Ararat Nursing Facility

Based on interview and record review, the facility failed to report an allegation of an employee-to-resident verbal abuse (harsh and insulting language directed at a person) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) within two hours to the State Survey Agency (SSA) for one of three sampled residents (Resident 1).

Certified Nursing Assistant (CNA) 1 reported an allegation of abuse to the Director of Nursing (DON) that allegedly occurred on 8/5/2025, committed by Life Enrichment Coordinator (LEC) 1 towards Resident 1.

The facility reported the allegation of abuse to the SSA on 8/29/2025, 24 days after the allegation of abuse was made.This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.Findings:During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 2/10/2023 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and dysphagia (a condition that makes it difficult to swallow).During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 6/25/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired.

During an interview on 9/9/2025 at 12:04 p.m. with RNA 1, RNA 1 stated he saw LEC 1 threw a towel or sweater at Resident 1's face in the dining room. RNA 1 stated he heard LEC 1 yelling at Resident 1. RNA 1 stated LEC 1's actions were considered an alleged verbal and physical abuse. RNA 1 stated he reported the alleged verbal and physical abuse to the DON on 8/29/2025.

During an interview on 9/9/2025 at 4:05 p.m. with the Assistant Administrator (AADM), the AADM stated he was the facility's Abuse Coordinator.

The AADM stated on 8/29/2025, RNA 1 reported the allegations of verbal and physical abuse that allegedly happened on 8/5/2025.

The AADM stated RNA 1 should have reported the allegations of abuse within two hours.

The AADM stated he was aware allegations of abuse must be reported within two hours to the SSA, Ombudsman, and law enforcement.

During an interview on 9/9/2025 at 4:34 p.m. with the Director of Nursing (DON), the DON stated on 8/29/2025, RNA 1 informed her about the allegation of abuse by LEC 1 to Resident 1 on 8/5/2025.

The DON stated not reporting allegations of verbal and physical abuse had the potential for the abuse to continue.

The DON stated RNA 1 failed to report the allegation of abuse within 2 hours that led to the facility reporting the allegations on 8/29/2025.

During a review of the facility's policy and procedure (PnP) titled, Abuse Prevention and Prohibition Program, last reviewed on 7/23/2025, the PnP indicated, the facility will report allegations of abuse . immediately. no later than two hours after forming the suspicion.

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.

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