Inspection·March 20, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some needed help with her shoes from Unlicensed Staff D. Resident 42 stated she was explaining how she needed to put her foot down to secure the straps of her shoes, when Unlicensed Staff D cut her off and stated, I know what I'm doing. Don't tell me what to do. Resident 42 stated Unlicensed Staff D leaned close to her face and told her to stop hollering at me. Resident 42, with eyes wide, demonstrated how close Unlicensed Staff was, by holding a palm about two inches from her face. Resident 42, occasionally blinking back tears during the interview, stated, It was scary. I've never had anybody do that to me in the real world; I did not expect that to ever happen here. Resident 42 stated Unlicensed Staff D continued to be assigned to her care even after she had notified staff about the incident. During an interview on 3/17/23 at 10:03 a.m., the Administrator stated he was the facility's Abuse Coordinator. Administrator stated he investigated the event and interviewed Residents 149 and 42 but was unable to substantiate the events as abuse. When asked if yelling and threatening gestures such as towering and intimidation could be considered abuse, Administrator stated there were some customer service issues and attitudes, but as both Residents 149 and 42 stated they were not abused, the facility therefore determined it was not abuse. During an interview on 3/20/23 at 8:21 a.m., Director of Staff Development (DSD) stated yelling at, aggression towards, and threatening residents are abusive behaviors. DSD stated such incidents should immediately be stopped, reported to the nurse. DSD stated, We need to protect the residents. DSD stated Unlicensed Staff D's actions towards Residents 149 and 42 were threatening, inappropriate, and abusive. During an interview on 3/20/23 at 8:48 a.m., Director of Nursing (DON) stated abuse could be any inappropriate interaction with residents. DON stated inappropriate tone, such as demeaning or yelling, and intimidation, were abusive. DON stated Unlicensed Staff D's actions were inappropriate, and [Unlicensed Staff D] should have been suspended immediately. A review of the facility policy titled, Abuse: Prevention of and Prohibition Against, dated 10.2022, indicated, It is the policy of this Facility that each resident has the right to be free from abuse . Abuse if the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . It includes verbal abuse . Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Verbal abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 2 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based 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) Findings: Record review of the Grievance Binder on 3/16/23 2:42 p.m. revealed the facility received two verbal abuse allegations against Unlicensed Staff D, from Residents 149 and 42, on 2/27/23. During a concurrent interview, Social Services Director (SSD) stated she verbally reported the incidents to the Administrator immediately on 2/27/23. During an interview on 3/17/23 at 8:35 a.m., the Administrator stated he was the facility's Abuse Coordinator. The Administrator stated he was notified of Residents 149's and 42's complaints against Unlicensed Staff D. When asked about reporting abuse allegations, the Administrator stated the State [Department] was only notified if, after facility investigation, the abuse allegation was substantiated. A review of Resident 149's admission Record indicated diagnoses including need for weakness, assistance with personal care, and anxiety disorder (a mental health disorder characterized by intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 149's Grievance Resolution Form, dated Date Received: 2/27/23, Time: 2:15, indicated, SUMMARY STATEMENT OF THE RESIDENT'S GRIEVANCE: Resident asked a CNA [Unlicensed Staff D] to move the chair . and the CNA responded rudely and threatened her . She does not feel safe around this CNA and resident said that she is afraid of her and does not want her near her. During an interview on 3/17/23 at 9:01 a.m., Resident 149 stated Unlicensed Staff D was rude and would not listen to her request to move a chair that was blocking her path to the bathroom. Resident 149 stated Unlicensed Staff D raised her voice and asked, Why are you arguing with me?! Resident 149 paused and looked down on her clasped hands on her lap. A few moments passed, and in a quiet voice, Resident 149 stated, I don't like it when people yell at me. She did not have to yell at me. When asked how the incident made her feel, Resident 149 stated, I was scared. I feel like I was threatened. Resident 149 stated, If I did not speak up, what if she was doing the same thing to others? A review of Resident 42's admission Record indicated diagnoses including major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder. Resident 42's Grievance Resolution Form, dated Date Received: 02/27/23, Time: 2:00 p.m., indicated, SUMMARY STATEMENT OF THE RESIDENT'S GRIEVANCE: .a female CNA . got right in her face . she does not feel safe around that CNA and does not want to work with her again . During an interview and concurrent observation on 3/17/23 at 9:34 a.m., Resident 42 stated she needed help with her shoes from Unlicensed Staff D. Resident 42 stated she was explaining how she needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 3 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to put her foot down to secure the straps of her shoes, when Unlicensed Staff D cut her off and stated, I know what I'm doing. Don't tell me what to do. Resident 42 stated Unlicensed Staff D leaned close to her face and told her to stop hollering at me. Resident 42, with eyes wide, demonstrated how close how close Unlicensed Staff was, by holding a palm about two inches from her face. Resident 42, occasionally blinking back tears during the interview, stated, It was scary. I've never had anybody do that to me in the real world; I did not expect that to ever happen here. During an interview on 3/17/23 at 10:03 a.m., the Administrator stated he investigated the event and determined there were some customer service issues and attitudes. Administrator stated he interviewed Residents 149 and 42 who stated they were not abused; therefore, the facility was unable to substantiate the events as abuse and were subsequently not reported. A review of the facility policy titled, Abuse: Prevention of and Prohibition Against, dated 10.2022, indicated, Reporting/Response: 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 timeframes, as per this policy and applicable regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 4 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to: Residents Affected - Some 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. Findings: Record review of the Grievance Binder on 3/16/23 2:42 p.m. revealed the facility received two verbal abuse allegations against Unlicensed Staff D, from Residents 149 and 42, on 2/27/23. During a concurrent interview, Social Services Director (SSD) stated she verbally reported the incidents to the Administrator immediately on 2/27/23. During an interview on 3/17/23 at 8:35 a.m., Administrator stated he was the facility's Abuse Coordinator. The Administrator stated he was aware of the verbal abuse allegations by Residents 149 and 42 against Unlicensed Staff D. Administrator stated, I did my due diligence and investigated immediately. The Administrator stated the investigation was conducted by interviewing both Residents 149 and 42, and Unlicensed Staff D. Concurrent review of the investigation reports provided by the Administrator revealed two undated pages indicating, Interview with Ms. [Resident 149] and Interview [Resident 42]. Further review revealed the pages contained a summary of the interviews between the Administrator and Residents 149 and 42. When asked if there were any other investigation notes, Administrator stated it was all written on the pages provided. A review of Resident 149's admission Record indicated diagnoses including need for weakness, assistance with personal care, and anxiety disorder (a mental health disorder characterized by intense, excessive, and persistent worry and fear about everyday situations). A review of Resident 149's Grievance Resolution Form, dated Date Received: 2/27/23, Time: 2:15, indicated, SUMMARY STATEMENT OF THE RESIDENT'S GRIEVANCE: Resident asked a CNA [Unlicensed Staff D] to move the chair . and the CNA responded rudely and threatened her . She does not feel safe around this CNA and resident said that she is afraid of her and does not want her near her. During an interview on 3/17/23 at 9:01 a.m., Resident 149 stated Unlicensed Staff D was rude and would not listen to her request to move a chair that was blocking her path to the bathroom. Resident 149 stated Unlicensed Staff D raised her voice and asked, Why are you arguing with me?! Resident 149 paused and looked down on her clasped hands on her lap. A few moments passed, and in a quiet voice, Resident 149 stated, I don't like it when people yell at me. She did not have to yell at me. When asked how the incident made her feel, Resident 149 stated, I was scared. I feel like I was threatened. Resident 149 stated, If I did not speak up, what if she was doing the same thing to others? