Other·December 17, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an annual Re-Certification Survey. Representing the California Department of Public Health were Health Facilities Evaluator Nurses #38335, #40254, #40742, #41283,and #34975. Census on the date of entry, 7/29/19, was 45 with no bed-holds. There were 12 sampled residents. The following Facility-Reported Incidents (FRIs) were Investigated during the Survey: CA00623470 - Substantiated with no regulatory deficiencies cited CA00625571 - Unsubstantiated CA00648330 - Unsubstantiated CA00638537 - Substantiated with no regulatory deficiencies cited

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 09/13/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 1 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interviews and record reviews, the facility failed to follow its policy and procedure on reporting an allegation of abuse for one resident, Resident 10. This failure had the potential to cause serious harm to Resident 10, when he was not assessed immediately for physical harm, pain, or mental anguish, that may have resulted from the physical abuse. Findings: During a review of Resident 10's Admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 2 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Record, he was admitted to this Skilled Nursing Facility (SNF- a type of nursing home recognized by the Medicare and Medicaid systems as meeting long-term health care needs for individuals who have the potential to function independently after a limited period of care), on 12/2/13. Included in the list of his medical diagnoses for admission, were Diabetes, Dementia with behavioral disturbances, and Mood Disorder. Resident 10 was Hispanic and only spoke and understood the Spanish language. During an observation and concurrent interview with Resident 10, with the aid of Unlicensed Staff A acting as an interpreter, on 8/1/19, at 2:30 p.m., Resident 10 stated he remembered being physically abused by a patient care staff of the facility. Resident 10 remembered the staff member twisted his right hand. Resident 10 also stated he felt pain on his right hand after the incident. He further stated the staff member, who twisted his right hand, may have suffered pain as well, because of the force the staff member exerted in twisting his hand. Resident 10 could not recall how long ago the incident happened, but during the interview, he was looking at his right hand while alternately forming a clenched fist and relaxing his right hand. Resident 10 stated he was not affected mentally or emotionally by the incident. Resident 10 also stated he could take care of himself and was not fearful of any staff hurting him. Resident 10 was also unsure about the gender of the patient care staff who inflicted pain on his right hand, and at one point during the interview, referred to the staff member as, "hombre," a male staff member. Resident 10 did not exhibit aggression or combativeness during this interview. Resident 10 stated he did not remember the names of staff who provided patient care to him. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 3 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with Unlicensed Staff B on 8/1/19, at 5 p.m., she stated she learned about the incident after she was told about it by Unlicensed Staff C. Unlicensed Staff B stated Unlicensed Staff C told her she was getting frustrated because she reported the incident she witnessed to her supervisor, Licensed Staff E, one week prior, and Unlicensed Staff D, whom Unlicensed Staff C witnessed physically abusing Resident 10, was still working at the facility, as if the incident never happened. Unlicensed Staff B stated, after learning about the incident towards the end of her shift, she was able to report it to Administrative Staff F the following day. Unlicensed Staff B also stated Unlicensed Staff G had knowledge about the incident, because she (Unlicensed Staff G) had a close relationship with Unlicensed Staff C. Unlicensed Staff B also stated Unlicensed Staff C and Unlicensed Staff G were classmates in the same nurse aide training class of the facility. Unlicensed Staff B also stated she regretted not reporting what Unlicensed Staff C told her, immediately to the Administrator. Unlicensed Staff B also stated she was aware of her duties as a mandated reporter (Any person who is required by law to report a particular category or type of abuse to the appropriate law enforcement or social service agency. Mandated Reporters are legally responsible to report the incident themselves). During an interview with the DON (Director of Nursing) on 8/2/19, at 1:30 p.m., she stated she learned about the incident on 2/5/19, when she and the Administrator were notified by Administrative Staff F. The DON was not able to state the exact date when the incident happened, but stated the incident happened sometime in January. The DON also stated Unlicensed Staff C reported the incident to Licensed Staff E, the instructor of the nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 4 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE aide training class. The DON further stated, since 2/5/19, the time when she and the Administrator learned about the incident, they were not able to talk to Licensed Staff E because she was involved in an accident and had to go on leave. The DON further stated Licensed Nurse E sustained injuries during the accident and was