Ararat Nursing Facility
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
hospital and subsequently returns to the facility, an admission assessment is done and the assigned nurse must also do a progress note. The DON stated that an admission assessment is important because a baseline status is needed since the facility don't know what was done to the patient in the hospital. The DON reviewed Resident 1's electronic record and could not locate a completed admission assessment related to Resident 1's return to the facility on 8/26/2025. The DON stated an admission assessment should have been done.During a review of the facility's policy and procedure (P&P) titled, admission Assessment, dated 8/30/2019, the P&P indicated the following: Upon admission, a Licensed Nurse will conduct an admission assessment of the resident using NP - 102 - Form A - Resident admission Assessment or alternate form available on the electronic health record platform.b. 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.
Event ID:
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Ararat Nursing Facility in MISSION HILLS, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.