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The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ararat Post Acute during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering was left unsupervised in the Activity/Dining Room near an exit after an LPN handed off the resident to an activity staff member who was not informed of the resident's elopement risk. The activity staff member left at the end of her shift without ensuring clinical staff supervision, resulting in the resident leaving the facility unsupervised and being found by a family member at a nearby bus stop.
The facility failed to ensure that the POLST and Advance Directive Acknowledgment forms for two residents accurately reflected their wishes. One resident's POLST did not indicate if they had an Advance Directive, despite having the capacity to make decisions. The Social Services Director acknowledged the discrepancy and clarified with the family that the resident did not have an Advance Directive. Similarly, another resident's POLST lacked indication of an Advance Directive, and there was no evidence that an acknowledgment form was offered. This inconsistency could lead to misinformation about the residents' medical care preferences.
The facility failed to follow proper sanitation and safe food handling practices, as observed during an inspection. Rotten plums and expired kale were found in the refrigerator, while Danishes with an expired use-by date were in the freezer. A can of sliced apples with an expired discard date was also found in storage. The Dietary Supervisor confirmed that staff should have discarded these items by their discard dates or when spoiled.
The facility failed to ensure infection control by not properly sanitizing, labeling, and storing cloth gait belts, which were found in restrooms accessible to multiple residents. Observations confirmed that these belts were not labeled with resident names and were sometimes shared among residents without proper cleaning. Staff acknowledged the issue, and the facility's policy on cleaning resident care equipment was not followed.
A resident with type 2 diabetes and impaired cognition repeatedly refused Insulin Lispro injections, with refusals documented but not reported to the physician. The resident's family member was involved in the refusals, citing concerns about low blood sugar. The facility's policy required physician notification for treatment refusals, which was not followed, potentially impacting the resident's care plan.
A resident with diabetes and impaired cognition repeatedly refused Insulin Lispro injections, leading to high blood sugar levels. Despite family concerns about low blood sugar, the facility did not document alternative interventions or notify the physician, failing to develop a comprehensive care plan.
A resident's request for information on Advance Directives was not addressed by the facility's Social Services Director, leading to a delay in receiving necessary information. The resident, with diagnoses including dysphagia and dementia, was unable to make her own decisions, and her representative's request for assistance was overlooked due to a lack of follow-up by the SSD.
A resident with severely impaired cognition and diabetes did not receive the prescribed insulin dosage due to a family member's intervention, leading to a failure to follow physician orders. The facility's policy requires medications to be administered as prescribed, but only 1 unit of insulin was given instead of the ordered 2 units, increasing the risk of adverse effects.
A resident at moderate risk for falls and with osteoporosis did not have an individualized care plan, and the facility failed to monitor and document neurological assessments after a fall. The resident was on multiple anticoagulants, and a severe drug interaction warning was not addressed. After a fall, the resident developed a head injury and altered consciousness, requiring hospital transfer and intensive care.
A resident at moderate risk for falls experienced an unwitnessed fall and reported it to the Dietary Manager, who informed the DON. Despite the facility's policy requiring physician notification, the DON did not document the fall or notify the physician, as no injury was observed. The family was also not informed, leading to a deficiency in care.
The facility failed to properly dispose of refused or contaminated medications in a safe and secure manner. Medications were placed in an easily accessible blue container labeled 'pharmaceutical waste' in a medication cart, contrary to the facility's policy. This practice increased the risk of accidental exposure and diversion of prescription drugs.
