A list of the most recent deficiencies for Ararat Convalescent Hospital. 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? |
|---|---|---|---|---|
| Establish staff and initial training requirements. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-12 | 2023-11-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-08 | 2023-10-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-08 | 2023-10-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-08 | 2023-10-29 | 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 | 2023-10-08 | 2023-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-08 | 2023-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-08 | 2023-10-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-08 | 2023-10-29 | 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 | 2023-04-14 | 2023-05-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-04-14 | 2023-05-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-14 | 2023-05-14 | Y |
| 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 | 2023-04-14 | 2023-05-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-03 | 2022-10-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-03 | 2022-10-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-03 | 2022-10-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-03 | 2022-10-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-03 | 2022-10-28 | 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 | 2022-10-03 | 2022-10-28 | 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 | 2022-10-03 | 2022-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-03 | 2022-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-03 | 2022-10-28 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-10-03 | 2022-10-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-29 | 2022-10-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-09-27 | 2021-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-25 | 2021-06-17 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-09 | 2019-09-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-09-09 | 2019-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-29 | 2019-09-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-08-29 | 2019-09-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-08-29 | 2019-09-26 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-29 | 2019-09-26 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-29 | 2019-09-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-29 | 2019-09-26 | 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 | 2019-08-29 | 2019-09-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-09-26 | N |
| Keep all essential equipment working safely. | Health | 2019-08-29 | 2019-09-26 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-08-29 | 2019-09-26 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-29 | 2019-09-26 | N |
