Ararat Convalescent Hospital

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and investigate a potential fall for Resident 1 after the resident reported pain and stated she had fallen on 3/2/2026. Nursing staff did not initiate the facility's fall policy, including completing a post fall assessment, neurological monitoring, incident reporting, reassessment of mobility status. This failure resulted in delayed identification of injuries and placed the resident at risk for further harm, unmanaged pain, and unmet care needs.

Inspectors wroteBased on observation and interview and record review the facility failed to implement the policy and procedure on food storage, in accordance with professional standards for food service safety by failing to label a used by date for the following food items: -ground meat in a plastic container -three pieces of Armenian pizza -five croissants in a clear plastic bag -five glasses of milk This deficient practice had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumed it.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policies and procedures (P&P) titled Resident Rights, dated 5/1/2023, by failing to promote privacy and dignity for two of three sampled Residents (Resident 12 and 21) by: 1. Certified Nurse Assistant (CNA 1 and 2) standing over Resident 1 while assisting with feeding Resident 21. 2. CNA 4 did not draw the privacy curtain (a curtain that tracks around the resident's bed to create a private space) fully around Resident 12's bed grooming and shaving Resident 12. These deficient practices violated Resident 21 and Resident 12's resident rights to maintain and enhance their self-esteem and self-worth and the right to be treated with dignity and respect.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) titled Informed Consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sample residents (Resident 23) by not ensuring an Informed Consent was complete prior to administration of treatment of Mirtazapine (antidepressant, medication to treat depression). This deficient practice violated Resident 23 rights and her Representative Party (RP) to be informed of the risks and benefits of the proposed treatment and offered alternative treatments for Resident 23's antidepressant treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person-centered comprehensive care plan to address the resident's medical and physical needs for one of three sampled residents (Resident 9), who's cognitive skills were severely impaired, and was a high risk for fall, by not ensuring Resident 9's bed alarm (used to alert caregivers and staff when a person at risk of falls is getting out of bed) was properly working. This deficient practice had the potential to not alert the staff when Resident 9 attempted to get out of bed which could lead to a fall incident and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility provided necessary care and services to one of one sampled resident (Resident 22) in accordance with the facility's policy and procedure titled Care of Catheter. Resident 22's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was coiled and kinked obstructing the urine flow to the drainage bag. This failure had the potential for the urine to backflow to the bladder and bladder distention ( due to over accumulation of urine in the bladder) and result in catheter-associated urinary tract infection (CAUTI- an infection of the urinary system that occurs when bacteria enter through a indwelling catheter) and bladder collapse affecting the health and safety of Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an unplanned weight loss of 15.09% in six months for one of one sampled resident (Resident 7). The facility failed to: 1. Ensure staff identified Resident 7's decrease in oral intake (amount of food and water consumed), reassess and monitor interventions for weight loss when Resident 7 had a weight loss of 16 pounds in six months. 2. Ensure staff provided Resident 7 with a nutritional supplement twice a day as per physician's order from 8/6/2025 - 10/3/2025. These failures resulted in Resident 7's severe weight loss of 6 pounds (lbs.-unit of weight) in three months and placed Resident 7 at risk for malnutrition (lack of proper nutrition, caused by not eating enough), and dehydration (dangerous loss of body fluid).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that three (3) Certified Nurse Assistants (CNAs) demonstrated sufficient competency and skills to accurately document the food intake of one of four sample residents (Resident 7) by evaluating their how the CNAs documented meal intakes of the residents in accordance to the facility's policy and procedures (P&P) titled, Documentation - Nursing, dated 1/1/2016 and the Guidelines for Percentage of Meal Intake. This deficient practice resulted in the inaccurate meal percentage documentation for Resident 7 and may result in the resident not receiving interventions for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to accurately documentation for one of three residents (Resident 36)'s urine characteristics were in the Medical Administration Record (MAR) for October 2025 in accordance with the facility's policy and procedures (P&P) titled Documentation - Nursing, dated 01/01/2016. This deficient practice had the potential to result in inaccurate documentation in Resident 36's urine characteristics which may lead to a missed change of condition in Resident 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled 'Infection Prevention and Control Program, dated 12/1/2021 for three of three sampled residents (Resident 13, 23, and 35) by failing to ensure: 1. Ensure Resident 13's nasal cannula (NS, a flexible tube with two prongs that rest in the nostril to develop supplement oxygen) was changed weekly and did not have a label or a date the last time it was changed. 2. Ensure the Housekeeper 1 performed adequate hand hygiene when going in and out of Resident 23 room while performing environmental cleaning and when bringing dirty laundry to the laundry room. 3. Ensure the Infection Preventionist (IP) 1 performed adequate hand hygiene when entering and exiting Resident 35's room. [...]