Resident Elopement Due to Inadequate Supervision and Staff Communication
Penalty
Summary
A deficiency occurred when a resident identified as high risk for elopement and wandering was left unsupervised in the Activity/Dining Room, which was adjacent to an exit door. The resident, who had diagnoses including dementia with psychosis, multiple rib fractures from recent falls, and severely impaired cognition, required hourly monitoring and specific supervision interventions as documented in their care plan. On the day of the incident, the resident was escorted to the Activity Room by an LVN, who did not confirm that the activity staff member was aware of the resident's elopement risk or the need for close monitoring. The activity staff member, who was not informed of the resident's high elopement risk and was unfamiliar with the resident's medical history, left the resident in the Activity Room at the end of her shift without ensuring that a clinical staff member would supervise the resident. Although two dietary staff members were present in the room, they were not responsible for resident supervision. The activity staff member left to notify a nurse at the nursing station but did not remain with the resident until relieved by appropriate staff. As a result of these actions and lack of communication among staff, the resident was left unsupervised and subsequently exited the facility. The resident was later found by a family member at a bus stop 0.4 miles from the facility, appearing lost and sweating heavily. The incident was reported to the charge nurse after the resident was discovered missing, and interviews with staff confirmed that supervision protocols and communication regarding the resident's risk status were not adequately followed.
Inconsistent Documentation of POLST and Advance Directives
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life Sustaining Treatment (POLST) and Advance Directive Acknowledgment forms for two residents accurately reflected their wishes. For Resident 20, the POLST did not indicate whether the resident had received information about an Advance Directive or if one was on file, despite the resident having intact cognition and the capacity to make decisions. The Social Services Director (SSD) acknowledged the discrepancy and noted that the POLST should be fully completed to reflect the resident's healthcare decisions. The SSD clarified with the family that Resident 20 did not have an Advance Directive and expressed the importance of consistent documentation. Similarly, for Resident 15, the POLST did not indicate the presence of an Advance Directive, and there was no evidence that an Advance Directive acknowledgment form was offered. The SSD confirmed that this information should have been completed upon admission as part of the resident's paperwork. The facility's policy requires providing residents with the opportunity to make healthcare decisions, but this was not adhered to, leading to potential misinformation about the residents' medical care and treatment preferences.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and safe food handling practices as per their policy and procedure. During an inspection, it was observed that the kitchen's walk-in refrigerator contained a plastic container with two rotten plums and a carton box of kale labeled with a discard date of 12/9/2024, which had not been discarded. Additionally, a clear plastic bag containing Danishes with a use-by date of 12/11/2024 was found in the walk-in freezer, and a metal can of sliced apples with an expired discard date was found in the dry storage area. The Dietary Supervisor acknowledged that all staff are expected to check the refrigerator every morning for spoiled food and produce. The supervisor stated that the spoiled plums, kale, and Danishes should have been discarded by their respective discard dates or when they were observed to be spoiled. The can of sliced apples should have been removed from storage on its discard date to prevent potential foodborne illnesses among residents.
Inadequate Infection Control: Improper Storage and Labeling of Gait Belts
Penalty
Summary
The facility failed to implement its infection control policy and procedure by not ensuring that resident care equipment, specifically cloth gait belts, was sanitary, labeled, and properly stored. Observations revealed that cloth gait belts were found in restrooms accessible to multiple residents, with no resident names labeled on them. This was noted for eight sampled residents, including those with various medical conditions such as periprosthetic fracture, pulmonary aspergillosis, and chronic kidney disease. During observations and interviews, it was confirmed that soiled cloth gait belts were present in restrooms of residents who either did not use the restroom or shared the space with others. In some cases, the belts were labeled as belonging to the Rehab department, but there was no clear indication of ownership for individual residents. Staff members, including a Registered Nurse and an Infection Prevention Nurse, acknowledged the presence of these belts and the lack of proper labeling and sanitation. The facility's policy on cleaning and disinfection of resident care equipment was not followed, as there was no way to properly sanitize the cloth gait belts between uses. Interviews with staff, including a Certified Nursing Assistant and the Director of Nursing, revealed that the belts were sometimes wiped down with a wipe, but there was no consistent method for cleaning them. The Director of Nursing admitted that cloth gait belts could not be sanitized effectively, highlighting a significant gap in infection control practices.