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 5 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 42's admission Record indicated diagnoses including major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder. Resident 42's Grievance Resolution Form, dated Date Received: 02/27/23, Time: 2:00 p.m., indicated, SUMMARY STATEMENT OF THE RESIDENT'S GRIEVANCE: .a female CNA . got right in her face . she does not feel safe around that CNA and does not want to work with her again . During an interview and concurrent observation on 3/17/23 at 9:34 a.m., Resident 42 stated she needed help with her shoes from Unlicensed Staff D. Resident 42 stated she was explaining how she needed to put her foot down to secure the straps of her shoes, when Unlicensed Staff D cut her off and stated, I know what I'm doing. Don't tell me what to do. Resident 42 stated Unlicensed Staff D leaned close to her face and told her to stop hollering at me. Resident 42, with eyes wide, demonstrated how close how close Unlicensed Staff was, by holding a palm about two inches from her face. Resident 42, occasionally blinking back tears during the interview, stated, It was scary. I've never had anybody do that to me in the real world; I did not expect that to ever happen here. Resident 42 stated she told the facility staff that she did not feel safe around Unlicensed Staff D and did not want her to be assigned to her care. Resident 42 stated, But I still got assigned to her after that! During an interview on 3/17/23 at 9:35 a.m., HR stated Unlicensed Staff D's last day of work was on 3/1/23. A concurrent review of the [Facility] Assignment Sheets indicated Unlicensed Staff D was working the afternoon shift on 2/27/23, the morning shift on 2/28/23, and the afternoon shift on 3/1/23. Further review of the assignment sheet and Resident 42's Census Report (history of resident room locations) revealed Resident 42 was assigned to Unlicensed Staff D during the afternoon shift on 3/1/23, two days after she had reported feeling unsafe around Unlicensed Staff D. HR stated Unlicensed Staff D was suspended, removed from the staffing schedule after 3/1/23, and was subsequently terminated. A review of Unlicensed Staff D's Counseling/Disciplinary Notice, dated 03/06/2023, indicated, On February 27th, 2023, we received two formal grievances from residents . During an interview on 3/17/23 at 10:03 a.m., Administrator stated he could not recall when he was notified of Residents 149's and 42's grievances against Unlicensed Staff D. Administrator stated he immediately addressed the grievances and suspended Unlicensed Staff D. During a concurrent review of the Assignment Sheets and the Grievance Forms, the Administrator confirmed Unlicensed Staff D worked at the facility on 2/27/23, 2/28/23 and 3/1/23. When asked why Unlicensed Staff D continued to work at the facility for two more shifts after the grievances were reported, Administrator stated, I immediately addressed it as soon as I've heard of it. During an interview on 3/20/23 at 8:48 a.m., Director of Nursing (DON) stated abuse allegations should be reported immediately. DON stated the incidents should be care planned, and the residents should be assessed and monitored for any psychosocial effects. DON stated neither Resident 149 nor Resident 42 had any follow-up after the incident. DON stated the abuse allegations were not handled as it should have been followed through. When asked about the Unlicensed Staff D continuing to work at the facility for two more shifts after the allegations were reported, DON stated Unlicensed Staff D should have been suspended immediately. A review of the facility policy titled, Abuse: Prevention of and Prohibition Against, dated 10.2022, indicated, F. Investigation: After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychological harm . All allegations of abuse . will be promptly and thoroughly investigated by the Administrator or his/her designee . The investigation will include the following: an interview with the person(s) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 6 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete reporting the incident, an interview with the resident(s), interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate, a review of the resident's medical record, an interview with staff members (on all shifts) who may have information regarding the alleged incident, interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident, an interview with staff members (on all shifts) having contact with the accused employee, and a review of all circumstances surrounding the incident . The investigation, and the results of the investigation, will be documented . G. Protection: If an allegation of abuse . is reported, discovered or suspected, the Facility will take the following steps to protect the all residents from physical and psychosocial harm during and after the investigation: respond immediately to protect the alleged victim and integrity of the investigation, examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed . make room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator . Event ID: Facility ID: 055734 If continuation sheet Page 7 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 32 did not have a respiratory assessment or medical orders for oxygen therapy (Reference F695) Residents Affected - Some Review of Resident 32's admission record indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnosis that included: Chronic Obstructive Pulmonary Disease, Unspecified (A group of lung diseases that block airflow and make it difficult to breathe). Review of Resident 32's MDS OBRA admission and quarterly assessments did not indicate the resident required oxygen therapy. During an observation on 3/16/23 at 10:30 a.m., Resident 32 was lying in bed, when asked how she was feeling the resident mumbled some words and stated she did not feel well. An oxygen concentrator next to the resident's bed was on and running at 2/liters of O2, the nasal canula was on the floor, no date was observed on the oxygen tubing. During an observation and concurrent interview on 03/17/23 at 09:30 a.m., Resident 32 was lying in bed awake and alert. The resident was asked how often she wears her oxygen, she stated I wear oxygen at night, sometimes. The resident stated she does become short of breath after she exercises. When asked if she smoked, the resident stated she had a cigarette and took a few puffs when she was able to go outside. During a review of Resident 32's medical record on 3/17/23, No physician orders or respiratory assessments was found in the medical record or on the resident's care plan at any time during the resident's admission. Resident 32 did have medical orders for respiratory inhalers. During an interview on 3/17/23 at 2 p.m. Licensed Staff K was asked if Resident 32 had an order for oxygen therapy. Licensed staff K reviewed the medical orders and stated she could not find an order for the resident's oxygen. When asked if an order was needed for oxygen therapy she stated Yes. During an observation on 03/20/23 at 10:29 a.m., Resident 32 was in bed, an oxygen concentrator was on and the nasal cannula was on the floor. The resident was mumbling some words and stated she did not feel well. Licensed Staff A was asked if Resident 32 had orders for Oxygen therapy. Licensed Staff A further assessed Resident 32 and reviewed the medical record and confirmed the resident did not have an order for oxygen. When asked if an order for Oxygen therapy was required, Licensed Staff A stated yes and proceeded to contact the physician. During an interview on 3/20/23 at 2:30 p.m., the DON verified that Resident 32 did not have an physician's order or care plan for nasal cannula oxygen. When asked if an order for oxygen is required the DON stated Yes. Review of the Facility policy and procedure titled Care Planning revised on 11/2022 indicated, It is the policy of this facility that the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) shall develop a comprehensive Person- Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Based 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: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 8 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. (Reference F686) 2. Resident 32 did not have a respiratory assessment or medical orders for oxygen therapy (Reference F 695). Findings: Resident 23 During a record review for Resident 23, the Face sheet indicated Resident 23 was admitted on [DATE] with diagnoses including but