Inspectors wroteBased on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 9/1/2025 up to 9/28/2025 in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Posting. This deficient practice of posting inaccurate nurse staffing information mislead information provided to the residents, resident's responsible parties and visitors about the nursing staffing for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's bedrooms accommodated no more than four residents for four (4) of 12 rooms (rooms [ROOM NUMBERS] with six beds in the room, and rooms [ROOM NUMBERS] with five beds in the room) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively affect the residents' privacy, safety, and quality of care due to inadequate space for quality nursing and emergency care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's bedrooms measured at least 80 square feet per resident in four (4) of 12 rooms (Rooms 1, 3, 4, and 5) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively impact the care and services of the facility's staff to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to report a Coronavirus 2019 (COVID-19, a contagious disease) outbreak (two or more linked cases of the same illness) to the California Department of Public Health (CDPH) in accordance with the facility's policy and procedure titled Communicable Diseases - Outbreak when the facility experienced a COVID-19 outbreak on 8/14/25. This deficient practice resulted in the facility failing to notify CDPH when an outbreak occurred and had the potential for the facility to underreport future outbreaks within the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 immediately notify a licensed nurse and not move a resident after a fall on 8/19/2025 prior to a licensed nurse' assessment, in accordance with the facility's policy and procedure (P&P) titled, Response to Falls, for one out of three sampled residents (Resident 1) reviewed for falls. CNA 1 lifted Resident 1 from the floor and moved the resident back to bed. CNA 1 did not notify Licensed Vocational Nurse (LVN) 1 until after 20 minutes. These deficient practices had the potential for Resident 1 to suffer further discomfort and complications from the unwitnessed fall. On 8/19/2025, LVN 1 found Resident 1 shivering and shaking in pain after the fall with a swollen and discolored left foot. [...]

Inspectors wroteDuring an observation, interview and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was free from the use of physical restraints (a manual method or device that limits a person's ability to move freely), in accordance with the facility ' s policy and procedure titled Restraints by failing to: 1. Identify a situation that constitutes abuse when Certified Nurse Assistant [CNA] 1 had knowledge that Resident 1 was tied to the wheelchair with a white sheet, on 11/9/24, during the 3 PM to 11 PM shift, as evidenced by a videoclip . CNA 1 did not untie (remove) the white sheet from Resident 1 and did not report the observation to the licensed vocational nurse (LVN 1) immediately. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 removed her personal protective equipment (PPE, specialized equipment such as gown, gloves, and mask that minimize exposure to hazards that may cause illness) before leaving a designated isolation room. 2. Ensure CNA 2 used proper hand hygiene in between Resident 8 and Resident 3 ' s room. 3. Ensure Kitchen Assistant [KA] wore gloves when handling and preparing food/drink in the kitchen. 4. Family Visitor (FM) 2 observed walking into the facility and resident hallway without wearing a surgical mask. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 1) with history of fall and a high risk for fall, in accordance with the facility ' s policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 1 not to receive assistance especially during a fall or not receive immediate care with Activities of Daily Living (ADL) if unable to reach the call light.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of practice for one of three sampled residents (Resident 1), who sustained an unknown injury, when Resident 1 was found with swelling on the left cheek from an unknown cause. The facility failed to conduct neurological assessments (series of tests that evaluate a patient's nervous system function) and develop a care plan. As a result of these deficient practices, Resident 1 had the potential to suffer further deterioration of health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) was accurate for one of two sampled residents (Resident 20): These deficient practices had the potential to result in Resident 20 not receiving appropriate treatment and/or services.

Inspectors wrote2. A review of Resident 20's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficult in breathing) with acute (sudden ) exacerbation and chronic congestive heart failure (a condition where the heart has difficulty pumping blood thought out the body). A review of Resident 20's History and Physical assessment dated [DATE], indicated Resident 20 did not have the capacity to understand and make decisions. A review of Resident 20's Order Summary Report indicated the following: a. On 5/06/2024, a physician order was made to change oxygen tubing weekly, every Sunday for oxygen use and as needed. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three out five Licensed Vocation Nurses (LVN ' s 2, 4, 5) in the facility completed their annual competency assessment and evaluation(a process that assess and evaluates an employees skills, knowledge and performance) for the appropriate job category, in accordance with the facility's Facility Assessment (facility assessment to determine what resources and services are necessary to care for its residents). This deficient practice placed the residents at risk for not receiving appropriate services, treatments, and risk for infection from daily care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling based on the facilities policy and procedure by failing to ensure: 1. A plastic container containing sugar was labeled with visible dates 2. A Styrofoam cup containing Baba ghanoush in the refrigerator was dated and labeled. These deficient practices had the potential to place residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on interview and record review the facility failed to notify the physician of a significant change of condition in accordance with the plan of care and the facility's policy and procedure for one of three sampled residents (Resident 23) with severe weight loss (involuntary loss of 10% or more of usual body weight within 6 months) of 10.13% in three months. As a result of this deficient practice Resident 23 received delayed necessary care and intervention to maintain and prevent further weight loss that could lead to a decline in the resident's well being.

