Ararat Nursing Facility
Ararat Nursing Facility in MISSION HILLS, CA — inspection on August 29, 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
During a concurrent interview and record review on 8/28/2025 at 10:33 a.m. with RN 1, Resident 1's medical record was reviewed. RN 1 stated that for any unwitnessed fall, the nurses must assess the resident's neurological status for 72 hours after the fall occurs. RN 1 stated the resident's neurological status is to be checked every 15 minutes for 1 hour; followed by every 30 minutes for 1 hour; followed by every hour for 2 hours; and then, every 4 hours until 72 hours have been reached. RN 1 stated the neurological checks are documented on a paper form that is titled, Neurological Assessment Flowsheet. RN 1 reviewed Resident 1's Neurological Assessment Flowsheet, which indicated that Resident 1's neurological status was assessed on 8/25/2025 at 2:20 p.m. and 2:35 p.m. RN 1 stated when Resident 1 was re-admitted to the facility, the assessment of his neurological status resumed on 8/26/2025 at 1:05 a.m. but stopped after 4:05 a.m. RN 1 stated that Resident 1's neurological status was not assessed for 72 hours after he had an unwitnessed fall.
During a concurrent interview and record review on 8/29/2025 at 1:57 p.m. with the DON, Resident 1's Neurological Assessment Flowsheet that was initiated on 8/25/2025 was reviewed.
The DON stated Resident 1's neuro checks should have been done for 72 hours.
The DON stated neurological assessments are important for an unwitnessed fall because we don't know if they hit their head or not, and two days later we could have a bleed [in the brain].
The DON stated if something did happen, we can catch it right away by performing neurological checks.
During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment, dated 8/1/2014, the P&P indicated the nurses will perform a neurological assessment.[f]ollowing an unwitnessed fall.for a combined total of 72 hours.
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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.