Ararat Nursing Facility in Mission Hills: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH made an unannounced visit on July 9, 2026 to investigate a facility-reported incident. CDPH found that on June 26, 2026, Resident 1, a 97-year-old man with dementia and a history of falls who took a blood thinner and depended on staff for mobility and daily care, fell from his bed while CNA 1 changed his disposable brief by herself. He reached for his eyeglasses on the bedside table, and his head struck the corner of the table. He had a 1 cm by 1 cm cut on the top of his scalp and was sent to an acute care hospital, where a CT scan showed bilateral acute on chronic subdural hematomas (new bleeding on top of older collections of blood between the brain and the skull, on both sides of the head).

Inspectors found that his assessment called for two-person assistance, yet the facility did not ensure two or more staff helped turn him in bed. The department determined the facility also failed to identify his need for two-person help given his fall risk, his bleeding risk from the anticoagulant, his dependence on staff and his dementia, and failed to follow its own fall management program, which required reassessing how many staff a resident needs. According to the 2567 report, a restorative nursing assistant told inspectors the resident needed two-person assistance, while CNA 2 said he changed the resident's brief without help.

CDPH found these failures violated state and federal requirements and issued a Class A citation with a $20,000 penalty that was trebled to $60,000. The federal 2567 report cites F689 (free of accident hazards, supervision and devices) at severity G.

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CDPH found that Resident 1, a 97-year-old woman with chronic atrial fibrillation (an irregular heartbeat that can lead to blood clots) and a prosthetic heart valve, was admitted on May 27, 2026 with a hospital order for apixaban (a blood thinner) 2.5 mg twice a day. According to the citation, the physician ordered staff to skip that night's dose because of a nosebleed. The physician told inspectors he did not discontinue the medication and that stopping it may lead to a stroke.

Inspectors found that RN 1 did not resume the apixaban on May 28 as the physician ordered. The medication administration record had no order for the drug, and a licensed vocational nurse documented that it was no longer on the resident's medication list. CDPH found the resident missed six doses from May 28 through June 1 and that the facility did not follow its policy on physician orders. On the morning of June 1, a CNA noticed the resident leaning to her left side during a transfer. A nurse found left-side facial drooping, left-side weakness and slurred speech, and the facility called 911. At an acute care hospital she was diagnosed with an acute ischemic stroke (a sudden loss of blood flow to part of the brain) due to a blockage of the right middle cerebral artery.

According to the citation, CDPH issued a Class A citation with a $20,000 penalty that was trebled to $60,000. The 2567 report states the facility failed to keep the resident free of significant medication errors and cites F760 at severity G.

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CDPH found that on January 14, 2026, at about 3 a.m., LVN 1 found the hands of Resident 1, an 82-year-old woman with dementia and Alzheimer's disease who depended on staff for care, tied firmly together at the wrists with a scarf while she lay in bed. According to the citation, she had no way to move or free her hands. On entering the room, the nurse saw her twisting her body to show that her hands were bound.

Inspectors found that no licensed nurse assessed the resident before a physical restraint was applied, as the facility's restraint policy required. CDPH found that CNA 1, the aide assigned to the resident, was suspected of tying her hands and was seen sleeping during the shift, yet stayed on the schedule and kept caring for her until clocking out at 7:16 a.m. The department determined this went against the facility's abuse prevention policy, which calls for suspending accused staff during an investigation, and allowed the potential for further abuse. According to the citation, the restraint created a risk of injury and of feelings of hopelessness, helplessness and humiliation.

The 2567 report states inspectors called an immediate jeopardy (a situation likely to cause serious harm) on February 3, 2026 and removed it on February 4 after the facility carried out an accepted removal plan, which included suspending CNA 1 on the morning of January 14 pending a human resources investigation. CDPH issued a Class A citation with a $20,000 penalty. The federal report cites F604 (right to be free from physical restraints) at severity J, and F609 (reporting of alleged violations) and F610 (investigating, preventing and correcting alleged violations) at severity D.

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According to the citation, CDPH visited the facility on October 6, 2025 to investigate a facility-reported incident involving a resident who broke a bone. CDPH found that Resident 1, a 93-year-old woman with dementia, blindness in her right eye and macular degeneration (an eye disease that affects central vision) in her left eye, had been assessed as high risk for falls. She also had a prior fall, took medications linked to a higher fall risk, and needed moderate staff help with toilet transfers and moving around.

