Ararat Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to store, prepare, distribute and serve food for all the 24 residents in the facility receiving food from the kitchen in accordance with professional standards for food service safety, and the facility's policy and procedure titled, Food Storage, dated 11/1/2014. This deficient practice had the potential for the residents to acquire food-borne illnesses (a life threatening infection due to consuming contaminated food) from ingesting expired food.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices in accordance with the facility's policy and procedure by failing to: 1. Ensure a humidifier bottle (a small bottle attached to the oxygen tubing that holds water to keep oxygen from drying out a person's nose and lungs) was changed for one of six sampled residents (Resident 26) reviewed for infection control that required oxygen therapy in accordance with the facility's policy and procedure (P&P) titled Oxygen administration. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy and a homelike environment for two of two sampled residents (Resident 29 and Resident 39) by failing to report the missing to the maintenance supervisor to replace the missing horizontal window blind slats in Resident 29 and Resident 39's room. This deficient practice resulted in having a non-homelike environment and a violation of the residents' rights for privacy when the residents were exposed to the other people outside in the walkway and neighboring building near the facility. In addition, the loss of privacy had the potential to affect their psychosocial wellbeing of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 39 and Resident 41) and their representatives, reviewed for resident's rights were offered an information regarding Advance Directives (AD a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in accordance with facility policy titled Advance Directives and regulatory requirements. This deficient practice has the potential for care and services to not be performed during medical emergencies according to the residents and/or family wishes. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure to provide the Medicare change status form: Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, notice of liability) and Notice of Medicare Non-Coverage (NOMNC) letters/forms to one of three sampled residents (Residents 45) within two (2) days of the last Medicare part A covered day. This deficient practice had the potential for Resident 45 not to exercise the right to appeal and not be aware of possible charges for services rendered that were not covered after her last Medicare part A coverage day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 32) reviewed for pressure ulcer ( a skin breakdown due to prolonged unrelieved pressure and skin friction) receives care, consistent with professional standards of practice, to prevent pressure ulcers had recommended inflation/adjustment setting for the low air loss mattress (LAL - therapeutic mattress that uses blower and airflow to relieve pressure and keep the skin dry and prevent moisture build up). This deficient practice had the potential to result in the resident to be at risk of developing pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 41's) with intravenous (IV- a catheter inserted with a needle into the vein) peripheral catheter (a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) on the left arm had dried up blood on the site covered with transparent dressing and was not changed in accordance to the facility's policy and procedure titled Peripheral Venous Catheter Insertion. This deficient practice can potentially cause infection on the on the IV site that can lead to severe infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident evaluations including a written report of a physical examination was completed within 72 hours following admission and the initial comprehensive visit was not done by the Nurse Practitioner, Physician Assistant, and the Clinical Nurse Specialist for one of six sampled residents (Resident 17). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove a lidocaine patch (a medicated sticky patch placed on the skin to numb an area and relieve pain) at 9 PM and place a new patch at 9 AM to ensure the patch was on for 12 hours and off for 12 hours as ordered by the physician order for one of two sampled residents (Resident 10) reviewed for pharmacy services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 4), reviewed for use of unnecessary medications, was monitored for complications of Apixaban (a blood thinner medication) such as bruising and bleeding as indicated in the resident's care plan and the physician's order. This deficient practice had the potential for the resident not to receive immediate care or no care that can lead to a resident decline in well-being. for complication of Apixaban such as discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the documentation in the Licensed Nursing Weekly Summary (LNWS) accurately documented one of six sampled residents (Resident 5) reviewed for identifyable residents records, the actual status of having unplanned weight loss and behavior of yelling requiring the use of psychotropic medications (a medication that affects mood and behavior) in the weekly assessment from 12/1/2025, 12/8/2025, 12/22/2025, 1/12/2026, and 1/19/2026. This deficient practice can result in a lack of or a delay in communication between the staff and can interrupt provision of care/intervention to the resident.

