Ukiah Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents reviewed from resident-to-resident abuse (Resident 2) by another resident (Resident 1). The facility failed to implement effective interventions after identifying an escalating pattern of accusations, threats, and aggressive behaviors directed by Resident 1 toward Resident 2. This finding resulted in Resident 1 striking Resident 2 in the arm on June 1, 2026. This finding had the potential to result in physical and psychosocial harm to Resident 2. A review of Resident 1's admission record (facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included vascular parkinsonism (a neurological disorder affecting movement) and major depression. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered fall care plan for one resident (Resident 1) of three sampled residents reviewed after fall incidents. This failure had the potential to result in additional falls with injury to Resident 1. A review of Resident 1's Face Sheet, indicated her medical diagnoses included difficulty in walking, unsteadiness on feet, need for assistance for personal care, muscle weakness, and abnormalities of gait and mobility. A review of Resident 1's Order Summary Report, indicated she did not have the capacity to make her own decisions. Her daughter was her decision maker. A review of Resident 1's Progress Notes, dated 5/24/26, at 3:47 p.m., indicated Resident 1 was sitting in her wheelchair in hallway at Station 1and fell asleep. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that one resident (Resident 31) of three sampled residents received a shower and nail trimming to maintain good grooming and personal hygiene. This failure decreased the facility's potential to prevent skin breakdown and other health related issues related to poor hygiene among residents.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing services to one of three sampled residents (Resident 1), according to professional nursing standards of practice when:1. Licensed Nurse 1 (LN 1) clocked out for her meal period, leaving Resident 1 unattended by licensed nursing supervision, while she (Resident 1) was in uncontrolled pain, and performing a risky procedure, 2. LN 1 failed to recognize Resident 1's change in condition and notify a facility physician.3. LN 1 failed to notify Resident 1's facility physician, and family she was transferred to a General Acute Care Hospital (GACH) emergency department.4. LN 1 failed to report to the oncoming Licensed Nurse, the need to notify Resident 1's family that she had been transferred to the hospital emergency department during her shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide scheduled showers for one resident (Resident 1) of three sampled residents when Resident 1 received one shower or bed bath of nine scheduled opportunities while in the facility. This failure increased the potential for delayed wound healing of Resident 1's wounds due to poor personal hygiene (the practice of maintaining cleanliness of the body to promote comfort, health, and well-being).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition, palatability and served at an appetizing temperature when eight out of 46 residents (Resident 4,Resident 11, Resident 253, Resident 29, Resident 35, Resident 154, Resident 36, Resident 1) received meals that were cold, flavorless and overcooked. This failure had the potential to decrease nutritive content and decrease meal intake by the residents eating meals served by the kitchen and adversely affecting their health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when: 1. Kitchen staff improperly restrained facial hair and hair net use. 2. Kitchen staff Improperly used gloves. 3. Dietary staff observed to wear jewelry while at work in the kitchen. 4. Kitchen staff did not monitor ambient food cooling. 5. Expired food found in the reach in refrigerator and dry storage area. 6. Condiment containers found with drip residue in caps and along sides of containers. 7. Soiled equipment observed in a food prep area. 8. Resident refrigerator did not have a cleaning process. 9. Cross contamination of products in the resident refrigerator in the nutrition room. [...]

Inspectors wroteBased on interview and record review the failed to ensure a Quality Assurance Performance Improvement (QAPI) plan that resolved consistent complaints from residents about environmental temperatures, food temperatures, food palatability, and food preferences. This failure resulted in the lack of a systematic approach to determine underlying causes of problems impacting temperature of the environment, food palatability, medication errors; and no guidance on how the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain essential patient care equipment in safe operating condition when: 1. The air conditioner in dry storage room is soiled. 2. The walk-in refrigerator condenser fans are dripping soiled water on food box. 3. Freezer number 2 had frozen ice drips on ceiling. 4. Ice machine and ice chest cleaning process is unsafe. 5. Resident refrigerator in nourishment room had a damaged gasket. These failures have the potential to contaminate food and pose a risk for food borne illness for 46 of 46 residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote resident respect and dignity when three out of eight residents (Resident 36, 10 and 154) were served their lunch trays late when others in the dining room were already eating. This failure had the potential to impact the three residents' self-esteem and self-worth.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure medications were administered timely for three out of three sampled residents (Residents 11, 32 and 45). This failure put Residents 11, 32 and 45 at significantly increased risk of worsened health condition, untreated symptom, and complications from untreated symptoms.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient and competent staff were scheduled to carry out the functions of the food and nutrition service safely when: 1. Two staff members worked tray line affecting timeliness of meal delivery. 2. One dietary aide (DA B) could not verbalize or demonstrate proper method to check sanitizing solution. 3. Presentation of pureed food was not appetizing.