Failure to Notify Physician of Insulin Refusal
Penalty
Summary
The facility failed to notify the physician when a resident, identified as Resident 18, refused to receive Insulin Lispro injections on multiple occasions. Resident 18, who was admitted with several diagnoses including type 2 diabetes mellitus with complications, had severely impaired cognition and lacked the capacity to make decisions. Despite this, the resident's family member, referred to as FM 1, was present during some refusals and declined the administration of insulin, citing concerns about low blood sugar levels. The Medication Administration Record (MAR) indicated that Resident 18 refused Insulin Lispro on several dates, with blood sugar levels recorded above the normal range. Progress notes documented the refusals and the family member's involvement but did not show evidence of physician notification. The Minimum Data Set Registered Nurse confirmed the lack of documentation regarding physician notification, which was necessary for planning the resident's care. The Director of Nursing acknowledged that staff should have notified the physician about the refusals, as it was considered a significant change in condition. The facility's policy on refusal of treatment required documentation of physician notification, which was not adhered to in this case. This oversight had the potential to impact the resident's care and treatment plan, as the physician was not informed to provide new orders or adjustments to the care plan.
Failure to Develop Care Plan for Insulin Refusal
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with diabetes who repeatedly refused to receive Insulin Lispro injections. The resident, who had severely impaired cognition and lacked the capacity to make decisions, was admitted with multiple diagnoses, including type 2 diabetes mellitus with unspecified diabetic retinopathy and macular edema. Despite the physician's orders for Insulin Lispro to be administered according to a sliding scale, the resident's blood sugar levels remained high due to frequent refusals of the medication. The resident's refusals were documented on several occasions, with blood sugar levels recorded as elevated each time. Family member 1, who was present during some of these refusals, expressed concerns about the resident's blood sugar levels dropping too low and declined the full dose of insulin on multiple occasions. Despite the staff explaining the risks and benefits of the medication, the refusals were respected, and no alternative interventions were documented in the care plan. Interviews with the MDS RN and the Director of Nursing revealed that there was no documented evidence of a care plan addressing the resident's refusal to take Insulin Lispro. The facility's policy on refusal of treatment indicated that the interdisciplinary team should assess the resident's needs and offer alternative treatments, but this was not done. The Director of Nursing stated that the physician should have been notified of the refusals to adjust the care plan accordingly.
Failure to Provide Requested Advance Directive Information
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as Resident 11, in accordance with its policy and procedure titled Social Services Program. The Social Services Director (SSD) did not follow up or assist when Resident 11's representative requested additional information about the Advance Directive (AD), a legal document that states a person's wishes about receiving medical care if they are no longer able to make medical decisions. This oversight led to a delay in receiving the requested AD information, which could impact the resident's healthcare decisions in an emergency. Resident 11 was readmitted to the facility with diagnoses including dysphagia and unspecified dementia, and was noted to be unable to make her own decisions. The resident's Physician's Order of Life Sustaining Treatment (POLST) indicated the absence of an Advance Directive. Despite the resident's representative signing an Advance Healthcare Directive Acknowledgement form requesting more information, the SSD did not refer the representative to the Ombudsman for assistance, as he was unaware of the request made to the previous SSD. The facility's policy requires medically related social services to maintain and improve residents' wellbeing, which was not adhered to in this case.
Failure to Administer Insulin as Prescribed
Penalty
Summary
The facility failed to follow physician's orders for a resident who was receiving insulin to manage diabetes. The resident, who had severely impaired cognition and lacked the capacity to make decisions, was prescribed Insulin Lispro to be administered subcutaneously before meals according to a sliding scale. On a specific occasion, only 1 unit of insulin was administered instead of the prescribed 2 units because the resident's family member declined the full dose, citing concerns about low blood sugar levels earlier in the day. This action was contrary to the physician's orders and the facility's policy, which requires medication to be administered as prescribed. The Director of Nursing (DON) stated that staff are expected to follow physician orders to prevent negative reactions. The facility's policy on medication administration emphasizes that medications should be administered by a licensed nurse per the physician's order, with checks to ensure accuracy. The failure to administer the correct insulin dosage as ordered by the physician increased the risk of adverse effects for the resident, who had a history of type 2 diabetes mellitus with unspecified diabetic retinopathy and macular edema.