Inspectors wroteBased on interview and record review, the facility failed to post an accurate nurse staffing information worked by License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Posting, when posted document on 1/20/2026 at 11:34 AM titled Posted Nurse Staffing Information indicated 11 to 7 shift actual staff are one LVN and two CNA's during morning facility rounds. (actual staff for 11 to 7 shift was posted in advance, during the day not at the beginning of the 11 to 7 shift). This deficient practice of posting inaccurate nurse staffing information in advance 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 provide a safe and secured environment for Resident 1, who was identified as being at high risk for elopement (when a person with cognitive impairment leaves a safe area, such as a care facility or home, without awareness of potential dangers) and wandering (when a person roams and becomes lost or confused about their location) for one of two sampled residents (Resident 1). The facility failed to: Ensure that facility staff supervise Resident 1 and did not leave the resident unattended in the Activity/Dining Room, which was located adjacent to an exit door. Ensure that Activity Staff (AS) 1 was informed of Resident 1's high risk for elopement and need for monitoring, when Licensed Vocational Nurse (LVN) 1 observed the resident wandering out of her room and left the resident with AS 1 in the Activity Room. 3. [...]

Inspectors wrote2. During a review of Resident 15 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone),hyperlipidemia(a condition in which there are high levels of fat particles in the blood). During a review of Resident 15 ' s History and Physical Assessment [HPA] dated 7/02/2024, the HPA indicated Resident 15 has the capacity to understand and make medical decisions. During a review of Resident 15 ' s MDS, dated [DATE] indicated Resident 15 ' s cognition was intact. During a review of Resident 15 ' s POLST dated 7/4/2024, the POLST did not indicate if Resident 15 had an Advance directive. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling in accordance with the facilities policy and procedure by failing to ensure: 1. Rotten plums were not kept in the food supply for residents and stored in the plastic container in kitchen walk in refrigerator. 2. A half full box of Kale vegetable was discarded as indicated in the label to with discard date 12/9/2024. 3. A plastic bag with five Danishes were kept sealed in the freezer with used by date 12/11/24. 4. A sliced can of apple was discard as indicated in the label to be discarded on [DATE] 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 observation, interview, and record review, the facility failed implement the policy and procedure for infection control by ensuring resident care equipment utilized for residents was sanitary, labeled and properly stored for eight of 8 sampled residents: For Residents 20 and 70 cloth gait belts (safety device used to help people move around safely, especially when they are at risk of falling) were inside the restroom. For Residents 2,3,5,9,11 and 15.the cloth gait belts were inside the restroom that any resident could readily access. This deficient practice had the potential for the residents to share resident care equipment, which can spread infection and cross contamination (transfer disease causing organism) to other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified for one of one sampled residents (Resident 18), who refused to receive insulin Lispro injection (a medication that is injected into the skin with a needle to lower the blood sugar level and help keep blood sugar level under control for Resident 18 with diabetes [a group of diseases that result in too much sugar in the blood] complications) on multiple occasions. This deficient practice had the potential for Resident 18 to not receive appropriate care, treatment and/or services and increased the risk for Resident 18 to be hyperglycemic (a condition in which the level of glucose (sugar) in the blood is higher than normal, symptoms include: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan that included for one of one sampled resident (Resident 18), that indicated alternative interventions were implemented for refusal receive insulin Lispro injection (a medication that is injected into the skin with a needle to lower the blood sugar level and help keep blood sugar level under control for Resident 18 with diabetes [a group of diseases that result in too much sugar in the blood] complications) on multiple occasions. As a result, Resident 18 ' s blood sugar remained high which can result in complications such as high blood sugar levels such as ketoacidosis (a life-threatening condition that occurs when the body produces too many ketones), kidney failure (failure of the kidney to get rid of toxins and extra fluids, and blindness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medically related social services were provided to one of two (Resident 11) sampled residents, in accordance with the facility ' s policy and procedure titled Social Services Program, when the Social Services Director [SSD] by failing to follow-up or assist when Resident 11's representative requested for additional information about the Advance Directive (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions). [...]