not limited to Fracture of Shaft of Left Fibula (a break in the small bone that runs along the outside of the lower leg); Diabetes Mellitus (disease that result in too much sugar in the blood); Protein Calorie Malnutrition (when a person is not consuming enough protein and calories) and COVID (Corona Virus Disease - an infectious respiratory disease). During a record review for Resident 23, the document titled LN - Braden Scale (a tool to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer) for Predicting Pressure Sore Risk dated 2/07/23 indicated Resident 23 scored 13 indicating she was moderate risk for pressure ulcer (total Score of 9 or less was Very High Risk; 10 to12 was High Risk; 13 to 14 was Moderate Risk; 15 to 18 was Mild Risk and 19 to 23 was No Risk). During a record review for Resident 23, the document titled LN - Initial admission Record dated 2/07/23 indicated Resident 23 had an immobilizer (removable devices that maintain stability of the knee) to her left lower extremity. During a record review for Resident 23, the Care Plan initiated on 02/08/23 indicated, [Resident 23 had the potential for pressure ulcer development related to immobility, incontinence, and use of brace (a device used to immobilize a joint or body segment) to LLE (Left Lower Extremity). Care Plan interventions indicated, Monitor/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage; and Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 23, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 2/14/23 indicated Resident 23 was at risk for developing pressure ulcers. The MDS indicated Resident 23 did not have unhealed pressure ulcers during the assessment period. During a record review for Resident 23, the document titled SBAR (Situation, Background, Assessment and Recommendation - a tool used by health care professionals to communicate with each other about critical changes in patient's status) communication form dated 2/25/23 indicated Resident 23 was noted to have discoloration to her left heel that measured 7.5 x 2.5 cm (centimeters). The document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 9 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 indicated Resident 23 was wearing immobilizer to her left foot. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent records review with the DON (Director of Nursing) on 3/15/23 at 2:51 p.m. when asked about her expectation from the nurses for resident who came with an immobilizer, the DON stated if the doctor gave an order to leave the immobilizer in place, then nurses were not allowed to remove the immobilizer; however, nurses could check for circulation like pulse and skin temperature. Review of the physician's order with the DON and verified there was no doctor's order to not remove Resident 23's left leg immobilizer. The DON stated if there was no order to leave the immobilizer in place, nurses should definitely check the skin integrity for changes under the immobilizer at least once a day and document. Review of Resident 23's care plan with the DON did not indicate interventions to prevent the development of pressure ulcer under the left leg immobilizer. Residents Affected - Some Resident 38 During a record review for Resident 38, the Face sheet indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the document titled LN - Braden Scale for Predicting Pressure Sore Risk (a tool to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer) dated 12/22/22 indicated Resident 38 had a total score of 14. During a record review for Resident 38, the document titled Initial Care Plan dated 12/22/22 indicated Resident 38 had left heel pressure ulcer and potential for pressure ulcer. Care Plan intervention include but not limited to: daily body skin checks; Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the MDS dated [DATE] indicated Resident 38 was at risk for developing pressure ulcers. The MDS indicated Resident 38 had an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead tissue that separates from living tissue in a wound) or eschar (dead tissue that sheds or falls off from the skin) that was present upon admission. During a record review for Resident 38, the document titled Skin Wound Note dated 1/17/23 at 1:22 p.m. indicated Resident 38's pressure ulcer to left heel was resolved. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (the standard imaging test for patients suspected of having acute DVT) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister. During an interview and concurrent record review with the DON on 3/15/23 at 2:51 p.m. when DON was asked about process for care planning, the DON stated a care plan for change of condition should be created within 24 to 72 hours after the identification of the resident's change of condition. The DON verified there was no care plan developed for Resident 38's left heel blister. The DON verified the pressure ulcer care plan for Resident 38 did not indicated interventions to prevent the recurrence of pressure ulcer to Resident 38's left heel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 10 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview and concurrent record review with the DON on 3/15/23 at 3:12 p.m. when asked about facility process with skin assessment for residents who had previous pressure ulcers, the DON stated nurses were to do a weekly skin assessment and CNAs providing daily care like shower to residents would be able to identify any skin issues and would be reported to the nurse for further assessment. The DON verified there was no documentation from nursing staff indicating Resident 38's left heel was checked regularly for skin changes since Resident 38's old pressure ulcer resolved. Event ID: Facility ID: 055734 If continuation sheet Page 11 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) Residents Affected - Some Findings: Resident 23 During a record review for Resident 23, the Face Sheet (A one-page summary of important information about a resident) indicated Resident 23 was admitted on [DATE] with diagnoses including but not limited to Fracture of Shaft of Left Fibula (a break in the small bone that runs along the outside of the lower leg); Diabetes Mellitus (disease that result in too much sugar in the blood); Protein Calorie Malnutrition (when a person is not consuming enough protein and calories) and COVID (Corona Virus Disease - an infectious respiratory disease). During a record review for Resident 23, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 2/14/23 indicated Resident 23 had a BIMS score of 01 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated it was very important for Resident 23 to choose between a tub bath, shower, bed bath or sponge bath; however, the MDS indicated Resident 23 did not receive a full bath/ shower or sponge bath during the seven-day observation period. MDS indicated Resident 38 did not reject evaluation or care that was necessary to achieve her goals for health and well-being. Review of the facility's shower schedule indicated Resident 23 was scheduled for shower every Tuesday and Saturday on PM (evening) shift. During a record review for Resident 23, the document titled Progress Note dated 2/28/23 at 11:17 a.m. indicated Resident 23 had a non-blanchable purple tissue with some dry well adherent eschar to her left heel. During an interview and concurrent record review with the DON (Director of Nursing) on 3/15/23 at 3:12 p.m. the DON stated nurses were to do a weekly skin assessment and CNAs providing daily care like shower to residents would be able to identify any skin issues and would be reported to the nurse for further assessment During a review of the bathing record for Resident 23 with the Infection Preventionist (IP) on 3/16/23 at 2:29 p.m., the IP verified from 2/15/23 to 3/16/23, Resident 23 received bed bath once on 3/14/23 and no record of shower given. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 23 from February 2023 to present; however, this writer did not receive shower sheets for Resident 23 at time of exit from the facility. Resident 38 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 12 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm During a record review for Resident 38, the Face sheet indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). Residents Affected - Some During a record review for Resident 38, the document titled Initial Care Plan dated 12/22/22 indicated Resident 38 had left heel pressure ulcer and potential for pressure ulcer. Care Plan intervention include but not limited to: daily body skin checks; Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the MDS dated [DATE] indicated it was very important for Resident 38 to choose between a tub bath, shower, bed bath or sponge bath; however, the MDS indicated Resident 38 did not receive a full bath/ shower or sponge bath during the seven-day observation period. MDS indicated Resident 38 did not reject evaluation or care that was necessary to achieve her goals for health and well-being Review of the facility's shower schedule indicated Resident 38 was scheduled for shower every Wednesday on PM (evening) shift. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (the standard imaging test for patients suspected of having acute DVT [Deep Vein Thrombosis - a blood clot forms in one or more of the deep veins in the body, usually in the legs]) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister. During an interview with Unlicensed Staff E on 3/16/23 at 9:11 a.m. when asked about resident's shower schedule, Unlicensed Staff E stated they give shower twice a week for all residents. Unlicensed Staff E stated they would do head to toe skin check when giving shower to residents; any skin changes would be documented to the shower sheet and would be given to the nurse. When Unlicensed Staff E was asked if he checked Resident 38's left heel when providing care, Unlicensed Staff E stated, no because her left leg was always wrapped. During a review of the bathing record for Resident 38 with the IP on 3/16/23 at 2:29 p.m., the IP verified from 2/15/23 to 3/16/23 Resident 38 received shower once on 3/11/23. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 38 from February 2023 to present, however, there were only two shower sheets received for 2/15/23 and 3/15/23. Resident 40 During a record review for Resident 40, the Face sheet indicated Resident 40 was admitted on [DATE] with diagnoses including but not limited to Metabolic Encephalopathy (an alteration of brain function or consciousness due to failure of other internal organs); Muscle Weakness; and Major Depressive Disorder. During a record review for Resident 40, the MDS dated [DATE] indicated Resident 40 had a BIMS score of 9 out of 15. The MDS indicated Resident 40 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assist with personal hygiene (how resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 13 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, and hands). The MDS indicated it was very important for Resident 38 to choose between a tub bath, shower, bed bath or sponge bath; however, the MDS indicated Resident 40 did not receive a full bath/ shower or sponge bath during the seven-day observation period. MDS indicated Resident 38 did not reject evaluation or care that was necessary to achieve her goals for health and well-being. Review of the facility's shower schedule indicated Resident 40 was scheduled for shower every Thursday and Sunday on PM (evening) shift. During an observation in Resident 40's room on 3/14/23 at 11:16 a.m., Resident was on her bed, awake. Resident 40's upper and lower teeth was observed with white matter that appeared to be a dental plaque (a sticky film of bacteria that constantly forms on teeth). During an interview with Resident 40 on 3/15/23 at 9:37 a.m. Resident 40 stated CNAs (Certified Nursing Assistants) did not offer her to brush her teeth. During an interview with Unlicensed Staff E on 3/16/23 at 9:11 a.m. when Unlicensed Staff E was asked how often was oral hygiene offered to residents, Unlicensed Staff E stated, before and after meals. Unlicensed Staff E stated risk for residents who do not receive oral hygiene would be dental breakdown, oral infection and could also affect appetite. During a review of the bathing record for Resident 40 with the IP on 3/16/23 at 2:29 p.m., the IP verified from 2/15/23 to 3/16/23 Resident 40 received shower on 2/09/23 and 3/6/23. The IP was asked to provide shower sheets for Resident 38 from February 2023 to present, however, there was only one shower sheet provided for 3/16/23 indicated resident 40 refused shower. Review of the Facility policy and procedure titled ADL, Services to carry out revised on 10/2016 indicated, Residents who are unable to carry out activities of daily living (ADL) will receive necessary services, on a daily and on as needed basis, to maintain: Good nutrition, Grooming, Personal hygiene, and Oral hygiene. The policy indicated, Grooming and Personal Hygiene include Nail Care, Shaving, Hair care, Bathing, Showering, Toileting and personal facial make up, among others. Review of the Facility policy and procedure titled, Oral Care revised on 2/2023 indicated, The purposes of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. Review of the Facility policy and procedure titled Bath, Shower revised on 5/2007 indicated, It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Review of the Facility policy titled Skin and Wound Monitoring and Management revised on 1/2022 indicated procedure for monitoring, Skin inspection on showering: On shower days, CNAs to observe resident skin; identify any areas of skin breakdown, discoloration, tears, or redness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 14 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) Residents Affected - Few Findings: During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the document titled Progress Notes dated 3/9/23 at 3:54 p.m. indicated Resident 38 had a change of condition. The Progress Notes indicated Resident 38 had left hand and left leg swelling. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (an imaging test that uses sound waves to create a picture of organs, tissues, and other structures inside the body) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister (a painful skin condition where fluid fills a space between layers of skin). During an observation and concurrent interview with Resident 38 in her room on 3/13/23 at 3:21 p.m., Resident 38 was sitting on her wheelchair, awake wearing a Prevalon heel protection boot (help reduce the risk of pressure ulcer (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time)by keeping the heel floated) to her left leg. Resident 38's top of left foot appeared swollen. When Resident 38 was asked if she had any concern with her skin, Resident 38 stated she believed she had an open area to her left foot and stated, it hurts. During an observation in Resident 38's room on 3/14/23 at 8:57 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello. During a record review for Resident 38, the ultrasound report dated 3/14/23 indicated the ultrasound was performed on 3/14/23 at 4:23 p.m. The report indicated, There is extensive DVT involving left common femoral vein (a large blood vessel in your thigh), superficial femoral vein and popliteal vein (vein located behind your kneecap). During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello, and help. During an interview with Licensed Staff F on 3/15/23 2:28 p.m. when asked about reason for delay of the left leg ultrasound for Resident 38, Licensed Staff F stated the Social Service Director (SSD) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 15 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 was responsible for scheduling all appointments for the residents. Licensed Staff F stated they sometimes had a hard time to schedule an appointment with the hospital. Level of Harm - Actual harm Residents Affected - Few During an interview with the SSD on 3/15/23 at 4:10 p.m. when asked about the reason for the delay of the ultrasound for Resident 38's left leg, the SSD stated the hospital would not schedule Resident 38 for the ultrasound until they get an order that had the doctor's signature, so she had to return the request form to the nurses to obtain the doctor's signature. The SSD stated when she was able to arrange the appointment for Resident 38, there was no transportation available to take Resident 38 to the appointment. During an observation in Resident 38's room on 3/16/23 at 8:29 a.m., Resident 38 was sitting on her wheelchair with a diabetic shoe on her left foot. Resident had facial grimacing, moaning, and repeatedly saying hello and help me. During an interview with Licensed Staff F on 3/16/23 11:24 a.m. Licensed Staff F stated she was not sure if Resident 38 was in pain, she stated it was normal for Resident 38 to call out and count loudly. When Licensed Staff F was asked how she would determine actual pain from behavior, Licensed Staff F stated she would observe for nonverbal indications of pain like facial grimacing, fidgeting, and restless; Licensed Staff F stated she would try to console Resident 38 and if it did not work, then it could be an indication that Resident 38 was in pain. Licensed Staff F stated Resident 38 received Tylenol (pain reliever) for two consecutive days and had asked Resident 38's doctor for a routine pain medication to manage potential pain from the pressure ulcer and DVT. During an interview with Licensed Staff B on 3/16/23 at 1:45 p.m., Licensed Staff B stated Resident 38 was super restless and moved her feet all the time. When Licensed Staff B was asked if Resident 38 having the DVT and pressure ulcer on her left heel would experience pain, Licensed Staff B stated, she could. Licensed Staff B was asked how pain was assessed when resident had behavior, Licensed