still on medical leave during this interview. The DON also stated, after she learned about the incident, Unlicensed Staff D was suspended from working at the facility. When the DON was asked if they conducted an investigation on the incident, she stated, "Yes." When the DON was asked if they were able to substantiate the allegation, she stated, "Yes." The DON further stated there was another team from Sacramento who had already conducted an investigation on the incident. During an interview with Unlicensed Staff G on 8/2/19, at 2:45 p.m., she stated she learned about the incident on the same day it happened. Unlicensed Staff G also stated she was unsure about the exact date of the incident, but she stated she gave Unlicensed Staff C a ride home on that day. It was during this commute when Unlicensed Staff C told her that Unlicensed Staff D grabbed and twisted Resident 10's hand after he became combative during patient care. Unlicensed Staff G also stated Unlicensed Staff C asked Unlicensed Staff D to stop. Unlicensed Staff G told Unlicensed Staff C they needed to call Licensed Staff E, who was their instructor on their Nurse Aide Training Program and report the incident, because they did not know what to do. Unlicensed Staff G further stated she and Unlicensed Staff C called Licensed Staff E and told her about the incident on the same day that it happened. Unlicensed Staff G stated Licensed Staff E told her and Unlicensed Staff C the incident would be reported and investigated. Unlicensed Staff G also stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 5 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that after two weeks had passed, she and Unlicensed Staff C asked Licensed Staff E about the developments on the incident that they reported to her. Unlicensed Staff G stated Licensed Staff E told her she had already reported the incident. Unlicensed Staff G stated that after a couple of weeks had passed, she, Unlicensed Staff B, and Unlicensed Staff C, were given counseling by the DSD (Director of Staff Development) regarding abuse prevention and reporting. During an interview with Licensed Staff H on 8/2/19, at 4 p.m., she stated that she was aware that she is a mandated reporter. She also stated that the facility staff just got an inservice on abuse prevention a week ago. She also stated that she knew what official form to use when reporting abuse but she could not remember the name of that official form. She also stated that the Administrator is the abuse coordinator. The facility policy and procedure titled," Abuse: Prevention of and Prohibition Against," last revised on 11/28/17, and a current policy and procedure the facility used, indicated on Section H. Reporting/Response: 1). All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2). Allegations of abuse, neglect, misappropriation of resident property, or exploitation, will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframe's, as per this policy and applicable regulations.

F687 Foot Care FORM CMS-2567(02-99) Previous Versions Obsolete

F687 Event ID: KWOZ11 09/13/2019 Facility ID: CA010000080 If continuation sheet 6 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.25(b)(2)(i)(ii) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(b)(2) Foot care. To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: (i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and (ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide one sampled resident (Resident 6) podiatry care, including toenail trimming. This had the potential to cause injury, discomfort and infection to Resident 6. Findings: During a concurrent observation and interview on 8/2/19 at 11:27 a.m., Resident 6 had long toenails and fingernails. When asked if she would like to have her nails cut, she said, "Yes, but not my fingernails, only my toenails." When asked if she had seen a podiatrist recently, she said, "No, I have been asking for the past few months to see a podiatrist. I asked my aide. I want my toenails trimmed ...I have been asking to see the podiatrist for a few months." During an interview with the Social Services Supervisor (SSS) on 08/02/19 at 11:35 a.m., regarding why Resident 6 had not seen a podiatrist, she stated, "She should have been on the list the last two times, I am not sure what happened and why she was not seen." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 7 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Copies of the logs from the last two podiatrist visits were requested. Record review of the podiatrist logs titled, "Podiatry Billing Office," dated 4/3/19 and 6/27/19, from the last two visits, did not show Resident 6 listed or having refused visits. Her name was absent from the patient logs. The facility policy, dated 12/3/18, titled, "Ukiah Post Acute Podiatry Policy and Procedure," indicated the following: "Policy: It is the policy of this facility that residents will be offered podiatry services on an as needed and a routine basis. Procedure: Nursing staff will secure orders for podiatry service and communicate with the Social Services Director, or designee, the need for service. Social Service Director, or designee, will coordinate with in-house podiatric group to schedule podiatric rounds. Social Services will coordinate appointments with community podiatrists, if resident prefers. Podiatry progress notes to be filed under Physician Progress Note section of the resident chart."

