Ararat Nursing Facility
Ararat Nursing Facility in MISSION HILLS, CA — inspection on February 25, 2026.
Found 4 citations. 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 an observation on 2/25/2026 at 9:58 a.m., observed the medication cart computer at nurse station 1 was open with Resident 4's medical record on the computer screen. Resident 4's visible medical records included the resident's name, picture, and medication list.
Observed facility staff walked past the medication cart computer with Resident 4's medical information on it.
During a concurrent observation and interview on 2/25/2026 at 10:02 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 4's medical records were observed on the medication cart computer. LVN 2 stated she did not lock the medication cart computer before she left to assist another resident. LVN 2 stated Resident 4's medical information was visible to the people walking on station 1 hallway. LVN 2 stated Resident 4's medical records left unattended had the potential to violate resident confidentiality.
During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated Resident 4's medical records should not be left unattended.
The DON stated facility staff not involved in Resident 4's care, other residents, and visitors had the potential for unauthorized access to Resident 4's medical records.
The DON stated the facility failed to ensure private information in Resident 4's medical records was safe from unauthorized access.
During a record review of the facility's policy and procedure (PnP) titled, General Provisions, last reviewed on 1/26/2026, the PnP indicated protected health information contained in the record is confidential and will only be released accordance with the facility's HIPPA policies.
The PnP indicated active records are to be located in an area not accessible to unauthorized persons.
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
555579 02/25/2026
Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired.
During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain.
The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain.
The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body).
During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's Care Plans, reviewed with Registered Nurse (RN) 1, RN 1 stated Resident 1 complained of right hip pain on 2/9/2026. RN 1 stated there was no care plan created for Resident 1's COC on 2/9/2026. RN 1 stated a care plan should be initiated to address Resident 1's right hip pain. RN 1 stated if Resident 1's care plan was not created, the facility staff will not be aware of the interventions to address the resident's COC.
During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated a care plan was a list of care and services to be provided for the residents.
The DON stated a care plan should be created after Resident 1's COC on 2/9/2026.
The DON stated Resident 1 did not have a care plan that included Resident 1's right hip pain.
The DON stated Resident 1's care had the potential to lack interventions to prevent further injuries and manage the resident's pain.
The DON stated the facility failed to ensure Resident 1 had a care plan after the resident's COC on 2/9/2026 that addressed the resident's right hip pain.
During a review of the facility's policy and procedure (PnP) titled, Care Planning, last reviewed on 1/26/2026, the PnP indicated the purpose to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.
The PnP indicated each resident's comprehensive care plan will describe the. services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.
During a review of the facility's PnP titled, Change of Condition Notification, last reviewed on 1/26/2026, the PnP indicated a licensed nurse will. update the Care Plan to reflect the resident's current status.
555579 02/25/2026
Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired.
During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain.
The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain.
The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body).
During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's medical records, reviewed with RN 1, RN 1 stated Resident 1's COC Evaluation, dated 2/9/2026, indicated on 2/9/2026 at 2:40 p.m., Resident 1 complained of right hip pain. RN 1 stated Resident 1's COC should be monitored every shift for 72 hours. RN 1 stated Resident 1's Progress Notes indicated there was no documented evidence that the resident was monitored on 2/9/2026 (11 p.m. to 7 a.m. shift). RN 1 stated she did not document her full assessment of Resident 1's right lower extremity on the resident's Progress Notes. RN 1 stated a resident care that was not documented was considered as not done. RN 1 stated incomplete documentation of Resident 1's health status had the potential for the resident's health condition to worsen.
During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated Resident 1 should be monitored every shift for at least 72 hours after the resident's COC.
The DON stated there was no documented evidence that Resident 1 was monitored on 2/9/2026, 11 p.m. to 7 a.m. shift.
The DON stated RN 1 did not document the assessment done on Resident 1's lower extremities that included pain on palpation and the appearance of the right lower extremity.
The DON stated that if resident care was not documented it meant the resident care was not done.
The DON stated not assessing and monitoring the resident after a COC had the potential for the resident's progress or decline to be missed.
The DON stated the facility failed to provide safe resident care by failing to ensure Resident 1 was assessed and monitored after a COC.
During a review of the facility's policy and procedure (PnP) titled, Change of Condition Notification, last reviewed on 1/26/2026, the PnP indicated the licensed nurse will assess the resident's change of condition and document the observations and symptoms.
The PnP indicated a licensed nurse will document the. date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes.
The PnP indicated a licensed nurse will document each shift for at least seventy-two (72) hours.
555579 02/25/2026
Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345
During a review of the facility's policy and procedure (PnP) titled, Documentation - Nursing, last reviewed on 1/26/2026, the PnP indicated the purpose to provide documentation of resident status and care given by nursing staff.
The PnP indicated . F. nurse's notes are dated, timed, and signed when written. H. medication administration records and treatment administration records are completed with each medication or treatment completed. K. documentation will be completed by the end of the assigned shift.
During a review of the facility's PnP titled, Medication - Administration, last reviewed on 1/26/2026, the PnP indicated the purpose to provide standards for safe administration of medications for residents in the facility.
The PnP indicated the time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment.
During a review of the facility's PnP titled, Completion & Correction, last reviewed on 1/26/2026, the PnP indicated the purpose to ensure that medical records are complete and accurate.
The PnP indicated . II. entries will be recorded promptly as the events or observations occur, III.
Entries will be complete, legible, descriptive and accurate. V. when adding an entry at a later date, the entry is to be clearly identified as a late entry, late entries should be documented as soon as possible. VII.
Documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner.
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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.