Staff B stated she would observe for physical signs of pain like facial grimacing, tensed muscle, moaning, and restlessness. Licensed Staff B stated although these signs of pain were observed from Resident 38, Licensed Staff B stated she could not tell if Resident 38 was in pain due to Resident 38's history of calling out in the past. During an observation in Resident 38's room on 03/17/23 at 9:29 a.m., Resident 38 was on her bed with eyes closed, moaning. During a record review for Resident 38, the Medication Administration Record (MAR) for March 2023 indicated Resident 38 was monitored for pain every shift. The MAR indicated from 3/01/23 to 3/16/23, Resident 38 had 4 out of 10 level of pain (score of 0 no pain; 1 to 3 mild pain; 4 to 6 moderate pain and 7 to 10 severe pain) on 3/05/23. The MAR indicated Resident 38 received Tylenol on the following days: 3/3/23 for 6 out of 10 level of pain; 3/5/23 for 4 out of 10 level of pain; and 3/15/23 for 4 out of 10 level of pain. Review of the Facility policy titled Skin and Wound Monitoring and Management revised on 1/2022 indicated, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed injury was unavoidable; and A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Procedure indicated, It is understood that a resident may experience pain associated with the presence of skin injury and/or any form of compromise. Therefore, the nursing staff shall be responsible to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 16 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate. Level of Harm - Actual harm Review of the Facility policy titled Recognition and Management of Pain dated 2/2023 indicated, It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 17 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Residents Affected - Some 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. This failure resulted to the development of a 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 [(a painful skin condition where fluid fills a space between layers of skin]) to Resident 23's left heel. 2. The facility did not assess Resident 38's skin integrity to her left heel after an old pressure ulcer resolved. This failure resulted to the development of a stage two (Partial-thickness loss of skin with exposed dermis [middle layer of skin]) pressure ulcer in a form of a ruptured blister to Resident 38's left heel to which Resident 38 experienced pain and inability to relax when she repeatedly called out for help and moaned (to make a long, low sound of pain, suffering). Findings: Resident 23 During a record review for Resident 23, the Face sheet indicated Resident 23 was admitted on [DATE] with diagnoses including but not limited to Fracture of Shaft of Left Fibula (a break in the small bone that runs along the outside of the lower leg); Diabetes Mellitus (disease that result in too much sugar in the blood); Protein Calorie Malnutrition (when a person is not consuming enough protein and calories) and COVID (Corona Virus Disease - an infectious respiratory disease). During a record review for Resident 23, the document titled LN (Licensed Nurse) - Braden Scale for Predicting Pressure Sore Risk dated 2/07/23 indicated Resident 23 scored 13 indicating she was moderate risk for pressure ulcer. During a record review for Resident 23, the document titled LN - Initial admission Record dated 2/07/23 indicated Resident 23 had an immobilizer to her left lower extremity. During a record review for Resident 23, the Care Plan initiated on 02/08/23 indicated, [Resident 23 had the potential for pressure ulcer development related to immobility, incontinence, and use of brace (a device used to immobilize a joint or body segment) to LLE (Left Lower Extremity). Care Plan interventions indicated, Monitor/document/report to MD (Medical Doctor) PRN (as needed) changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size and stage; and Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 23, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 2/14/23 indicated Resident 23 had a BIMS score of 01 out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 18 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Some of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 23 required extensive (resident involved in activity; staff provide weightbearing support) two-person physical assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). The MDS indicated Resident 23 was at risk for developing pressure ulcers. The MDS indicated Resident 23 did not have unhealed pressure ulcers during the assessment period. During a record review for Resident 23, the document titled SBAR (Situation, Background, Assessment and Recommendation - a tool used by health care professionals to communicate with each other about critical changes in patient's status) communication form dated 2/25/23 indicated Resident 23 was noted to have discoloration to her left heel that measured 7.5 cm (centimeter - a metric unit of length, equal to one hundredth of a meter) in length and 2.5 cm. in width. The document indicated Resident 23 was wearing immobilizer to her left foot. During a record review for Resident 23, the document titled Progress Note dated 2/28/23 at 11:17 a.m. indicated Resident 23 had a non-blanchable purple tissue with some dry well adherent eschar to her left heel. During a review of the Certified Nursing Assistant (CNA) job description dated 12/17/21 indicated essential duties and responsibilities for CNAs include but not limited to observe and report the presence of pressure areas and skin breakdowns to prevent pressure ulcers. During an interview with Licensed Staff G on 3/14/23 at 11:28 a.m., Licensed Staff G stated Resident 23's left leg was on immobilizer which caused a pressure ulcer to Resident 23's left heel. When Licensed Staff G was asked how often did nursing staff check the skin integrity under Resident 23's LLE immobilizer, she stated dressing to Resident 23's left knee was left untouched until the doctor said it was okay to remove the dressing. When Licensed Staff G was asked if there was an order to not remove the immobilizer, she stated there was no order. Licensed Staff G concurred Resident 23' LLE under the immobilizer should be checked daily for skin changes. During an interview and concurrent record review with Licensed Staff F on 3/15/23 at 10:13 a.m., when Licensed Staff F was asked how often did nursing staff check Resident 23's skin integrity under the LLE immobilizer, Licensed Staff F stated Resident 23's entire left leg was checked daily for skin changes and would document findings in Resident 23's record. Review of the document titled Nursing Weekly skin assessment for Resident 23 dated 3/14/23 with Licensed Staff F indicated the check box for current pressure ulcer was not checked. Licensed Staff F verified Resident 23 was receiving treatment to her left heel pressure ulcer. During an interview and concurrent record review with the Director of Rehabilitation (DOR) on 3/15/23 at 2:42 p.m. when asked whose responsibility to ensure, skin integrity under the immobilizer of Resident 23's left leg was not compromised, the DOR stated Physical Therapist (PT - A health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities) had to make sure Resident 23's skin under the left lower immobilizer did not have any skin problem every time PT provided treatment. The DOR stated PT would document their skin observation to Resident 23's record. During an interview and concurrent records review with the DON (Director of Nursing) on 3/15/23 at 2:51 p.m. when asked about her expectation from the nurses for resident who came with an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 19 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Some immobilizer, the DON stated if the doctor gave an order to leave the immobilizer in place, then nurses were not allowed to remove the immobilizer; however, nurses could check for circulation like pulse and skin temperature. Review of the physician's order for February 2023 with the DON and verified there was no doctor's order to not remove Resident 23's LLE immobilizer. The DON stated if there was no order to leave the immobilizer in place, nurses should definitely check the skin integrity for changes under the immobilizer at least once a day and document. Review of Resident 23's Progress notes with the DON did not show any documentation from nursing staff indicating Resident 23's left heel was checked at least once a day for skin changes prior to the identification of the SDTI. During a review of the bathing record for Resident 23 with the Infection Preventionist (IP) on 3/16/23 at 2:29 p.m., the IP verified the bathing record from 2/15/23 to 3/16/23 indicated Resident 23 received bed bath once on 3/14/23 and no record of shower given. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 23 from February 2023 to present; however, this writer did not receive shower sheets for Resident 23 at time of exit from the facility. Resident 38 During an observation and concurrent interview with Resident 38 in her room on 3/13/23 at 3:21 p.m., Resident 38 was sitting on her wheelchair, awake wearing a Prevalon heel protection boot (help reduce the risk of pressure ulcer by keeping the heel floated) to her left foot. Resident 38's top of left foot appeared swollen. When Resident 38 was asked if she had any concern with her skin, Resident 38 stated she believed she had an open area to her left foot and stated, it hurts. During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the document titled LN - Braden Scale for Predicting Pressure Sore Risk (a tool to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer) dated 12/22/22 indicated Resident 38 had a total score of 14 (Total Score of 9 or less was Very High Risk; 10 to12 was High Risk; 13 to 14 was Moderate Risk; 15 to 18 was Mild Risk and 19 to 23 was No Risk). During a record review for Resident 38, the document titled Initial Care Plan dated 12/22/22 indicated Resident 38 had left heel pressure ulcer and potential for pressure ulcer. Care Plan intervention include but not limited to: daily body skin checks; Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the MDS dated [DATE] indicated Resident 38 was at risk for developing pressure ulcers. The MDS indicated Resident 38 had an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead tissue that separates from living tissue in a wound) or eschar (dead tissue that sheds or falls off from the skin) that was present upon admission. During a record review for Resident 38, the document titled LN - Skin Pressure Ulcer Weekly dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 20 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 1/11/23 at 6:20 a.m. indicated Resident 38 had an unstageable pressure ulcer to left heel. Level of Harm - Actual harm During a record review for Resident 38, the document titled Skin Wound Note dated 1/17/23 at 1:22 p.m. indicated Resident 38's pressure ulcer to left heel was resolved. Residents Affected - Some During a record review for Resident 38, the Care plan initiated on 1/18/23 indicated Resident 38 had the potential for pressure ulcer development related to Resident 38's history of pressure ulcer. Care Plan interventions include: Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. During a record review for Resident 38, the document titled Progress Notes dated 3/9/23 at 3:54 p.m. indicated Resident 38 had a change of condition. The Progress Notes indicated Resident 38 had left hand and left leg swelling. During a record review for Resident 38, the document titled Progress Note dated 3/10/23 at 5:37 p.m. indicated doctor assessed Resident 38's swollen leg and ordered ultrasound (the standard imaging test for patients suspected of having acute DVT [Deep Vein Thrombosis - a blood clot forms in one or more of the deep veins in the body, usually in the legs]) to rule out DVT. The Progress Note also indicated Resident 38 was on monitoring for left heel blister. During a record review for Resident 38, the ultrasound report dated 3/14/23 indicated the ultrasound was performed on 3/14/23 at 4:23 p.m. The report indicated, There is extensive DVT involving left common femoral vein (a large blood vessel in your thigh), superficial femoral vein and popliteal vein (vein located behind your kneecap). During an observation in Resident 38's room on 3/14/23 at 8:57 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello. During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was sitting on her wheelchair, appeared restless kept on saying hello, and help. During an interview and concurrent record review with the DON on 3/15/23 at 3:12 p.m. when asked about facility process with skin assessment for residents who had previous pressure ulcers, the DON stated nurses were to do a weekly skin assessment and CNAs providing daily care like shower to residents would be able to identify any skin issues and would be reported to the nurse for further assessment. The DON verified there was no documentation from nursing staff indicating Resident 38's left heel was checked at least once a day for skin changes since Resident 38's old pressure ulcer resolved. During an observation in Resident 38's room on 3/16/23 at 8:29 a.m., Resident 38 was sitting on her wheelchair with a diabetic shoe on her left foot. Resident had facial grimacing, moaning, and repeatedly saying hello and help me. During an interview with Unlicensed Staff E on 3/16/23 at 9:11 a.m. when asked about resident's shower schedule, Unlicensed Staff E stated they give shower twice a week for all residents. Unlicensed Staff E stated they would do head to toe skin check when giving shower to residents; any skin changes would be documented to the shower sheet and would be given to the nurse. When Unlicensed Staff E was asked if he checked Resident 38's left heel when providing care, Unlicensed Staff E stated, no because her left leg was always wrapped. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 21 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Actual harm Residents Affected - Some During an interview with Licensed Staff F on 3/16/23 11:24 a.m. Licensed Staff F stated she was not sure if Resident 38 was in pain, she stated it was normal for Resident 38 to call out and count loudly. When Licensed Staff F was asked how she would determine actual pain from behavior, Licensed Staff F stated she would observe for nonverbal indications of pain like facial grimacing, fidgeting, and restless; Licensed Staff F stated she would try to console Resident 38 and if it did not work, then it could be an indication that Resident 38 was in pain. Licensed Staff F stated Resident 38 received Tylenol (pain reliever) for two consecutive days and had asked Resident 38's doctor for a routine pain medication to manage potential pain from the pressure ulcer. During an interview with Licensed Staff B on 3/16/23 at 1:45 p.m., Licensed Staff B stated Resident 38's left heel blister would be a stage 2 pressure ulcer (Partial-thickness loss of skin with exposed dermis [middle layer of skin]) because it was a ruptured blister, and the location of wound was on a bony prominence. Licensed Staff B stated Resident 38 was super restless and moved her feet all the time. When Licensed Staff B was asked if Resident 38 having pressure ulcer on her left heel would experience pain, Licensed Staff B stated, she could. During a review of the bathing record for Resident 38 with the IP on 3/16/23 at 2:29 p.m., the IP verified the bathing record from 2/15/23 to 3/16/23 indicated Resident 38 received shower once on 3/11/23. The IP stated CNAs would document skin changes to the shower sheet and give to the nurse for follow-up. IP was asked to provide shower sheets for Resident 38 from February 2023 to present however, there were only two shower sheets received for 2/15/23 and 3/15/23. During an observation in Resident 38's room on 03/17/23 at 9:29 a.m., Resident 38 was on her bed with eyes closed, moaning. During a telephone interview with the Medical Director on 3/21/23 at 12:09 p.m. when asked about his expectation for resident skin assessment, the Medical Director stated daily skin assessment was very important for pressure ulcer prevention especially for residents who were at risk for pressure ulcer. Review of the Facility policy titled Skin and Wound Monitoring and Management revised on 1/2022 indicated, A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed injury was unavoidable; and A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Procedure indicated: - It is understood that a resident may experience pain associated with the presence of skin injury and/or any form of compromise. Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate. - Monitoring indicated Skin inspection on showering: On shower days, CNAs to observe resident skin; identify any areas of skin breakdown, discoloration, tears, or redness. Review of the Facility policy titled Pressure Ulcer dated 2/2023 indicated The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable and that the facility provides care and services to: Promote the prevention of pressure ulcer development . Procedures indicated monitoring daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 22 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. This failure had the potential for Resident 38 to aspirate (to breathe a substance into your lungs by accident) which could lead to choking, respiratory complications, serious infections or even death. Findings: Resident 249 During a record review for Resident 249, the Face sheet (A one-page summary of important information about a resident) indicated Resident 249 was admitted on [DATE] with diagnoses including but not limited to Difficulty Walking; Muscle Weakness; and Hemiplegia and Hemiparesis (paralysis of one side of the body). During a record review for Resident 249, the document titled LN (Licensed Nurse) - Fall Risk Evaluation dated 6/09/22 indicated Resident 249 was high risk for fall. During a record review for Resident 249, the Fall Care Plan initiated on 6/11/22 indicated Resident 249 was at risk for falls related to generalized weakness. Care Plan interventions indicated: - Be sure the call light is within reach and encourage to use it to call for assistance as needed - Bed in lowest position with fall mat at bedside - Educate resident/family/caregivers about safety reminders and what to do if a fall occurs - Keep needed items, water, etc., in reach - Occupational, Physical Therapy evaluation and treatment per physician orders - Educate resident/ family/caregivers about safety reminders and what to do if a fall occurs - Monitor placement of wedge cushion and dycem (non-slip products) in reclining wheelchair During a record review for Resident 249, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 6/16/22 indicated Resident 249 had a BIMS score of 4 out (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 23 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few of 15 points (Brief Interview for Mental Status - a 15-point cognitive (involving conscious intellectual activity [such as thinking, reasoning, or remembering)]) screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 249 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assist from staff with transfers and walking. First Fall 6/25/22 During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 10:10 a.m. indicated Resident 249 was found on the floor yelling for help. The Progress Note indicated Resident 249 claimed he had fallen from the wheelchair trying to get to restroom. The Progress Note indicated Resident 249 sustained small laceration outside right eye, inner area alongside nose and larger laceration to outer, lower area under right eye. During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 12:34 p.m. indicated Resident 249 was sent to the emergency room for evaluation. During a record review for Resident 249, the document titled Progress Notes dated 6/25/22 at 6:13 p.m. indicated Resident 249 returned to the facility. During a record review for Resident 249, the document titled Progress Notes dated 6/27/22 at 10:59 a.m. indicated the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) met to discuss Resident 249's fall incident. The Progress Note indicated, [Resident 249] must be within view of staff/family members when sitting up in wheelchair. During a record review for Resident 249, the Fall Care Plan indicated interventions initiated on 6/25/22 indicated, Staff will not place the resident on wheelchair without family/staff supervision. Second Fall 7/7/22 During a record review for Resident 249, the document titled Progress Notes dated 7/7/22 at 6:30 a.m. indicated, at 0612 [Resident 249] was heard hollering from room. Found on floor on left side curled around transfer pole. Bed was in lowest position and call light was within reach. Resident assisted back on the bed. Crescent shaped skin tear back of left hand ; bruising left elbow. Said hit head (pink mark to back of head to left side, but no swelling or broken skin), but that it only hurt a little. During a review of the Fall Care Plan for Resident 249 and concurrent interview with the DON on 03/17/23 at 3:01 p.m., the DON verified Resident 249's Fall Care Plan did not have new intervention to prevent Resident 249 from further fall. Third Fall 7/13/22 During a record review for Resident 249, the document titled Progress Notes dated 7/13/22 at 7:09 a.m. indicated Resident 249's roommate notified the nurse that Resident 249 was on the floor. The Progress Note indicated the nurse and the CNA (Certified Nursing Assistant) found Resident 249 next to the bed on floor laying on a pillow on his right side. The Progress Note indicated Resident 249 had redness to his right elbow and right shoulder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 24 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few During a record review for Resident 249, the document titled Progress Notes dated 7/14/22 at 2:42 p.m., indicated, IDT met to discuss resident recent fall. Resident was found on floor at bedside Will do room change closer to nurses' station, to monitor resident closer. Will provide floor mat at bed side. During an interview and concurrent record review with the DON on 03/17/23 at 3:07 p.m. when asked what interventions were put in place after the 7/13/22 fall incident to prevent Resident 249 from falling, the DON stated Resident 249 was moved to 18B which is closer to the nurse's station. The DON stated they also used regular mattress on the floor at bedside to prevent Resident 249 from sustaining fall related injury. The DON verified the fall care plan did not indicate floor mattress was used. Fourth Fall 9/11/22 During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 4:32 p.m. indicated, 0800 at the Hallway [Resident 249] was in his wheelchair eating breakfast. The Progress Note indicated the housekeeper observed Resident 249 from afar leaning on his right side all the way to the floor and saw Resident 249 fell down. The Progress Note indicated staff immediately responded to the incident and found Resident 249 with blood coming from his nose and some blood coming from his mouth. The Progress Notes indicated Resident 249 possibly bit his right cheek with 2 small openings, right eyebrow laceration, right side of nose has laceration. The Progress Note indicated staff was assisting the resident across the room when the incident occurred. The Progress Note indicated Resident 249 was transferred to the hospital at 8:21 a.m. During a record review for Resident 249, the document titled ED (Emergency Department) Physician Notes dated 9/11/22 at 8:47 a.m. indicated, [Resident 249] was apparently complaining of neck pain after the fall. The Physician Note indicated a rhino rocket (designed for the treatment of nosebleed) was placed which was initially avoided due to Resident 249 nasal bone fractures, discomfort, and deviated septum, however Resident 249 had ongoing profuse bleeding. The Physician Note indicated Resident 249 received a dose of Fentanyl (a powerful pain medication). During a record review for Resident 249, the document titled Computerized Tomography (diagnostic imaging that shows detailed images of any part of the body, including the bones) dated 9/11/22 indicated, New on old bilateral nasal bone fractures with a new fracture of the bony nasal septum (the cartilage and bone in your nose) since 06/25/2022. During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 4:33 p.m. indicated Resident 249 returned to the facility with rhino rocket clamp in right nose in place. During a record review for Resident 249, the document titled Progress Notes dated 9/11/22 at 5:35 p.m. indicated Resident 249 had some grimacing. During a record review for Resident 249, the Medication Administration Record (MAR) indicated Resident 249 received two tablets of Tylenol 325 mg (milligram) for pain level of 7 out of 10 on 9/11/22 at 5:31 p.m. The MAR indicated a score of 0 was no pain; 1 to 3 was mild pain; 4 to 6 was moderate pain; and 7 to 10 was severe pain During a record review for Resident 249, the MAR indicated Resident 249 received two tablets of Tylenol 325 mg (milligram) for pain level of 5 out of 10 on 9/12/22 at 1:56 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 25 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview with Unlicensed Staff J on 3/17/23 at 09:29 a.m., Unlicensed Staff J stated Resident 249 required extensive assist with transfers and toilet use, Resident 249 was non-ambulatory. Level of Harm - Actual harm Residents Affected - Few During an interview with Unlicensed Staff E on 3/17/23 at 2:03 p.m., Unlicensed Staff E stated Resident 249 required two-person total assist with transfer and non-ambulatory. Unlicensed Staff E stated Resident 249 had at least 2 to 3 fall incidents since he was admitted to the facility. When Unlicensed Staff E was asked about interventions put in place to prevent Resident 249 from further fall, Unlicensed Staff E stated Resident 249 was put on frequent check, lowered his bed, and placed fall mat at bedside right after the first fall incident. Unlicensed Staff E was asked if Resident 249 had complained of pain after he sustained a nasal fracture from the 9/11/22 fall incident, Unlicensed Staff E stated Resident 249 spoke Spanish; however, he stated he knew Resident 249 was in pain because his body language indicated he was in pain like grimacing and guarding. During an interview with Licensed Staff A on 3/17/23 at 2:08 p.m., Licensed Staff A stated Resident 249 had complained of pain a few times after he sustained the nasal fracture and was medicated with Tylenol. Licensed Staff A was asked what interventions were put in place to prevent Resident 249 from further fall, Licensed