Health inspection·August 4, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few indicated that Resident 1 sustained a skin tear (a type of wound where the outer layers of skin separate from each other due to friction, shear or blunt force) on the left side of the mouth due to roommate (Resident 2) throwing a cup of thickened liquid at Resident 1 on 7/25/2025. (Resident 1's COC indicated the injury as scratch.) The CP interventions included cleansing the affected area (Resident 1's left lower lip) with normal saline (a mixture of water and salt). During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/10/2025 with diagnoses including CVA, hemiplegia, and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's H&P dated 2/12/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive functioning (the state where a resident's mental processes, including memory, attention, language, reasoning, and executive functions, are working at a normal or expected level for their age and background). The MDS further indicated Resident 2 required moderate assistance (helper does less than half of the effort) from staff with oral hygiene and upper body dressing. The MDS further indicated Resident 2 required maximal assistance from staff with toileting hygiene, showers, and lower body dressing. During a review of Resident 2's COC form, dated 7/25/2025, timed at 2:48 p.m., the COC form indicated that on 7/25/2025 (time not indicated), CNA 1 entered Room A after shouting was heard between two residents (Resident 1 and Resident 2). The COC form indicated Resident 1 was observed with blood on the lip, resulting from a three cm scratch on the left side of Resident 1's lower lip. The COC form further indicated that Resident 2 admitted to throwing a four-ounce thickened flavored water cup at Resident 1. During a review of Resident 2's CP (untitled), initiated on 7/28/2025, the CP indicated that on 7/25/2025, Resident 2 was involved in an incident in which he (Resident 2) threw an object at his roommate (Resident 1). During a review the facility's five-day conclusion report titled, Abuse Investigation Reporting Form, dated 7/28/2025, the report indicated Resident 2 threw a four-ounce thickened flavored cup at Resident 1 on 7/25 2025 at 2:30 p.m. The report indicated Resident 1 had blood on his lip from a three-centimeter scratch on the left side of the lower lip. The report indicated Resident 1's left lower lip scratch was cleaned and left open to air. During an interview on 8/1/2025 at 10:18 a.m., with Resident 2, Resident 2 stated that during an argument with his roommate (Resident 1), in Room A , Resident 1 used profanity (offensive language) towards him (Resident 2) after which Resident 2 threw a cup at Resident 1, hitting Resident 1 in the face (left lower lip). Resident 2 was unable to recall the exact date and time of the incident. During an interview on 8/1/2025 at 1:18 p.m., with LVN 1, LVN 1 stated the incident (Resident 2 threw a cup at Resident 1) happened at approximately 2:30 p.m., (unable to recall the exact date of the incident). LVN 1 stated LVN 2 requested assistance from her (LVN 1) to provide translation in Room A. LVN 1 stated that during the interview with Resident 1, Resident 1 stated that he (Resident 1) had asked Resident 2 to lower the television volume, at which point Resident 2 threw a cup at Resident 1. LVN 1 further stated that during a separate interview (on 7/25/2025) with Resident 2, Resident 2 admitted to throwing an object (cup) from his (Resident 2's) meal tray at Resident 1 to scare him (Resident 1). LVN 1 further stated Resident 1 was observed to have a scratch on the lower lip. LVN 1 stated that the incident between Resident 1 and Resident 2 was physical abuse. LVN 1 further stated that Resident 2 could potentially hit Resident 1 in the head, which could result in a hematoma (a localized collection of blood outside of blood vessels, often resulting in a swollen, painful lump or bruise [an injury where blood vessels under the skin break, causing blood to leak into surrounding tissues]), or other serious injuries. During an interview on 8/1/2025 at 1:28 p.m., with LVN 2, LVN 2 stated that on 7/25/2025 (unable (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555579 If continuation sheet Page 2 of 3 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 555579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345 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)

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to recall the exact time of the incident), he (LVN 2) observed CNA 1 exiting Room A and requesting assistance. LVN 2 stated upon entering Room A, LVN 2 observed Resident 1 with bleeding from a scratch on the mouth. LVN 2 stated that during an interview (on 7/25/2025), with LVN 1 providing translation services, Resident 2 admitted to throwing a cup at Resident 1. LVN 2 further stated that the incident between Resident 1 and Resident 2 was a resident-to-resident physical abuse (refers to situations where one resident intentionally inflicts physical harm on another resident). During an interview on 8/4/2025 at 12:05 p.m., with the Director of Nursing (DON), the DON stated that the incident between Resident 1 and Resident 2 was a resident-to-resident physical abuse resulting in Resident 1 sustaining a scratch on his (Resident 1) mouth (left lower lip). The DON further stated that the incident had the potential to negatively affect Resident 1's psychosocial (refers to the interplay between psychological factors [thoughts, feelings, behaviors] and social factors [relationships, environment, culture]) well-being. During an interview on 8/4/2025 at 12:40 p.m., with the Administrator, the Administrator stated that the incident between Resident 1 and Resident 2 was a physical abuse that resulted in Resident 1 sustaining a scratch on his mouth (left lower lip). During a review of the current facility-provided policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, the P&P indicated, To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to . protect residents, and to ensure a standardized methodology for the prevention . of abuse . in accordance with federal and state requirements. Each resident has the right to be free from abuse. The facility has zero-tolerance for abuse . Staff must not permit anyone to engage in . physical abuse. The Facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents Event ID: Facility ID: 555579 If continuation sheet Page 3 of 3