Inspectors found that on September 30, 2025, the facility did not supervise Resident 1 and did not give her a front-wheeled walker when she walked to the bathroom. Her care plan called for supervision when she stood up and got in and out of bed, and a physical therapy discharge summary recommended an assistive device for safe mobility. According to the citation, she fell that morning at 7:53 a.m. and was found on the floor of her room, sitting against the wall. She sustained a left femoral intertrochanteric fracture (a break in the upper part of the left thigh bone) and was sent to an acute care hospital for evaluation and treatment.

The department determined the facility failed to keep the resident free from accidents and to provide adequate supervision and assistive devices to prevent them. CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000.

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According to the citation, CDPH made an unannounced visit on July 14, 2025 for the annual recertification survey and to look into a facility-reported altercation between residents. CDPH found that on June 28, 2025, at 2:45 p.m., a CNA saw Resident 45 come out of his room and hit Resident 224 several times on the head and right leg with a single-point cane. Resident 224, a 90-year-old man with Alzheimer's disease and dementia, was sitting in his wheelchair in the hallway and yelling at the time.

Inspectors found that the facility failed to protect Resident 224's right to be free from physical abuse. According to the citation, he had bruising and swelling on his right leg from blunt force, redness on top of his head and mild pain rated two out of 10. He reported a mild headache and was given Tylenol, and progress notes over the next two days still showed bruising on the leg. The 2567 report states the CNA saw Resident 45, an 85-year-old man with Alzheimer's disease and dementia, become agitated at Resident 224's yelling before the incident, and a care plan started that day noted impulsive behavior and physical aggression toward the other resident.

CDPH found these facts supported a Class A citation and assessed a $25,000 penalty. The federal 2567 report cites F600 (free from abuse and neglect) at severity G and F609 (reporting of alleged violations) at severity D. The full narrative on the reporting finding is in the linked report.

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According to the citation, CDPH made an unannounced visit on June 20, 2025 to investigate a complaint and a facility-reported incident of sexual abuse. CDPH found that at about 4:50 a.m. that day, a CNA and a licensed vocational nurse saw Resident 2 topless and leaning over Resident 1, her roommate, who was lying in bed. Resident 2 was rubbing her bare breasts against Resident 1's chest and sucking her chin, which left a red mark. Resident 1 was an 80-year-old woman with dementia and moderately impaired thinking.

Inspectors found the facility failed to identify the risk that Resident 2's sexually inappropriate behavior posed to other residents, and failed to make sure licensed staff monitored and documented that behavior and put protective interventions in place. A 2024 care plan had already documented that behavior. CDPH found the facility also did not evaluate whether Resident 1 could consent to sexual activity, and did not assess and document her condition for possible injuries for 72 hours afterward as its abuse policy required. According to the citation, Resident 1 appeared panicked and in shock during the incident, and afterward she refused help with changing, became agitated and began shaking.

The 2567 report states inspectors called an immediate jeopardy (a situation likely to cause serious harm) on June 25, 2025 and removed it on June 27 after the facility carried out an accepted removal plan. Under that plan, staff separated the two residents and provided one-on-one supervision, and Resident 2 was sent to an acute care hospital for a psychological evaluation. CDPH issued a Class A citation with a $25,000 penalty, and the federal report cites F600 (free from abuse and neglect) at severity J.

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The 2567 report states that on July 25, 2025, at about 2:30 p.m., Resident 2 threw a four-ounce cup of thickened flavored water at his roommate, Resident 1, inside their shared room. The cup hit Resident 1 on the left lower lip and left a 3 cm scratch that bled and needed first aid. Inspectors found that Resident 1 had a history of stroke, hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing), had moderately impaired thinking and depended on staff for much of his daily care.

Inspectors found that a CNA went into the room after hearing the two residents shouting and saw blood on Resident 1's lip, and Resident 2 admitted throwing the cup. The two residents gave different accounts of how the argument started. Resident 1 said he had asked Resident 2 to lower the television volume, and Resident 2 said Resident 1 had used profanity toward him. A licensed vocational nurse told inspectors Resident 2 said he threw the cup to scare his roommate, and she described the incident as physical abuse. Staff cleaned the scratch, left it open to air, and placed Resident 1 on monitoring for skin changes and signs of emotional distress.

CDPH found the facility failed to protect Resident 1's right to be free from physical abuse while under the facility's care. The 2567 report cites F600 (free from abuse and neglect) at severity G.