Inspectors wroteBased on interview and record review, the facility failed to assess and evaluate and determine the cause of severe weight loss in accordance with the facility ' s policy and procedure for one of one three sampled residents (Resident 23) who had an unplanned severe weight loss of 10.13% in three months by failing to: 1. Ensure to report the severe weigh loss to the physician from July to August 2024 to determine the cause of weight loss related to resident ' s disease process 2. Ensure the licensed staff consult with the dietician assessment and for any new dietary recommendations. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident for four out of twelve resident rooms (Rooms 1, 3, 4, 5). The 4 resident rooms consisted of 2 (two) -six (6) bed capacity rooms and 2 -five (5) bed capacity rooms. This deficient practice had the potential to impact the care and services of the facility staffs to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient monitoring and supervision to one of three sampled residents (Resident 1) who had an unwitnessed fall on 4/11/24. This deficient practice resulted to a laceration on the head and above the right eye of Resident 1 that needed medical attention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the medical need for the use of a bed side rail for one of three sampled residents (Resident 1) that resulted to an unwitnessed fall. This deficient practice made Resident 1 suffer a laceration above her right eye and on her head that required medical attention.

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2), received restorative nursing services (RNA -a program available in nursing homes that helps residents maintain any progress they've made during therapy treatments, enabling them to function at a high capacity) as indicated in the physician order. As a result, Residents 1 did not receive RNA services on the following dates: 1. Resident 1 on 2/27/2024, 2/28/2024, and 2/29/2024, from 3/01/2024 to 3/18/2024. 2. Resident 2 on 2/21/2024, 2/22/2024, 2/23/2024, and 2/24/2024, 2/27/2024, 2/28/2024, and 2/29/2024, 3/01/2024 to 3/18/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of 12 sampled residents (Residents 90 and Resident 1) by failing to: 1a. Develop an individualized/person-centered care plan with goals and interventions for Resident 90 with diagnosis of dementia (a brain disorder that results in memory loss and personality changes that affects the daily life). 1b. Develop an individualized/person-centered care plan with goals and interventions for Resident 90 who was receiving oxygen therapy. 2. Develop an individualized/person-centered care plan for Resident 1 who was receiving Aspirin (a medication that prevents blood clot to form). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen therapy (treatment that provides supplemental, or extra, oxygen) according to physician's order and in accordance the facility's policy and procedure for two of two sampled residents (Resident 30 and 90). The facility failed to ensure: 1. Resident 30 was observed with the nasal cannula (NC, a plastic tube used to deliver oxygen to the nare) tubing was on the floor at the bedside. 2. Resident 90's was observed with the NC placed in resident's left nostril and none in the right nostril (one prong of the nasal cannula placed in the left nostril and the other prong was right open to air). This deficient practice placed Resident 30 and 90 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious injury or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of practice and it's policy and procedure on food service safety, proper sanitation and food handling practices by failing to: 1. Ensure the kitchen Aide (KA 1) 1 was wearing a hair net while washing the dishes in the facility's kitchen. 2. Ensure that food items stored in the refrigerator were dated when it was first opened. These deficient practices had the potential for residents to be at risk for contracting food borne illnesses (infections or irritations of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread and transmission of infections for three of three residents ( Residdent 30, 22 and 90) in accordance with the facility's policy and procedure by failing to: 1. Ensure that nasal cannula or oxygen tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor for Resident 30. 2. Ensure that Certified Nursing Assistant (CNA) 1 don (put on) personal protective equipment (PPE such as gown, gloves, mask, face shield) before entering Resident 22's room with contact isolation precautions (infectious agents, including epidemiologically important microorganisms which are spread by direct or indirect contact with the patient or the patient's environment) signage. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of need for one of one sampled resident (Resident 33) who was at risk for fall. The facility failed to ensure the Resident 33's call light was within reach as indicated in the facility's policy and procedure, titled Communication and resident's care plan. This deficient practice had the potential for the resident not to receive necessary care and services, or receive delayed care to in an event of an emergeny that could result in fall and accident.

Inspectors wroteBased on interview and record review, the facility failed to act upon the consultant pharmacist's recommendation to obatain a blood draw of a basic metabolic panel (BMP- blood test that check the body's fluid balance and levels of electrolytes [minerals that carry an electric charge] evaluate the need of potassium (an electrolyte) supplement for one of five sampled resident (Resident 35). This deficient practice had the potential for Resident 35 to have abnormal body and heart function due to the abnormal laboratory test due to the licensed staff's failure to act upon the reported irregularities by the pharmacist.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft. unit of measurement) per resident for four of twelve resident rooms (Rooms 1, 3, 4, 5). The 4 resident rooms consisted of 2 (two) six (6) bed capacity rooms and 2 five (5) bed capacity rooms. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.