Failure to Provide Resident-Centered Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate care and services to a resident, leading to several deficiencies. The resident, who was at moderate risk for falls and had a history of osteoporosis, did not have an individualized care plan addressing these specific needs. The facility also failed to monitor and document a neurological assessment after the resident experienced a fall, which was against the facility's policy. Additionally, the facility did not inform the physician before administering the resident's prescribed medication, Apixaban, after the fall, which is a deviation from professional standards of practice. The resident was on multiple anticoagulant medications, including Apixaban, Aspirin, and Plavix, which required careful monitoring due to the risk of severe drug interactions. Despite an alert in the electronic medical record system indicating a severe drug-to-drug interaction, the facility did not address this warning, potentially leading to adverse effects. The resident experienced a fall resulting in a head injury, and the facility did not complete a post-fall assessment or notify the physician promptly, as required by their policy. Following the fall, the resident developed a bump on the forehead and an altered level of consciousness, necessitating transfer to a general acute care hospital. The resident's condition deteriorated, leading to a critical state requiring intensive care. The facility's failure to develop a comprehensive care plan, monitor the resident's condition adequately, and address medication warnings contributed to the resident's adverse outcomes.
Failure to Notify Physician of Resident Fall
Penalty
Summary
The facility failed to notify the physician regarding an unwitnessed fall of a resident who was assessed as a moderate risk for falls. The resident, who had a history of osteoporosis and atrial fibrillation, was admitted with moderate cognitive impairment and required substantial assistance with daily activities. On the morning of the fall, the resident reported being unable to reach the call light and struggled to get back into bed. The Dietary Manager was informed by the resident about the fall and subsequently notified the Director of Nursing (DON). The DON conducted a body assessment and found no visible injury, leading to the decision not to document the fall or notify the physician. The facility's policy required prompt notification of the physician and family members in the event of a significant change in the resident's condition, such as a fall. Interviews with the DON and family members revealed that the family was not informed of the fall, and the physician was not consulted. The facility's policy and procedure documents emphasized the importance of notifying the physician and family in such situations, but these protocols were not followed, resulting in a deficiency in care.
Improper Disposal of Medications
Penalty
Summary
The facility failed to properly dispose of refused or contaminated medications in a safe and secure manner. During an observation, a blue container labeled 'pharmaceutical waste' was found in the top drawer of a medication cart. This container, which had a transparent lid that could be easily opened, contained multiple unknown medications. Licensed Vocational Nurse (LVN) 1 stated that refused or dropped medications were placed in this container and later discarded in the biohazard waste bin. However, LVN 1 could not specify what medications were in the container or when it was last emptied. LVN 2 confirmed that refused medications were documented and placed in the same container, which should be emptied at the end of each shift. The Director of Nursing (DON) stated that controlled medications were locked in the DON's office until the pharmacist arrived, while non-controlled medications were placed in a locked cabinet and then discarded in the biohazard bin. The DON acknowledged that the use of the blue container increased the risk of accidental exposure and diversion of prescription drugs because it was not secured and properly disposed of. Further interviews revealed that LVN 4 also placed refused medications in the blue container and could not specify how long the medications remained there before being properly discarded. The facility's policy and procedure (P&P) for medication disposal indicated that all medications should be placed in the proper waste container. However, the observed practice did not align with this policy, as the blue container was not a secure or proper method for disposing of medications. The facility's P&P for medication storage also required that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to procedures, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glendale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glendale Post Acute Center | 0.8 mi | — | 23 | 0 |
| Leisure Glen Post Acute Care Center | 0.9 mi | — | 0 | 0 |
| Glendale Adventist Medical Center Dp/snf | 1 mi | — | 0 | 0 |
| Autumn Hills Health Care Center | 1.1 mi | — | 7 | 0 |
| Solheim Senior Community | 1.1 mi | — | 17 | 0 |
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