Inspectors wroteBased on observation, interview and record review the facility failed to accommodate resident food preferences or offer snacks to seven of 46 residents (Resident 154, Resident 36, Resident 1, Resident 3, Resident 27, Resident 11, Resident 29), when alternate menu items were continuously repeated, and snacks were not offered to all residents in the facility. This failure had the potential for residents in the facility to experience weight loss and become malnourished.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure: 1. Staff were following the Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when administering medications via feeding tube (tube inserted into the stomach to provide a patient with enteral nutrition, used when someone is unable to eat or drink safely by mouth). This failure could lead to spread of infection, increased complications and adverse events. 2. Staff were performing hand hygiene (HH, cleansing of your hands with soap and water, antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers) prior to donning gloves. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility allowed one out of two sampled residents (Resident 11) to self-administer medications without the Interdisciplinary Team (IDT, a collaborative approach that combines data, techniques, and perspectives from multiple disciplines) determining if self-administration was clinically appropriate for Resident 11. This failure was a safety issue which could lead to dosing errors and ineffective symptom management.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure: 1. the opthalmic (eye) suspension medication of one out of two sampled residents (Resident 4) was labeled properly when the physician's order had changed. 2. the discontinued level II-V medications (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) were stored in a permanently affixed compartment prior to destruction. These failures had the potential to cause medication errors and/or lead to drug diversion. 1.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure: 1.there were adequate staff to care for the residents at the facility when three out of three sampled residents (Residents 1, 2 and Anonymous 1) complained the facility was short staffed and staff would take a long time to answer their call lights. 2.the Abuse Policy and Procedure (P&P) were updated to reflect correct reporting guidelines and staff were aware on which agencies to report abuse allegations and the reporting time frame for abuse allegations. These failures: 1a. resulted in residents feeling frustrated, upset and worried nobody will answer their call light on time in case of emergency. This also had the potential for neglect, late provision of care or care not being provided at all. 2a. [...]

Inspectors wroteBased on dietetic services observations, dietetic staff and Registered Dietitian interview and departmental document review the facility failed to ensure meals were prepared in a sanitary manner, in accordance with standards of practice and departmental procedures as evidenced by 1) holding of foods for extended periods of time at a temperature which may promote bacterial growth; 2) vegetable preparation without prior washing; 3) use of wiping cloths that were not immersed in a chemical sanitizer; 4) undated, thawed nutrition supplements; 5) multiple kitchen areas and equipment that were not clean and 5) storage of scoops in shelf stable foods. Failure to follow standardized sanitation practice may result in bacterial growth associated with foodborne illness, cross contamination of foods, retention of expired items and create an environment that supports a vermin infestation.

Inspectors wroteBased on dietetic services observations and administrative and dietetic staff interview the facility failed to ensure frequent and comprehensive consultative departmental oversight by a Registered Dietitian and to employ a qualified Director of Food Services for day-to-day management duties. Failure to provide an organizational structure led by qualified staff, in a consistent manner, resulted in lapses related to staff competency, safe food handling practices, ineffective meal distribution and poor sanitation practices in dietetic services. Failure to develop staff and systems in accordance with regulatory requirements and professional standards may result in practices that put residents at risk for foodborne illness, decreased meal intake further compromising the medical status of 44 residents receiving meals from the facility dietetic services.