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 09/13/2019 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 8 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure a fortified diet recommendation for one resident (Resident 18) was submitted to the Medical Doctor (MD). Failure to submit a request to the MD for a diet enhancement could have led to continued weight loss and further compromise of Resident 18's health. Findings: During a medical record review on 7/30/19 at 3:30 p.m., the Registered Dietician's (RD) note, dated 6/4/19, indicated, a -10.5% weight loss over six months and a new fracture (Fx) of the right trochanter (top part of the thigh bone) for Resident 18. The RD discussed Resident 18's weight variance during the weight loss committee meeting on 6/4/19, and recommended sending a request to the MD for a fortified diet. During review of the Interdisciplinary Team (IDT) update notes on 7/31/19 at 3:30 p.m., the IDT notes, dated 6/9/19, indicated the RD recommended a fortified diet; awaiting MD response. No MD response was found in the medical record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 9 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the RD on 7/31/19 at 3:30 p.m., she stated the request for the fortified diet for Resident 18, was submitted to the nursing staff on 6/4/19, and awaiting MD approval. During an interview with the DON (Director Of Nursing) on 8/1/19 at 8:55 a.m., the order sent to the MD for the fortified diet was requested. The DON stated, "The recommendation from the RD on 6/4/19, for the fortified diet was not sent over to the MD." The DON stated she would call the MD this day and send over the recommendation.

F801 SS=F Qualified Dietary Staff CFR(s): 483.60(a)(1)(2)

F801 09/22/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 10 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 11 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure comprehensive nutritional services were being provided when: 1. Hot food cool-down procedure did not meet professional standards; 2. Food ordering was not sufficient for menus; 3. Recipes were not followed as written; and, 4. Menus were not followed as written Failure to ensure comprehensive oversight by the Registered Dietician may result in systematic failures of nutrition service and diminished quality of life for all 54 residents in the facility and had the potential to cause widespread food-borne illness in a vulnerable population with complex medical conditions. Findings: During review of dietetic services operations from 7/29/19 -8/1/19, multiple issues were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 12 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE identified in relation to food safety standards (Cross reference F802, F803, F804, F812). During an interview with the Registered Dietician (RD) and RRD on 7/31/19 at 2:06 p.m., the RD described a typical consultation day at the facility. The RD stated she routinely checked with the Dietary Services Supervisor (DSS) and the Director of Nurses (DON) about Residents who might need to be seen and worked through high-risk residents first. She stated she always stopped in the kitchen to make sure everyone was keeping up with everything (the workload). She tested foods, and temperatures were taken. She made sure staff kept tray line on time. In the Dining room, she stated she observed tray pass, then did clinical, meeting residents and charting. She also stated she did a monthly sanitation check in the kitchen, she documented and gave a copy to the DSS, Administrator and DON. If she had time at the end of the day, then she would talk and go over her findings with the Administrator and would write on daily Registered Dietician reports what was discussed. The RD further stated she only attended Quality Assurance Performance Improvement (QAPI) if asked and had not been asked at this facility. She was unaware of meeting date/time, if issues had been taken to QAPI or if there were any specific QAPI projects from dietary. The surveyor reviewed the areas of concern with the RD. She acknowledged she had not identified issues with labeling/dating; facial hair; compromised utensils/utility carts or meeting resident preferences. On occasion, [she had] identified staff were not following recipes/menu. She stated equipment should be cleaned and not broken. If the protective coating was coming off, then equipment should be fixed or replaced. Additionally, the RD also looked at resident refrigerators on a monthly basis, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 13 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reviewing dates, labels, room numbers, cleanliness and refrigerator temperature logs. She stated, "I haven't looked this month and last month may have pulled a couple of things, but most everything was in good repair. If the DSS was checking the refrigerators every other day, then the food items should be ok, but it depends on the types of food in the refrigerator." She also stated she was not aware if checking dates and discarding food was nursing or dietary responsibility. Record review of the Registered Dietician Consultant Job Description duties, not dated, included: 1. Provides regularly scheduled on premise consultation as contract specifies; 2. Consults with administration regarding Food and Nutrition services in the area of Policy development, long-term and short-term goals, menus, and integration of RDs for Healthcare's systems into the facility's systems; 3. Supports the Food and Nutrition Services Director in maintaining department standards of food service in the areas of selection, receiving, storage, preparation, safety, and delivery to residents; 4. Conducts food safety and sanitation inspections with recommendations for items not meeting standards; 5. Documents nutrition information in resident's medical record in accordance with the standards of RDs for Healthcare and the accepted professional practice; 6. Provides in-service education for nutrition and food service related topics and assists with staff development programs for facility personnel. 7. Maintains and provides written reports of each consultation including date, hours, observations, recommendations, meetings attended, and in-services given; 8. Assists in the establishment and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 14 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE implementation of the Food and Nutrition Services budget, including staffing, food and supply costs; 9. Reviews and approves and menu changes the facility makes; and, 10. Keeps current in the regulations governing state and federal policy regarding food service and nutrition care for the facility.