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CDPH found that on March 12, 2025, at about 5:45 p.m., staff heard a loud argument and yelling between two residents in the dining area. According to the 2567 report, Resident 2 scratched Resident 1 on the upper right side of her nose during a physical altercation, and the scratch bled. Resident 1 had dementia, Alzheimer's disease and chronic obstructive pulmonary disease (a long-term lung disease), used a manual wheelchair and had moderately impaired decision-making.

Inspectors found that Resident 1 rated her pain at four out of 10 and was given acetaminophen. A physician ordered staff to clean the scratch, apply antibiotic ointment and cover it twice a day for ten days. At a care conference the next day, Resident 1 said Resident 2, who was also in a wheelchair, had been hitting and bumping into her wheelchair in the dining room and then scratched her face. The report states Resident 2 also had dementia and Alzheimer's disease and did not have the capacity to make decisions.

CDPH found the facility failed to protect Resident 1's right to be free from physical abuse. The report notes that a person with impaired cognition who is subjected to physical abuse may experience pain and feelings of hopelessness, helplessness and humiliation. The 2567 report cites F600 (free from abuse and neglect) at severity G.

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According to the citation, CDPH visited on February 6, 2025 to investigate a facility-reported fracture. CDPH found that Resident 3, a 97-year-old woman with Alzheimer's disease, dementia and osteoporosis (weak, brittle bones), was at high risk for falls, depended on staff for all transfers and, under her care plan, needed two staff members at all times.

Inspectors found that on January 24, 2025, at 9:30 a.m., CNA 1 transferred Resident 3 alone from her wheelchair to the shower bench, without the mechanical lift and second staff member her care required. Progress notes state she became agitated and pushed the CNA during the transfer. She fell from the wheelchair and hit her right knee on the shower bench. CDPH found that CNA 1 then moved her from the shower room floor to the wheelchair before a registered nurse had checked her for injuries. By that evening her right lower leg was discolored and swollen, with pain at nine out of 10. An X-ray showed a mildly displaced avulsion fracture (a small piece of bone pulled away where a tendon attaches) at the top of the shinbone below the knee. She was given pain medication and sent to an acute care hospital the next day.

The department determined the facility did not keep the resident free from falls and injury in line with her care plan. CDPH issued a Class A citation with a $25,000 penalty that was trebled to $75,000. The federal 2567 report cites F689 (free of accident hazards, supervision and devices) at severity G.

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According to the citation, CDPH made an unannounced visit on November 12, 2024 to investigate a facility-reported fall. CDPH found that Resident 1, a 91-year-old woman with dementia, Alzheimer's disease and general muscle weakness, was a high fall risk with unsteady balance, needed a walker and needed supervision or light hands-on help when walking.

Inspectors found the facility did not provide an assistive device for safe walking and did not follow its "Falling Star Program" policy, which calls for posting a high-fall-risk resident's name on bright yellow paper by the room door so staff know the risk. On October 29, 2024, at 7:08 a.m., she fell while walking to the bathroom alone and without a walker. A restorative nursing assistant reported that she was found on the floor beside her bed, and a nurse found her lying on her back with a cut on the back of her head and unable to move her left leg. At an acute care hospital she was diagnosed with a displaced fracture of the upper left thigh bone and had surgery to place a metal rod in the bone. According to the citation, a CNA told inspectors the resident was not identified as a fall risk because her name on the door was not highlighted in yellow.

CDPH found the facility failed to prevent the fall and injury and issued a Class A citation with a $25,000 penalty. The federal 2567 report cites F689 (free of accident hazards, supervision and devices) at severity G.

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The 2567 report from an August 2024 certification survey states the facility did not ensure its registered nurses and restorative nursing assistants (aides who help residents keep joint movement and function) were competent to assess and care for residents with limited range of motion. Inspectors found that six registered nurses, including the director of nursing, who performed joint mobility assessments had no competency evaluations for that task. Several restorative nursing assistants had no competency evaluations for range-of-motion exercises, splints and walking assistance, and others were evaluated by someone not qualified to do so. The director of nursing told inspectors there was no way to ensure the assessments were accurate.

CDPH found these failures affected four sampled residents. Resident 119, who had Alzheimer's disease and dementia and depended on staff for all care, had undetected worsening contractures (shortening and stiffening of muscles and tendons that limits joint movement) in both elbows and knees and developed new contractures in both hands and hips. Inspectors found staff did not check the fit of the resident's elbow and knee splints during several assessments from 2022 to 2024, did not report a significant decline in August 2024, missed ordered passive range-of-motion exercises for both hands on one day, put the right elbow splint on upside down, and did not notice that the right knee splint had been out of line with the knee for at least two weeks.

