Ararat Nursing Facility

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