F802 SS=E Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 09/22/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 15 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation and interview, the facility did not ensure the competency of two kitchen staff in relationship to proper cool-down procedures. This failure had the potential to expose Residents to food-borne illness. Findings: Potentially Hazardous Foods (PHF's) are those capable of supporting bacterial growth associated with food-borne illness. Cooked PHF's require time/temperature control monitoring during the cool-down process to ensure food safety. PHF's include cooked protein-based items, cooked starches and heat-treated vegetables. The standard of practice would be to ensure PHF's reach a temperature of 135-70 degrees Fahrenheit (F) within two hours and from 70-41 degrees F or below within an additional four hours, a timeframe not to exceed six hours. It would also be the standard of practice that if a food did not reach 70 degrees F within the first two hours, the item must be reheated to an internal temperature of 165 degrees F for 15 seconds, after which the cool-down monitoring would be repeated (Food Code, 2019). Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 16 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE identified as one of the leading contributing factors to food-borne illness. During slow cooling, time/temperature control for safety foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation temperatures, 70-125 degrees F, is to be avoided (USDA Food Code Annex, 2019). In an interview on 7/30/19 at 9 a.m., when asked to describe cool-down procedures for previously cooked foods that were held for future use, Dietary Staff (DS) Q stated items were first cooked to 165 degrees F. Dietary Staff Q further stated the item needed to cool to 140 degrees F within two hours, and within the next four hours the temperature of the item should be 70 degrees F and within an additional four hours (a total of ten hours) to a temperature of 41 degrees F or below. DS Q was verbalizing the procedure while reading the cool-down log. In a concurrent interview, the Dietary Services Supervisor (DSS) stated, "The AM cook will start the process of cool down and the PM cook will finish." In an interview on 7/30/19 at 3:24 p.m., Dietary Staff T stated, "When cooling we'll put the cooked food in an ice bath and has to get down to 40 degrees in six hours, will check every hour." When asked to describe the process, if an item with a beginning temperature of 135 degrees F was 75 degrees after two hours, DS T stated, "Would put more ice in the ice bath and continue to cool and would continue to cool for six hours and if not below 41, would throw away." When asked to describe the process of making tuna salad, DS T stated the item was prepared about once per month. DS T further stated the tuna was placed in the walk-in refrigerator two hours before preparing the tuna. She also stated upon completion, the prepared item was placed in an ice bath (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 17 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE method used to facilitate cooling by placing ice and water in a container then placing a second container on top of the ice/water mixture), however there was no temperature monitoring. In a concurrent interview, the DSS stated there was no cool-down monitoring because the items were refrigerated prior to preparation. In a follow-up interview on 7/30/19 at 4 p.m., the DSS stated the expectation was for cooks to be knowledgeable in cool-down monitoring while using the cool down log as a reference. Facility policy titled, "Monitoring Temperatures and Cool Down Log," dated 2018, guided staff to reheat cooked, hot food to 165 degrees F for 15 seconds and start the cooling process again, using a different cooling method when the food was above 70 degrees F, two hours or less into the cooling process, or above 41 degrees F and six hours or less into the cooling process. Additionally, the policy guided staff to discard cooked, hot food immediately when the food was above 70 degrees F and more than two hours into the cooling process, or above 41 degrees F and more than six hours into the cooling process. The policy was not consistent with the standards of practice.

