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Complaint Investigation

Ararat Nursing Facility

August 13, 2025 · Mission Hills, CA · 15099 Mission Hills Road
Citations 1
CMS Rating 1/5
Beds 254
Provider ID 555579
Healthcare Facility
Ararat Nursing Facility
Mission Hills, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Ararat Nursing Facility in MISSION HILLS, CA — inspection on August 13, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0606
Freedom from Abuse, Neglect, and Exploitation Deficiencies

During a review of RN 1's Employee file, Employee file indicated RN 1 was hired on 3/18/1997.

The employee file indicated no documented evidence of a criminal background check. RN 1 is currently employed in the facility.

During a review of CNA 1's Employee file, the Employee file indicated CNA 1 was hired on 2/16/1998.

The employee file indicated no documented evidence of a criminal background check. CNA1 is currently employed in the facility.

Durin an interview with the Director of Staff Development (DSD) on 8/12/2025 at 9:10 a.m., the DSD stated, LVN 1, RN 1, and CNA 1 did not have a background check in their employee files because prior to 2014, the facility did not require new hires to have a background check. DSD stated, she was not working in the facility at that time and does not know what happened prior to 2014.

The DSD stated she will submit a background check for the staff.

The DSD stated all staff in the facility should have a background check because they need to be cleared from any abuse prior to start of work in the facility.During an interview with the Administrator (ADMIN) on 8/12/2025, ADMIN stated the Facility did not conduct any background checks prior to the year 2014 but was not able to provide a policy to corroborate his statement.

During an interview with Director of Nurses (DON) on 8/13/2025 at 4:10 p.m., the DON stated a background check was immediately ordered for LVN 1, RN 1, and CNA 1.

The DON stated it is important to have background checks on all staff working in the facility because they need to be cleared of any criminal findings and also be cleared from any abuse.A record review of the facility's policy and procedure titled, Staff Screening, dated August 1, 2023, indicated the facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers.

Prior to employment or commencement of a contract, the Facility will verify and document or obtain a copy, if applicable, of the following information that may include, but is not limited to: criminal background checks.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MISSION HILLS, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Ararat Nursing Facility or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.