Health inspection·October 17, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few As a result of these deficient practices, Resident 1 had the potential to suffer further deterioration of health. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a change in how the brain works due to an underlying condition), Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and muscle weakness. A review of Resident 1 ' s History and Physical (H&P), dated 9/19/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (a federally mandated resident assessment tool), dated 9/22/2024, indicated the resident has severe cognitive impairment. A review of Resident 1 ' s Incident Note, dated 10/6/2024, timed at 9:32 PM, signed by the Director of Staffing Development (DSD), indicated Resident 1 was observed with light blue colored swelling on left cheek that was noted with 2 small red spots on it. The notes added Resident 1 had light discoloration on lower lip. A review of the facility ' s investigation conclusion, dated 10/10/2024, signed by Administrator (ADM), indicated when Resident 1 was interviewed regarding the cause of the swelling, Resident 1 responded that she fell outside. A review of resident ' s entire medical chart did not indicate documented evidence that NA was conducted to assess Resident 1 in response to Resident 1 ' s left cheek injury. A review of Resident 1 ' s entire care plans did not indicate documented evidence that a care plan was developed in response to Resident 1 ' s left cheek injury that would have included goals and interventions for facility staff to follow to address the resident ' s left cheek injury. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555126 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555126 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Convalescent Hospital 2373 Colorado Blvd. Los Angeles, CA 90041 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)