F803 SS=F Menus Meet Resident Nds/Prep in Adv/Followed CFR(s): 483.60(c)(1)-(7)

F803 09/22/2019 §483.60(c) Menus and nutritional adequacy. Menus must§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.; §483.60(c)(2) Be prepared in advance; §483.60(c)(3) Be followed; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 18 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups; §483.60(c)(5) Be updated periodically; §483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and §483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the menu and recipes were followed. This failure had the potential for residents not meeting their nutritional requirements as set forth in the menus. Findings: During observation and interview on 7/30/19 at 11:30 a.m., the Dietary Services Supervisor (DSS) was asked to weigh a slice of turkey being served for lunch. She weighed three pieces, and the weights were: 2.5 ounces (oz), 2.8 oz and 2.75 oz. The DSS confirmed the weights and stated: "They [staff] weigh one piece and eyeball the rest." The menu/cooks' spreadsheet, dated 7/30/19, showed 3 oz. of turkey should be served. During tray line observation and interview on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 19 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 7/30/19 from 11:30 a.m. to 12:08 p.m., Dietary Staff (DS) Q was using a four oz. ladle, filled half way, to serve gravy. DS Q stated of the two oz. gravy, "I used four oz. ladle; I gave half." In a concurrent interview, the DSS stated the serving size for gravy should be 1 oz. The menu/cooks' spreadsheet, dated 7/30/19, showed 1 oz. of gravy should be served.

F804 SS=F Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) 09/22/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to serve flavorful food to residents. This failure had the potential for residents not enjoying their lunch, and not meeting their nutritional requirements, as set forth in the menu. Findings: A test tray was completed on 7/30/19 at 12:45 p.m. It was noted the pureed stuffing, pureed broccoli, regular broccoli and regular stuffing, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 20 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was bland. In a concurrent interview, when asked, whether she tasted any spices in these foods, the Dietary Services Supervisor (DSS) stated she thought she tasted some onion in the stuffing. During an interview on 7/30/19 at 12:47 p.m., Dietary Staff Q stated he forgot to add the celery, and he did not add the chicken broth/base, because he was out of it and used plain water. At 12:48 p.m., the Regional RD stated, "That would explain why it tasted bland." Concurrently the DSS stated, "Out of chicken base, it did not get put on the white board. I didn't know." At 12:53 p.m., the DSS stated, "[Dietary Staff Q] should have asked the RD what to substitute, because vegetable base and beef base was available." During record review, the, "Facility Policy Food Substitutions During Tray line," dated 2018, indicated the cook should refer to the Recipe Substitutions Guide found in the RDs for Healthcare's Binder #1, miscellaneous section, to find what may be substituted and the recipe for that item. During review, the standardized recipe for Bread Dressing (Stuffing) listed ingredients as wheat bread cubed, salt, pepper, poultry seasoning, onion minced, celery chopped, margarine, low sodium chicken stock, large pasteurized eggs, beaten. During an interview on 07/31/19 at 11:46 a.m., Resident 21 stated, "The stuffing served yesterday at lunch had no taste or seasoning. It tasted like mushy bread. "

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 09/22/2019 §483.60(i) Food safety requirements. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 21 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food, in accordance with professional standards for food service safety when: 1. Dishes were not cleaned or dried properly; 2. Condition of utensils, in a serving cart, were not maintained; 3. Portable fan in the kitchen was not clean; 4. Food was contaminated; 5. Dietary staff did not have hair consistently restrained; and, 6. Food was found in the Resident refrigerator with no dates and spoiled. These failures had the potential to cause foodborne illness in residents. Findings: 1. During an observation on 7/29/19 at 9:31 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 22 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a.m., a pan pulled from the back of the bottom shelf of clean pans, had white residue inside. 2. During an observation and concurrent interview on 7/29/19 at 9:50 a.m., a plastic serving cart, filled with clean cooking utensils was on a dish rack. Within the bin were three spatulas with cracks in the rubber and one with a dark residue on the rubber. The DSS stated, "Spatulas should be thrown away when in poor condition, but residue was ok." A metal scraper, in the bin with, "clean" utensils, had sticky residue on its blade. The rubber handle had black, red and blue residue imbedded on its rough plastic handle. The DSS stated: "If there is a damaged utensil, we replace it, that wasn't properly cleaned." Dietary Staff Q stated he used it as a griddle scraper. During an observation on 7/29/19 at 10 a.m., nine pans used for holding food, were stacked and stored wet, on a clean equipment rack. Plastic containers were tightly stacked. Two of the plastic containers had what resembled food residue on the inside. The DSS confirmed the presence of residue and stated it was, "ok because we'll air dry while stacked." During observation in the dry storage room, of the kitchen, on 7/30/19 at 9 a.m. two plastic serving carts had coating on the top shelf, which was not intact, was rough and caked with residue. The DSS stated it was, "ok because not touching food." The Facility Policy titled, "Sanitation," dated 2018, item number 9 indicated, "All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair." Item number 10 indicated, "Plastic ware, china, and glassware that becomes unsightly, unsanitary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 23 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or hazardous because of chips, cracks or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining." 