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Deficiency Records for Ararat Nursing Facility
A list of the most recent deficiencies for Ararat Nursing Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Ararat Nursing Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-21 | 2024-09-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-09-21 | 2024-09-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-09 | 2024-09-02 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-09 | 2024-09-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-09 | 2024-09-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-09 | 2024-09-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-09 | 2024-09-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-09 | 2024-09-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-08-09 | 2024-09-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-08-09 | 2024-09-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-09 | 2024-09-02 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-09 | 2024-09-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-09 | 2024-09-02 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-08-09 | 2024-09-02 | N |
| Dispose of garbage and refuse properly. | Health | 2024-08-09 | 2024-09-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-09 | 2024-09-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-09 | 2024-09-02 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-08-09 | 2024-09-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-08-09 | 2024-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-14 | 2024-09-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-08-14 | 2024-09-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-14 | 2024-09-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-08-14 | 2024-09-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-14 | 2024-07-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-14 | 2024-07-03 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-05-15 | 2024-07-03 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-15 | 2024-07-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-15 | 2024-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-15 | 2024-06-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-15 | 2024-06-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-18 | 2024-04-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-09 | 2024-04-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-04-09 | 2024-04-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-06 | 2024-02-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-06 | 2024-02-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-22 | 2023-10-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-13 | 2023-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-13 | 2023-07-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-03 | 2023-05-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-03 | 2023-05-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-03 | 2023-05-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-03 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-05-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-23 | 2022-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-29 | 2022-08-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-13 | 2022-05-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-21 | 2021-12-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-22 | 2021-11-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-22 | 2021-11-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-22 | 2021-11-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-22 | 2021-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-22 | 2021-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-22 | 2021-11-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-22 | 2021-11-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-22 | 2021-11-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-22 | 2021-11-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-10-22 | 2021-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-22 | 2021-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-22 | 2021-11-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-26 | 2019-04-18 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-03-26 | 2019-04-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-26 | 2019-04-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-26 | 2019-04-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-26 | 2019-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-26 | 2019-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-26 | 2019-04-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-03-28 | 2019-04-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-03-28 | 2019-04-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-28 | 2019-04-18 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-03-28 | 2019-04-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-28 | 2019-04-18 | N |
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