DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
751614 A. BUILDING __________
B. WING ______________ 		06/22/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ARARAT HOSPICE CARE, INC 1601 NEW STINE ROAD, SUITE 185, BAKERSFIELD, CA, 93309
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0524      
34510 Based on observation, interview, and record review, the agency failed to document bruising of the right upper arm on the skin assessment for one of 11 sampled patients (Patient 11). This failure had the potential for Patient 11's injuries not to be treated, monitored, and/or addressed. Findings: During a home visit observation on 6/22/21, at 12 PM, in Patient 11's home, Patient 11 was in bed with oxygen in use via nasal cannula. Patient 11 showed his bruises on his right upper arm. Licensed Vocational Nurse (LVN) looked at Patient 11's skin. LVN checked Patient 11's back and arms. LVN told Family Member (FM) to take photos of the bruises of the right upper arm and send them to him (LVN) via text message. During an interview on 6/22/21, at 12:02 PM, with FM, FM stated Patient 11 fell three times since the last nurse visit. FM stated, "We fell together while helping him use the bathroom and he had those [upper arm] bruises." During a review of Patient 11's "LVN [Licensed Vocational Nurse] Visit Note," dated 6/22/21, LVN Visit Note indicated, "Integumentary-Skin: None." During a concurrent interview and record review, on 6/22/21, at 3 PM, with Director of Patient Care Services Designee (DPCSD), DPCSD reviewed LVN's Visit Notes dated 6/22/21 and stated, "I can't find any documentation of bruises." During a review of agency's policy and procedure (P&P) titled, "Ongoing Comprehensive Assessments", dated 4/17, the P&P indicated, ". . . 2. The nurse will assess the patient on each visit, for: G. Skin integrity. . .5. Based on assessments, the plan of care including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case."
L0733      
34510 Based on observation and interview, the agency failed to implement infection control practices for one of 11 sampled home visit patients (Patient 10) when Licensed Vocational Nurse (LVN) did not dispose of the used gloves and used disinfecting wipes before leaving Patient 10's home. This failure had the potential to spread infection to Patient 10 and her family. Findings: During an observation on 6/22/21, at 10 AM, in Patient 10's home, LVN placed his clipboard on Patient 10's bedside table without a barrier. LVN was wearing gloves and he disinfected his medical equipment with a disinfecting wipe. LVN placed the used disinfecting wipes on Patient 10's bedside table, and then removed his gloves, placing the gloves on the bedside table. LVN then said goodbye to Patient 10, and left without picking up the used gloves and disinfecting wipes he had placed on Patient 10's bedside table. During an interview on 6/22/21, at 11 AM, with LVN, LVN stated he forgot to dispose of the used gloves and used disinfecting wipes before leaving. LVN stated, "I usually put them in a plastic bag." LVN stated he placed his clipboard on Patient 10's bedside table without a barrier. LVN stated, "We have a barrier chucks (disposable underpad) but I did not use one." During an interview on 6/22/21, at 3:02 PM, with Director of Patient Care Services Designee (DPCSD). DPCSD stated the agency does not have a specific policy on the use of barrier and disposing gloves and disinfecting wipes after use.