Health inspection·August 29, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care to attain or maintain the highest practicable physical well-being, when the facility failed to: 1. Complete Resident 1's admission Assessment upon his re-admission to the facility after being transferred to the General Acute Care Hospital (GACH) 1 due to a fall incident. 2. Complete Resident 1's neurological checks for 72 hours post-fall in accordance with the facility's policy and procedure.These deficient practices had the potential to result in Resident 1 receiving inadequate care.Findings: a. During a review of Resident 1's admission Record, dated 8/28/2025, the admission Record indicated Resident 1's diagnoses included atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and too fast), chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe due to damage to the lungs and airways), and vascular dementia (a condition where a lack of blood flow to the brain causes damage, leading to a decline in memory, thinking, and problem-solving skills). During a review of Resident 1's History and Physical Examination (H&P - when a doctor obtains a patient's medical history, performs a physical exam, and documents his/her findings in the patient's medical record), dated 8/14/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/13/2025, the MDS indicated Resident 1 needs substantial assistance with personal hygiene, toileting, and dressing the upper and lower body (a helper does more than half the effort in completing the activity). The MDS indicated Resident 1 needed supervision for eating (a helper provides verbal cues or contact assistance as the resident completes the activity).During an interview on 8/28/2025 at 10:13 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had moments of confusion. LVN 1 stated he found Resident 1 lying on the floor in his room at approximately 2:30 p.m. on 8/25/2025. LVN 1 stated when he asked Resident 1 why he was on the floor, Resident 1 stated that he was trying to go to the bathroom but fell. LVN 1 stated he notified the RN supervisor.During a concurrent interview and record review on 8/28/2025 at 10:33 a.m. with Registered Nurse (RN 1), an Incident Note, dated 8/25/2025, was reviewed. RN 1 stated that on 8/25/2025, LVN 1 notified RN 1 of Resident 1's fall at approximately 2:30 p.m. RN 1 stated that she and a physical therapist entered Resident 1's room and began assessing Resident 1, who was lying on the floor on his left side. RN 1 stated it was determined that Resident 1 should not be moved and that an ambulance should be called. RN 1 reviewed Incident Note dated 8/25/2025, which indicated emergency personnel arrived at 2:55 p.m., and Resident 1 was then transferred to GACH 1 for further evaluation.During a review of Resident 1's Order Summary Report, dated 8/28/2025, the Order Summary Report indicated that on 8/26/2025, Resident 1's doctor ordered for Resident [to] return to the facility and to resume all previous orders. During a concurrent interview and record review on 8/29/2025 at 1:57 p.m. with the Director of Nursing (DON), Resident 1's electronic medical record was reviewed. DON stated that when a resident is transferred to a Residents Affected - Few Page 1 of 2 555579 555579 08/29/2025 Ararat Nursing Facility 15099 Mission Hills Road Mission Hills, CA 91345

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital and subsequently returns to the facility, an admission assessment is done and the assigned nurse must also do a progress note. The DON stated that an admission assessment is important because a baseline status is needed since the facility don't know what was done to the patient in the hospital. The DON reviewed Resident 1's electronic record and could not locate a completed admission assessment related to Resident 1's return to the facility on 8/26/2025. The DON stated an admission assessment should have been done.During a review of the facility's policy and procedure (P&P) titled, admission Assessment, dated 8/30/2019, the P&P indicated the following: Upon admission, a Licensed Nurse will conduct an admission assessment of the resident using NP - 102 - Form A - Resident admission Assessment or alternate form available on the electronic health record platform.b. During a concurrent interview and record review on 8/28/2025 at 10:33 a.m. with RN 1, Resident 1's medical record was reviewed. RN 1 stated that for any unwitnessed fall, the nurses must assess the resident's neurological status for 72 hours after the fall occurs. RN 1 stated the resident's neurological status is to be checked every 15 minutes for 1 hour; followed by every 30 minutes for 1 hour; followed by every hour for 2 hours; and then, every 4 hours until 72 hours have been reached. RN 1 stated the neurological checks are documented on a paper form that is titled, Neurological Assessment Flowsheet. RN 1 reviewed Resident 1's Neurological Assessment Flowsheet, which indicated that Resident 1's neurological status was assessed on 8/25/2025 at 2:20 p.m. and 2:35 p.m. RN 1 stated when Resident 1 was re-admitted to the facility, the assessment of his neurological status resumed on 8/26/2025 at 1:05 a.m. but stopped after 4:05 a.m. RN 1 stated that Resident 1's neurological status was not assessed for 72 hours after he had an unwitnessed fall. During a concurrent interview and record review on 8/29/2025 at 1:57 p.m. with the DON, Resident 1's Neurological Assessment Flowsheet that was initiated on 8/25/2025 was reviewed. The DON stated Resident 1's neuro checks should have been done for 72 hours. The DON stated neurological assessments are important for an unwitnessed fall because we don't know if they hit their head or not, and two days later we could have a bleed [in the brain]. The DON stated if something did happen, we can catch it right away by performing neurological checks. During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment, dated 8/1/2014, the P&P indicated the nurses will perform a neurological assessment.[f]ollowing an unwitnessed fall.for a combined total of 72 hours. 555579 Page 2 of 2