Inspectors wroteBased on dietetic services observations, dietary and administrative staff interview and departmental document review the facility failed to ensure staff competency as evidenced by lack of training and orientation of 2 of 2 dietary staff (Dietary Staff 1 and 2) members present during the abbreviated survey.

Inspectors wroteBased on dietetic services observations, resident interview and departmental document review the facility failed to consistently follow the menu and when menus were altered did not have a method to advise residents of the changes. Failure to follow menus as outlined may result in decreased resident meal satisfaction, nutritional value of meals which in turn may result in decreased meal intake leading to weight loss, further compromising medical status.

Inspectors wroteBased on meal plating observation, dietary staff interview and departmental document review the facility failed to ensure the standardized menu, approved by the Registered Dietitian, was followed resulting in physician ' s orders not followed for six Residents (Residents 5,6,7,8,9 and 10) with fortified diet orders.

Inspectors wroteBased on food storage observations and resident interview the facility failed to store food in accordance with manufacturer ' s recommendations. Failure to follow manufacturer ' s recommendations may affect meal palatability resulting in decreased resident meal satisfaction.

Inspectors wroteBased on facility observations and administrative staff interview the facility failed to provide a functional space for the Director of Food Services to effectively provide supervision, guidance and oversight to the day-to-day operations of dietetic services.

Inspectors wroteBased on observations, interviews and records review, the facility failed to assess two of twelve sampled residents (Resident 23 and 38) who were identified at risk for pressure ulcer when: 1. The facility did not assess Resident 23's skin integrity under the left lower extremity (part of the body that includes the leg, ankle, and foot) immobilizer (removable devices that maintain stability of the knee) for a period of two weeks when nursing and therapy staff were providing care and treatment. [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to assess and provide necessary services to one of twelve sampled residents (Resident 38) when the facility did not ensure Resident 38 was free from pain due to left foot pressure ulcer and Deep Vein Thrombosis (DVT - a blood clot forms in one or more of the deep veins in the body, usually in the legs) to left leg. This failure resulted to Resident 38's inability to relax when she repeatedly called out for help and moaned (to make a long, low sound of pain, suffering). (Reference F686)

Inspectors wroteBased on observations, interviews, and records review, the facility failed to provide adequate supervision for two of twelve sampled residents (Resident 249 and 38) when: 1. The facility did not follow their Fall Care plan to provide staff supervision to Resident 249 when sitting on his wheelchair. This failure resulted to Resident 249's repeated falls requiring two hospitalizations due to nasal laceration (a deep cut or tear in skin) and bilateral nasal bone fractures (a break in the bone or cartilage over the bridge, or in the sidewall or septum [structure that divides the nostrils] of the nose) to which Resident 249 experienced pain. 2. The facility failed to follow the doctor's order for nectar thick liquid for Resident 38 who had difficulty swallowing and did not provide staff supervision when drinking liquid. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system, installed in 16 of 16 resident bathrooms, were accessible to residents from the bathroom floor. This failure had the potential for residents to not be able to alert staff and call for assistance, should they sustain a fall in the bathroom.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect two (Residents 149 and 42) of three sampled residents' rights to be free from verbal abuse by a staff member (Unlicensed Staff D). This failure resulted in Residents 149 and 42 to experience fear and verbalize feelings of being unsafe, which could lead to negative effects to the residents' emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, when two of three resident abuse allegations (by Residents 149 and 42) were not reported to other officials, including to the Department, in accordance with State law. This failure decreased the Department's ability to ensure a complete investigation and appropriate interventions were started and implemented timely to protect Residents 149 and 42, and the 40 other vulnerable residents, from further potential abuse reoccurrence. (Cross Reference F600)