3. During observation on 7/30/19 at 10:44 a.m., a portable plastic box fan on the dish machine counter was pointing toward the clean dish area. The fan blade cover was covered with a significant layer of gray, fuzzy debris. The DSS stated, "Fans are deep cleaned by maintenance every month, and kitchen staff will wipe down as needed." She stated she did not consider the fan clean. During an interview, on 8/1/19 at 11:45 a.m., the Maintenance/Housekeeping Manager stated he was not sure if he was responsible for cleaning portable fans, but he cleaned them when staff brought them to him. He stated he thought dietary kept a fan in the kitchen, as they brought one to him yesterday for cleaning. 4. During an observation on 7/30/19 at 11:30 a.m., a pan of beans fell into the steam well. Dietary Staff S put on an oven mitt, and when he reached in to grab it, the mitt touched the beans. He then placed the beans back on the tray line and continued to serve food. When asked if it was ok for the oven mitt to come into contact with the beans the DSS stated, "No, it's a contaminant. Start over. Toss Serving." During observation and concurrent interview on 7/30/19 at 3:24 p.m., the mitts had food caked on the outside surface. The DSS stated, "Oven mitts are thrown away when they are torn or caked with food. They are not cleaned." 5. 2019 USDA Food Code ARTICLE 5. Personal Cleanliness 113969. (a) Except as specified in subdivision, (b) all food employees preparing, serving, or handling food or utensils shall wear hair restraints, such FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 24 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE as hats, hair coverings, or nets, which are designed and worn to effectively keep their hair from contacting non-prepackaged food, clean equipment, utensils, linens, and unwrapped single-use articles. During an observation 7/30/19 at 12:08 p.m., Dietary Staff S was wearing a beard cover, but Dietary Staff R was not. The DSS stated, "[Dietary Staff R's name] beard is trimmed, [Dietary Staff S's name] is not." The facility policy titled, "Dress Code for Women and Men," not dated, indicated under Proper Dress Item number 6: "Hair net or hat which completely covers the hair (Long hair shall be worn in a tight bun)." Item number 7 indicated: "Beards and moustaches which are not closely cropped and neatly trimmed should be covered." The facility policy was not consistent with current standards of practice. During observation and concurrent interview on 7/29/19 at 2:27 p.m., multiple undated items were noted in the resident refrigerator/freezer, located in the employee break room: Two Mighty shakes, with no thaw-date; Store-bought apple pie, undated; Zucchini and carrots, undated; Two paper plates containing cake/frosting/blueberries, had ink written on the inside of paper plate and was touching the frosting; the cake was open to air; Large plastic bag of items on the bottom shelf had no date visible. The bag contained a plastic container of cut melon with no date. A plastic container of what appeared to be peanut butter, had no date. Corn salad had no date. There were also two avocados, over ripe and squishy, and plums breaking apart the bag containing them. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 25 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The DSS stated: "This food is not dated. The nursing staff was responsible. It is to be discarded in three days. I'll come every three days." She acknowledged there was no way to identify when the shakes were thawed. "It should have been discarded at midnight last night or this morning." The DON stated: "Usually store-bought items they do put a date on it. Cake, that was from Friday." The Housekeeping Manager stated: "Housekeeping cleans the refrigerator. My staff. I don't know their schedule, I'm not sure, once a week." When asked whether the refrigerator looked clean, the Housekeeping Manager stated, "No." The DSS stated, "The dietary (herself) is responsible for checking the dates on food and discarding food every two to three days. Foods can be kept for three days, and the first day is the day it was placed in the fridge." She stated nursing ensured it was labeled and dated when the family brought in the food. The DON stated, "The pie was brought in Saturday night on the 26th (according to the Resident). The DSS stated, "The veggies in the plastic container were brought in on Friday (according to the Resident), and the large bag of food was brought in at the beginning of last week." The last time the she looked in the resident refrigerator was Thursday of last week. During an interview on 7/30/19 at 8:39 a.m., the Housekeeping Manager stated there was no cleaning schedule for housekeeping, whom he confirmed was responsible for cleaning the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 26 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident refrigerator, which included the refrigerator and freezer. The facility policy titled, "Food for Residents from Outside Sources," revised 4/2016, under Procedures, Item number 4 indicated: "All items must be dated on delivery and written on the container." Item number 5 indicated: "All items will be discarded after 3 days or by the manufacturer's expiration date."