Inspectors wroteBased on interview and record review the facility failed to follow physician ' s orders for one of one sampled resident (Resident 18) who was receiving Insulin (medication that helps keep blood sugar under control and prevents diabetes [a group of diseases that result in too much sugar in the blood] complications). This deficient practice increased the risk of Resident 18 to experience adverse effects (unwanted and dangerous side effects of medication) that could lead to health complications, such as hyperglycemia (a condition in which the level of glucose (sugar) in the blood is higher than normal, symptoms include: urinating large amounts of urine, excessive thirst, feeling tired, blurred vision)

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided appropriate care and services, that was resident centered, by failing to: 1. Develop an individualized care plan that includes resident specific care needs and interventions for Resident 1 who was assessed at moderate risk for falls in accordance with the facility's policy and procedure for Care Planning. 2. Develop an individualized care plan that includes resident specific care needs and interventions for Resident 1 who had a history and diagnoses of osteoporosis (a bone disease that causes bones to become weak and more likely to break) to prevent fractures (a break in a bone, either partial or complete). 3. Monitor and document a neurological assessment (neurocheck: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician, for one of three sampled residents (Resident 1), who was assessed as a moderate risk for falls, and sustained an unwitnessed fall on 11/13/214. This deficient practice had the potential to result in the delay of care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of refused or contaminated medications in a safe, and secure manner. This deficient practice had the potential to result in misuse, drug loss, accidental exposure and/or potential diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended) of prescription drugs.

Inspectors wroteBased on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe], performed when the heart stops beating or beats ineffectively and/or to restore breathing), and call 911 (emergency services and/or emergency transfer to the general acute care hospital) for one (1) of three (3) sampled residents (Resident 34), who had a full code status (when resident's heart stopped beating and/or the resident stopped breathing, the resident or his/her representative wished for all lifesaving procedures to be provided to keep the resident alive) by failing to: 1. [...]

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 seven (7) of 13 sampled residents (Resident 6, 13, 87, 4, 19, 14, and 4) by failing to: 1. Develop an individualized/person- centered care plan for Resident 6 while receiving Eliquis (blood thinner - a medication that thins the blood and could cause bruising or bleeding) 2. Develop an individualized/person-centered care plan with goals and interventions for Resident 13 who has a diagnosis of type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) while receiving insulin. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed prevent unnecessary use of medication for three of five sampled residents (Resident 6, Resident 88, and Resident 7) who were not assessed and monitored for complications related to anticoagulant therapy (a medication prevent or delays blood clot to form, also known as blood thinner ) such as bleeding and bruising as indicated in the facility's policy and procedure titled, Anticoagulation Therapy Fact Sheet and the residents plan of care. This deficient practice had the potential to result in Resident 6, Resident 88, and Resident 7's to have undetected bruising and bleeding which could result in blood loss and bleeding in the brain and other major organs to bleed without immediate interventions and lead to a decline in the resident's wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow it's policy and procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure the Kitchen Aide (KA 1) 1 was wearing a hair net while cleaning the food preparation area. 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 provide safe, and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for five of six sampled residents (Resident 19, 4, 13, 86 and 87) as indicated int facility's policy and procedure, titled Cleaning and disinfection (process of removing disease causing organism) of Resident Care Equipment. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the basis for the discharge and/or the discharge summary was documented by the attending physician for one (1) of three (3) sampled residents (Resident 34). This deficient practice resulted in incomplete records for Resident 34.

Inspectors wroteBased on observation, interview, and record review, during the medication administration, the facility staff failed to ensure the opened (in-use) Basaglar KwikPen insulin (Insulin Glargine - long-acting insulin- a hormone that works by lowering levels of sugar in the blood) was marked with the date opened for one of four resident (Resident 13) as indicated in the facility policy. This deficient practice had the potential for Resident 13 to receive Basaglar KwikPen insulin (insulin pen) with less efficacy or adverse reaction (not desired effect) of insulin.