. Resident 34 required minimal assistance to stand from a seated position. RNA 3 was positioned on Resident 34's left side while Resident 34 walked using the right hand to maneuver the hemi-walker. Resident 34 walked more than 100 feet using the hemi-walker and RNA 3's assistance.

During a review of the MDS's Resident Assessment Instrument (RAI) Manual, published 10/2023, Page GG-7 of the RAI Manual indicated to avoid assessing ROM in isolation and to determine whether limited ROM had an impact on a resident's functional ability.

During a concurrent interview and record review on 8/9/2024 at 1:40 p.m. with the MDS Assistant (MDS 1), MDS 1 reviewed Resident 34's MDS, dated [DATE] and 6/23/2024, and the RAI Manual.

MDS 1 stated Resident 34's MDS assessments, dated 3/31/2024 and 6/23/2024, were inaccurate for functional ROM limitations. MDS 1 stated both MDS assessments should have indicated Resident 34 had functional ROM limitations in one arm and one leg.

During an interview on 8/9/2024 at 2:14 p.m. with MDS 1, MDS 1 stated the MDS assessments should be accurate to provide accurate information to the Federal database.

During a review of the facility's policy and procedure (P&P) titled, Resident Assessment, revised 3/1/2015 and reviewed 1/29/2024, the P&P indicated the resident assessments should be conducted regularly and comprehensively to monitor a resident's health status.

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 CP for medication self-administration. 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 have a CP for medication self-administration to provide information to the staff regarding the resident and the care to provide to them. LVN 1 stated care plans help guide the care for residents. LVN 1 further stated, without a CP the facility would not know how to care for the residents.

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 DON, on 8/9/2024, at 8:55 a.m., the DON stated there should be a CP for medication self-administration and the resident and family should be involved with its creation.

The DON stated the CP should include monitoring including checking where the medication will be stored, the medication the resident will be self-administering, and the frequency of administration.

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 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 resident) develops and implements a CP 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.

Cross-reference F-F554, F-F755 and F-F689.

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

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.

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 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.

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

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.

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

During a concurrent interview and record review on 8/9/2024 at 3:49 p.m. with the DON, 13 RNA

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.

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 ROM of a joint and to prevent or reduce contractures. b.1.

During a review of Resident 139's admission Record, the facility admitted Resident 139 on 4/28/2021 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in

555579 08/09/2024

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

During a concurrent interview and record review on 8/8/2024 at 11:33 a.m., Resident 213's Elopement

Coordinator (MDSC).

The MDSC verified the most current MDS Assessment was submitted and accepted on 7/25/2024.

The MDSC verified Resident 213's Elopement Risk Assessment was not done.

The MDSC verified all assessments that were due for the resident were completed 7/19/2024 and stated the Elopement Risk Assessment was not completed.

The MDSC stated it was important for the assessment to be completed quarterly so everyone would be aware of how the resident is and to keep the resident safe and provide the proper care needed.

During a concurrent interview and record review on 8/8/2024 at 4:30 p.m., Resident 213's Elopement Risk Assessment was reviewed with the Performance Improvement Quality Improvement Nurse 1 (PIQI 1).

The PIQI 1 stated assessments are completed quarterly. PIQI 1 verified Resident 213's elopement risk assessment was not completed for 7/2024.

The PIQI 1 stated she must have missed it.

During a concurrent interview and record review on 8/9/2024 at 5:34 p.m., the Director of Nursing (DON) stated assessments are completed upon admission, readmission, quarterly, and/or for a change of condition.

The DON stated the assessment should have been completed as it was important for the facility to identify a resident's risk for elopement and develop a care plan and implement interventions to prevent such incidents.

During a review of the facility's policy and procedure titled, Wandering and Elopement, last reviewed on 1/29/2024 indicated: The facility will identify residents at risk for elopement and minimize any possible injury because of elopement.

The Licensed Nurse (LN), in collaboration with the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of then residents), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition.

The resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition according to the RAI guidelines.

• During a review of Resident 43's admission Record, the admission record indicated the facility

admitted the resident on 3/17/2021 and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF - a long-term [NAME][TRUNCATED]

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

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[TRUNCATED]

555579 08/09/2024

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

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.

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

well-being.

The DON stated the facility and physician failed to timely review and address the CP MRR

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.

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

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.

555579 08/09/2024

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

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.

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

shall be stored in a separate location designated solely for this purpose.

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

(1) Within 2 hours from 57°F (135°F) to 21 °C (70°F); and (2) Within a total of 6

555579 08/09/2024

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

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.

555579 08/09/2024

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

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.

555579 08/09/2024

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

indicated oxygen items will be stored in a plastic bag at the resident's bedside to protect the

555579 08/09/2024

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

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], 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.

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.

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

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], 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.

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. ii.

Such documentation should include the date the education was offered.

555579 08/09/2024

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

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.

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.

The facility will ensure safe usage of power strips within the resident care environment.

Power strips will be 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 strips in resident's room.

555579 08/09/2024

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

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] 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.

555579

Form Approved OMB

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

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.

555579

Form Approved OMB

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

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

555579

Form Approved OMB

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

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).

555579

Form Approved OMB

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

During a review of Resident 177's admission record, the admission record indicated Resident 177 was admitted to the facility on [DATE] 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.

555579

Form Approved OMB

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

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.

555579

Form Approved OMB

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

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.

555579

Form Approved OMB

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

During a review of Resident 43's Admission Record, the admission record indicated Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] 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:

555579

Form Approved OMB

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