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 09/13/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 27 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 28 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interviews, and record reviews, the facility failed to: 1. Offer hand hygiene to Resident 21 and Resident 39, in their rooms before lunch. 2. Disinfect a blood pressure cuff after each use; 3. Bag/Contain contaminated laundry where collected; and, 4. Ensure the biohazard container, which contained medical waste, was kept closed to prevent the spread of infection. These failures had the potential to cause the development and transmission of communicable diseases and infections. Findings: 1. During an observation on 7/29/19 at 11:59 a.m., staff were passing lunch trays to residents eating in their rooms. Resident (39) was on contact precautions for a possible Carbapenem-resistant Enterobacteriaceae (CRE) infection. Anyone entering the room was to don Personal Protective Equipment (PPE); gown and gloves. A CNA (Certified Nursing Assistant) was cleansing her hands and putting on a gown and gloves; the nurse checking tray tickets handed the lunch tray to the CNA. The CNA was setting-up the lunch tray for Resident (39) and left the room. No hand hygiene was offered to Resident (39) prior to eating. During an observation on 07/31/19 at 12:22 p.m., Resident 21 was served lunch in her room and consisted of lettuce in a small salad, beets, cooked veggies of beans and carrots, apple sauce, and canned peaches for dessert. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 29 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE There was no hand hygiene for Resident 21 during this time. During an observation and interview on 8/1/19 at 12 p.m., Resident (39) was sitting up at the side of her bed having oxygen therapy delivered via nasal cannula at two liters per minute and was waiting for lunch. When asked how she was feeling, Resident (39) responded, "I feel good." Unlicensed Staff D, donned with gown and gloves, carried the lunch tray to Resident (39), and set-up the tray while reviewing the food items. Resident (39) thanked Unlicensed Staff D, and she left the room. When asked if she was offered a towel or hand wipe for her hands, Resident (39) stated, "No." 2. During an observation on 7/31/19 at 8:31 a.m., Licensed Staff M removed a Blood Pressure (B/P) cuff from medication cart #2 and took a resident's blood pressure. Licensed Staff M returned the B/P cuff to the medication cart. There was no cleaning of the B/P cuff. During an observation and interview on 08/01/19 at 8:28 a.m., blood pressure cuffs and stethoscopes were contained in drawer 5 on Med Cart #1. When asked how often the B/P cuffs were cleansed, Licensed Staff H stated she used her own B/P Cuff and cleansed it after each use; cleansing with the disinfectant wipes on the medication cart. During an observation and interview on 08/01/19 at 3:20 p.m., Licensed Staff N removed a B/P cuff from Med Cart #1, took a B/P of Resident 17 and put the B/P cuff back in the drawer. Licensed Staff N removed the B/P cuff again and took a B/P of Resident 38, with no B/P cleaning in-between resident use. When asked how often the B/P cuffs were cleansed, Licensed Staff N stated, "After med pass is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 30 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE over." During an interview on 8/2/19 at 4 p.m., the DON was asked for a policy and procedure (P&P) for cleaning of medical equipment, which included blood pressure cuffs. The DON stated the facility did not have a P&P specifically for cleaning B/P cuffs. "I do have a guidance from the CDC for cleaning non-critical resident-care items." Review of the facility procedure titled, "Cleaning and Disinfecting Non-Critical Resident-Care Items," revised June 2011, indicated, "Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment)." 3. During an observation and concurrent interview with Unlicensed Staff I, at the dirty laundry closet, between Rooms 22 and 24, on 08/2/19, at 9:42 a.m., Unlicensed Staff I was asked to remove the cover of the soiled laundry barrel to visualize its contents, which contained a mix of bagged and un-bagged contaminated laundry. The un-bagged laundry was a combination washable incontinent pads and soiled linens. The smell of urine was coming out of this dirty laundry barrel. Unlicensed Staff I stated the contaminated laundry should have been bagged for odor control. Unlicensed Staff I also stated," I was wondering how these dirty laundries were transported from the resident's room to this soiled laundry closet. 