Health inspection·September 11, 2025

F 0880 Provide and implement an infection prevention and control program. 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 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. A review of Resident 3's admission record indicated the Resident was originally admitted to the facility on [DATE], with a diagnosis of Poly-osteoarthritis (pain, swelling, and stiffness in the joints), heart disease (Problems with the heart, such as blocked arteries or heart damage) and hypertensive heart disease(Heart problems caused by long-term high blood pressure). A review of Resident 3's History and physical (H&P) dated 2/25/2025, indicated this Resident has the capacity to understand and make decisions. A review of Resident 3's Minimum data set ( MDS- a standardized assessment and screening tool ) dated 8/12/2025, indicated, Resident 3 has moderate cognitive impairment( may remember some things but have trouble with short- term memory, recalling information after a delay, or staying fully oriented to time), and requires partial assistance ( helper does less than half the effort) with showering. Only requiring set-up or clean - up for toileting, oral hygiene and dressing. A review of Resident 3's Change in Condition Evaluation dated 8/15/2025, indicated Resident 3 had a runny nose, voice hoarsening, occasional cough and weakness. The Evaluation Covid antigen test performed on 8/13/2025 indicated a positive COVID-19 result. A review of Resident 4's admission record indicated the Resident was admitted on [DATE], with a diagnosis of a fracture to the shaft of the right femur (a break in the long, straight part of the thigh bone on the right side). A review of Resident 4's History and physical (H&P) dated 11/1/2024, indicated the Resident does not have the capacity to understand and make decisions. A review of Resident 4's Minimum data set ( MDS- a standardized assessment and screening tool) indicated the Resident has severe memory impairment ( may not be able to remember or repeat words, recall information, or answer orientation questions) but only requires set up or clean up assistance meaning helper sets up or cleans up and Resident can complete activity by self-such as oral care and eating. A review of Resident 4's Change in Condition Evaluation dated 8/16/2025, indicated Resident 4 had a runny nose. Resident 4 was tested for COVID-19 on 8/16/25 and a positive result. A review of Resident 5's admission record indicated the Resident was admitted to the facility on [DATE], with a diagnosis of congestive heart failure ( the heart isn't pumping blood as well as it should, so fluid can build up in the body). A review of Resident 5's Minimum data set (MDS- a standardized assessment and screening tool) dated 5/4/2025, indicated the Resident had the ability to answer simple questions and participate in conversation, but will often need help with more complex decisions, problem - solving or remembering instructions. Resident 5 requires substantial assistance meaning a helper does more than half the effort when getting dressed Residents Affected - Few (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 09/11/2025 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)