Inspectors wroteBased on interview and record review, the facility failed to: a. Provide sufficient evidence to demonstrate thorough investigations of two of three abuse allegations (by Residents 149 and 42), and b. Prevent potential for further abuse when Unlicensed Staff D continued to work at the facility for two more shifts after the facility was notified of Resident 42's verbal abuse allegations against said staff, with one shift schedule even including Resident 42 under Unlicensed Staff D's assignment. These failures subjected the 44 vulnerable resident population to potential reoccurrence of abuse, and continued placement of Resident 42's care under her aggressor resulted in feelings of fear and anxiety.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement resident-centered care plans for three of twelve sampled residents (Resident 23, 32 & 38) when: 1. Resident 23 and Resident 38 were identified to be at risk for pressure ulcer and no resident centered care plan was developed to prevent facility-acquired pressure ulcers. This failure resulted in the development of a blister (a painful skin condition where fluid fills a space between layers of skin) to Resident 38's left heel and Suspected Deep Tissue Injury (SDTI - Intact or non-intact skin with localized area of persistent non-blanchable [when the skin is pushed and the area stays red, that means that there is little or no blood flow going to that area] deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister) to Resident 23's left heel. [...]

Inspectors wroteBased on observation, interviews, and records review, the facility failed to ensure showers and oral hygiene were provided to three of twelve sampled residents (Resident 23, 40 and 38). This failure resulted to an untimely identification of a facility acquired pressure ulcer for Resident 23 and 38 and a potential oral infection for Resident 40. (Reference F686)

Inspectors wroteBased on observations and interviews, and record review, the facility failed to ensure sufficient nursing staff to provide care for 2 of twelve sampled residents (Residents10 and 248) and 5 unsampled residents (Residents 27, 20, 33, 37 and 250). This failure resulted in untimely call light response placing them at risk for neglect and harm.

Inspectors wroteBased on dietetic service observations, dietary staff interviews, and administrative document review, the facility failed to ensure dietary staff had competencies and skills to carry out the functions of the food and nutritional services safely and effectively, when Dietary Staff did not: 1. Test dishwasher chlorine following manufactures instructions 2. Ensure freezer thermometers were functioning and accurate freezer temperatures were recorded on logs 3. Monitor Potentially hazardous foods (food that could cause food borne illness if not prepared and stored properly) for safe cool down. These deficient practices resulted in creating a false sense of security as to the safety of food preparation, and potentially expose Residents to food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and flavorful to 3 sampled residents (Resident 32, Resident 148, Resident 248) and 5 unsampled residents (Resident 20, Resident 34, Resident 35, Resident 37, and Resident 251). These failures had the potential to lead to decreased nutritional intake and weight loss in a vulnerable population.

Inspectors wroteBased on dietetic service observations, dietary staff interviews, and administrative document review, the facility failed to ensure dietary staff carried out the functions of the food and nutritional services safely and effectively, when Dietary Staff did not: 1. Test dishwasher chlorine following manufactures instructions 2. Ensure freezer thermometers were functioning and accurate freezer temperatures were recorded on logs 3. Monitor Potentially hazardous foods (food that could cause food borne illness if not prepared and stored properly) for safe cool down These deficient practices resulted in creating a false sense of security as to the safety of food preparation, and potentially expose Residents to food-borne illness.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to obtain and implement physician's order for one of 12 sampled residents (Resident 32) when: 1. The facility did not obtain a physician's order for oxygen (O2 - life-supporting component of the air) when Resident 32 was observed on oxygen inhalation for three days. This deficient practice placed Resident 32 at risk for unnecessary respiratory care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that meet the needs of their residents as evidence by: 1. Licensed Nurse A, Licensed Nurse B, and Licensed Nurse C did not rotate the site for injection for one of one sampled resident (Resident 148) on subcutaneous (SC-injection given under the skin) Insulin Lispro (medication to reduce blood sugar) in accordance with manufacturer specifications. This failure increases the risk for an adverse reaction to Insulin. 2. Two oral emergency medications kits were not replaced, when medications were taken out of the kit, within 72 hours as required by facility policy. This failure increases the risk for not having the necessary medications to treat residents.

Inspectors wroteThe facility failed to maintain an effective infection prevention and control program, designed to prevent the development and transmission of disease and infection for the residents in the facility when: a. A staff member brought in a bag of resident's soiled items directly to the clean area of the laundry room, and b. One of two sampled residents (Resident 248) who was on oxygen (O2 - life-supporting component of the air) therapy was using an undated nasal cannula (tube which on one end splits into two prongs which are placed in the nostrils) tubing and humidifier (add moisture to the air to prevent dryness that can cause irritation in many parts of the body). [...]