4. During observation and concurrent interview with Unlicensed Staff I, in the Utility Room by Station 1, on 8/2/19, at 9:47 p.m., she opened the dirty laundry barrel, and it contained one red biohazard bagged laundry, dirty laundry bagged in regular trash bags, and un-bagged washable incontinent pads. There was a mild FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 31 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE urine odor after the barrel was uncovered. Next to the soiled laundry barrel was a red biohazard waste container overflowing with red, biohazard bagged medical waste. This biohazard container was open because of it was overflowing. Unlicensed Staff I stated that this should have been emptied because the cover of the container should be able to close. During an interview with Unlicensed Staff J on 8/2/19, at 9:55 a.m., she stated the dirty laundry barrel should not be taken to collect soiled laundry in resident rooms. During an interview with Unlicensed Staff K on 8/2/19, at 10:03 a.m., she stated the soiled laundry from resident rooms should be bagged where they were collected. During an interview with the DSD (Director of Staff Development) and currently in charge of infection control, on 8/2/19, at 1:39 p.m., she stated the biohazard container in the Utility Room should not be overflowing, and the cover of the container should be able to close. During an interview with Unlicensed Staff L on 8/2/19, at 3 p.m., she stated the housekeeper was mainly responsible to empty the biohazard container when it was full, but the CNAs or the nurses could take them out as well when it was full. The facility policy and procedure titled, "Prevention and Control of MDRO (Multi-Drug Resistant Organism), last revised on 9/29/17, and was a current facility policy, indicated under Letter D, "Contaminated linens should be handled appropriately whether their source was an isolation room or a non-isolation room. All linen should be handled as if it were highly infectious. No special bagging of isolation linen required unless otherwise assessed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 32 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F908 Essential Equipment, Safe Operating Condition F908 CFR(s): 483.90(d)(2) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/13/2019 §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain medical equipment for one resident (Resident 19), when his wheelchair brakes were not working. This failure had the potential to put Resident 19 at risk for injury. Findings: During observation of mealtime on 7/29/19 at 11:56 a.m., Unlicensed staff O put a book on the floor behind Resident 19's wheelchair wheel so he would not roll back. At 12:10 p.m., Unlicensed staff O kicked the book aside and escorted Resident 19 back to his room. Unlicensed staff O was asked about the book, and he stated, "We are waiting to have the brake fixed, it just happened today, it is a new thing for him." During an interview on 7/30/19 at 9:50 a.m., Unlicensed staff B stated, "Resident's wheelchair is partially fixed, it'll lock but to get lock off is really hard." During an interview on 7/30/19 at 14:30 p.m., Unlicensed staff G stated, "I know that it is broken. I requested repair once." Unlicensed staff P stated, "I requested once also and Maintenance needs to order a part." During an interview on 7/30/19 at 16:08 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 33 of 34 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055734 (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE UKIAH POST ACUTE 1349 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the Maintenance/Housekeeping Manager, "I fixed it yesterday and today. He has convulsions, he pushes the brake past. I'm trying to order a new brake. I think it needs a whole new brake. I'm having trouble finding for that wheelchair." During an interview, the Maintenance/Housekeeping Manager stated on 8/1/19 at 11:45 a.m., he thought he knew about Resident 19's wheelchair for about a month. He found out about it when he received a work order from Nursing. During review of a Maintenance Log, dated 6/29/19, Unlicensed staff G reported the wheelchair right side brake did not work. The Maintenance/Housekeeping Manager signed the log as fixed on 6/30/19. Review of the Facility Policy/Procedure titled, "Wheelchair Cleaning/Maintenance," indicated, all patient wheelchairs will be cleaned monthly or as needed. Wheelchairs will be inspected at time of cleaning and any repairs made as necessary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWOZ11 Facility ID: CA010000080 If continuation sheet 34 of 34