Based on these findings, the 2567 report states the facility did not meet two federal requirements: F726 (competent nursing staff) and F688 (increase or prevent decrease in range of motion and mobility), both cited at severity G.

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According to the citation, CDPH made an unannounced visit on June 6, 2024 to investigate an allegation of a resident death. CDPH found that Resident 1, an elderly woman with parkinsonism (a brain condition that causes slowed movement, stiffness and tremors), Alzheimer's disease, dementia and osteoporosis, had severely impaired thinking, was at high risk for falls and depended on staff for all daily care.

Inspectors found that on June 1, 2024, at about 11 a.m., CNA 1 brought a mechanical lift into the resident's room alone to weigh her, although two staff members were required. After placing the sling under the resident, CNA 1 left her unattended to find another staff member. CDPH found the CNA did not follow the resident's care plan, which called for keeping her surroundings free of hazards because of her tremors and involuntary movements, and that the resident had no physician's order for the lift as facility policy required. The resident fell and her face landed on the base of the lift. At an acute care hospital she was found to have multiple facial fractures, and according to the citation she died there due to the extent of injuries related to the fall.

The 2567 report states inspectors called an immediate jeopardy on June 13, 2024 and removed it the next day after the facility carried out an accepted removal plan. Under that plan, CNA 1 was suspended the day of the fall and later terminated, and staff were trained that two people must be present when using a lift. CDPH issued a Class AA citation with a $120,000 penalty. The federal report cites F600 (free from abuse and neglect) and F689 (free of accident hazards, supervision and devices), both at severity J.

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According to the citation, CDPH made an unannounced visit on May 7, 2024 to investigate an allegation of a resident death. CDPH found that Resident 1, a 91-year-old woman with dysphagia (difficulty swallowing), Alzheimer's disease and parkinsonism, was on aspiration precautions (steps to keep food or liquid out of her airway).

Inspectors found that on March 9, 2024, at 5:30 p.m., staff allowed a family member to help Resident 1 eat dinner on a dining room patio with no staff present to monitor her. CDPH found the facility had not trained the family member first, did not provide a restorative nursing assistant to help her eat, and did not have a care plan specific to her needs. At 5:45 p.m., the family member saw she was unresponsive, and a licensed vocational nurse found her without a pulse and not breathing. Paramedics took her to an acute care hospital, where, according to the citation, she died on March 13 with diagnoses including aspiration pneumonia (a lung infection from food or liquid breathed into the lungs), cardiac arrest and anoxic brain injury (brain damage from lack of oxygen).

The 2567 report states the family members of three other residents also had not been trained before helping with meals. Inspectors called an immediate jeopardy on May 14, 2024 and removed it on May 15 after the facility educated families on safe feeding and required visitors to sign a feeding precautions form and feed residents under staff supervision. CDPH issued a Class AA citation with a $120,000 penalty; the state's record lists the final amount as $90,000. The federal report cites F684 (quality of care) at severity J.

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According to the citation, CDPH made an unannounced visit on March 17, 2023 to investigate a complaint about quality of care. CDPH found that Resident 1, a 95-year-old woman with Alzheimer's disease and heart disease, could not walk, used a wheelchair and was at high risk for falls. A physical therapist had identified abnormal posture, and her fall care plan listed abnormal posture as a problem without describing it or setting specific interventions for it.

Inspectors found the facility did not give Resident 1 postural support in her wheelchair. Her antipsychotic medication, Risperdal, had been ordered for constant attempts to get out of bed and her wheelchair, and it was stopped on February 11, 2023 with instructions to use non-drug interventions. CDPH found that staff did not monitor her afterward for restlessness, rocking back and forth, leaning forward and attempts to get up, and did not provide non-drug interventions, even though several staff described these behaviors. On March 11, 2023, at 3:30 p.m., she fell out of her wheelchair face first. She stayed at the facility, and at 8 a.m. the next day staff found her unresponsive. At an acute care hospital she was diagnosed with facial bone fractures and extensive intracranial hemorrhage (bleeding inside the skull). According to the citation, she died on March 13, 2023.

CDPH found the facility failed to develop and carry out a care plan that met her needs. It issued a Class A citation with a $25,000 penalty, and the state's record lists the final amount as $20,000. The federal 2567 report cites F689 (free of accident hazards, supervision and devices) and F656 (develop and implement a comprehensive care plan), both at severity G.

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