Ararat Gardens

87202-Fire Clearance -All facilities shall maintain a fire clearance approved by the city fire department..Prior to accepting or retaining.. non-ambulatory persons, the licensee shall notify the licensing agecy and obtain an appropiate fire clearance...This requirement was not met as evidenced by: Upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the 2nd to 4th floor. This poses an immediate health and safety risk to residents in care.

87463(a) Reappraisals-The pre-admission appraisal shall be submitted in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.,,This requirement was not met as evidenced by: it was noted that residents physician's reports and needs and services plan are not being updated as needed.This poses a potential health and safety risk to residents in care.

87202-Fire Clearance -All facilities shall maintain a fire clearance approved by the city fire department..Prior to accepting or retaining.. non-ambulatory persons, the licensee shall notify the licensing agecy and obtain an appropiate fire clearance...This requirement was not met as evidenced by:Upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the second floor. This poses an immediate health and safety risk to residents in care.

87208(a)-Plan of Operation-Each facility shall have and maintain a current, written definitive plan of operation. The plan and related mateials shall be on file in the facility and shall be submitted to licensing...Any significant changes in the plan of operation ...shall be submitted to licensing for approval. This requirement was not met as evidence by:Upon file review it as noted that facility is Implementing an"Independent Living Plus" program without having obtained prior approval from the Licensing Department This poses a potential health and safety risk to residents in care.

87204(b)-Limitations-Capacity and Ambulatory Status-Resident rooms approved for 24 hour care of ambulatory residents only shall not accommodate nonambulatory residents. Resdients whose conditon becomes nonambulatory shall not remain in rooms restricted to ambulatory residents,This requirement was not met as evidenced by:It was observed that non-ambulatory residents were residing in ambulatory rooms.This poses a potential health and safety risk to residents in care.

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: Based on observation, record review and interviews conducted, facility staff failed to meet the needs of resident (R1) when call button was press.This poses an immediate health and safety risk to residents in care.

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. Based on LPA inspection the licensee did not comply with the section cited above. Staff did not respond to 1 out of 3 emergency devices, which poses/posed a potential health and safety risk to persons in care.

87303 Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and record review, rodent droppings were observed within the facility.