Staff A stated Resident 249 could not be left alone in wheelchair without supervision because he moved a lot. During an interview and concurrent record review with the DON on 03/17/23 at 3:19 p.m. when asked about Resident 249's 9/11/22 fall, the DON stated the incident happened in the morning when Resident 249 was sitting on his wheelchair outside of his room. The DON stated staff were providing oversight supervision to Resident 249 while passing breakfast tray; however, fall incident happened. The DON verified the fall care plan for Resident 249 initiated on 6/25/22 indicated, Staff will not place the resident on wheelchair without family/staff supervision. The DON concurred they did not follow the care plan to provide supervision when Resident 249 was up on his wheelchair. Review of the Facility policy titled Fall Management System revised on 2/2023 indicated This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. Resident 38 During a record review for Resident 38, the Face sheet (A one-page summary of important information about a resident) indicated Resident 38 was admitted on [DATE] with diagnoses including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Congestive Heart Failure (CHF blood often backs up and fluid can build up in the lungs, causing shortness of breath); and Other Symptoms and Signs Involving Cognitive Functions and Awareness and Schizoaffective disorder (a mental health disorder). During a record review for Resident 38, the MDS dated [DATE] indicated Resident 38 required supervision (oversight, encouragement, or cueing) with eating. During a record review for Resident 38, the document titled Order Summary Report indicated an order for Resident 38 with a start date on 2/24/23 for CCHO diet (consistent, constant, or controlled carbohydrate [food consisting of or containing a lot of sugars, starch]) mechanical soft texture, nectar thick consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 26 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few During a record review for Resident 38, the document titled SLP (Speech Language Pathologist - also known as a Speech Therapist, is a health professional who diagnoses and treats communication and swallowing problems) Evaluation and Plan of Treatment with certification period from 1/17/23 to 2/12/23 indicated, Resident 38 was referred to Speech Therapy for Dysphagia (difficulty swallowing) services due to decline, risk for aspiration and oral/pharyngeal function. Resident 38referred to Speech Therapy due to decline in safety awareness, ability to use compensatory strategies and ability to effectively communicate needs/preferences. During an observation in Resident 38's room on 3/13/23 at 3:16 p.m., an unidentified CNA (Certified Nursing Assistant) offered a diet ginger ale to Resident 38. The CNA was observed opening the soda can, poured in a cup and assisted Resident 38 to drink. During an observation in Resident 38's room on 3/15/23 at 8:52 a.m., Resident 38 was up on her wheelchair. Kept on saying hello, cherry and help. Resident 38 had half full cup of thick clear liquid in front of her on top of the bedside table and a quarter full cup of thin consistency coffee. During an observation and concurrent interview with Director of Staff Development (DSD) on in Resident 38's room on 3/15/23 at 8:58 a.m., the DSD verified the cup of water in front of Resident 38 was thicker than the coffee. The DSD stated the coffee should be thick and took coffee away. During an observation and concurrent interview with the Director of Nursing (DON) in Resident 38's room on 3/16/23 at 3:11 p.m. DON verified Resident 38 had an almost empty container and an approximately 40 ml (milliliter - one thousandth of a liter) of Boost (nutritional supplement) in a cup on top of Resident 38's bedside table. The DON verified Resident 38 had an order for nectar thick liquid. The DON stated Resident 38 would be at risk for aspiration pneumonia when drinking thin liquid. During an interview with the Dietary Manager on 3/16/23 at 3:18 p.m. when asked about their process of preparing liquid consistency for residents prior to sending food trays out to the unit, the Dietary Manager stated they would put one pump of thickener for thin liquid, 2 pumps for honey thick and 3 pumps for nectar thick. The Dietary Manager stated they would send the nutritional supplements like boost with the resident's meal tray unopened and it was the nurse's responsibility to mix the drink according to the doctor's order before serving it to the residents. During an interview and concurrent observation with on 3/16/23 at 3:27 p.m., the Speech Therapist (ST) stated Resident 38 received speech therapy services due to difficulty swallowing and risk for aspiration. The ST verified Resident 38 should have nectar thick liquid. When ST was asked to check the boost on top Resident 38's bedside table, the ST stated the boost consistency was thin and it should have been thickened before it was served to Resident 38. The ST stated Resident 38 required supervision during meals and drinking due to Resident 38's fluctuating mentation (process of reasoning and thinking). During an interview with Licensed Staff F on 3/16/23 at 3:31 p.m. when asked how she prepared the boost for Resident 38, Licensed Staff F stated there was no need to thicken the boost because it was already thick. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 27 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Residents Affected - Few 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. Findings: Review of Resident 32's admission record indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnosis that included: Chronic Obstructive Pulmonary Disease, Unspecified (A group of lung diseases that block airflow and make it difficult to breathe). During an initital observation of the facility on 3/13/23 at 2:00 p.m., the resident was observed in bed sleeping, a nasal cannula attached to an oxygen concentrator was running at 2/liters of oxygen, the nasal cannula was on the floor and there was no date on the oxygen tubing. During an observation on 3/16/23 at 10:30 a.m., Resident 32 was lying in bed, when asked how she was feeling the resident mumbled some words and stated she did not feel well. An oxygen concentrator next to the resident's bed was on and running at 2/liters of oxygen, the nasal canula was on the floor, no date was observed on the oxygen tubing. During an observation and concurrent interview on 03/17/23 at 09:30 a.m., Resident 32 was lying in bed awake and alert. The resident was asked how often she wears her oxygen, she stated I wear oxygen at night, sometimes. The resident stated she does become short of breath after she exercises. When asked if she smoked, the resident stated she had a cigarette and took a few puffs when she was able to go outside. During a review of the medical record on 3/17/23, no physician orders or respiratory assessments was found in the medical record or on the resident's care plan at any time during the resident's admission. Resident 32 did have medical orders for respiratory inhalers. During an interview on 3/17/23 at 2:00 p.m., Licensed Staff K was asked if Resident 32 had an order for oxygen therapy. Licensed Staff K reviewed the medical orders and stated she could not find an order for the resident's oxygen. When asked if an order was needed for oxygen therapy she stated Yes. During an observation and 3/20/23 at 10:29 a.m., Resident 32 was in bed, an oxygen concentrator was on, and the nasal cannula was on the floor. The resident was mumbling some words and stated she did not feel well. Licensed Staff A was asked if Resident 32 had orders for Oxygen therapy. Licensed Staff A further assessed Resident 32 and reviewed the medical record and confirmed the resident did not have an order for oxygen. When asked if an order for Oxygen therapy was required, Licensed Staff A stated yes and proceeded to contact the physician. During an interview on 3/20/23 at 2:30 p.m., the DON verified that Resident 32 did not have an physician's order or care plan for nasal cannula O2. When asked if an order for oxygen is required the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 28 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 DON stated Yes. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy and procedure titled Physician Orders revised 02/2023, indicated, 1. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses; 6. Orders for medications must include: Residents Affected - Few A. Name and strength of the drug B. Quantity or specific duration of therapy C. Dosage and frequency of administration D. Route of administration if other than oral; and E. Reason or problem for which given. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 29 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based 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. Findings: During an interview with Resident 27 on 3/13/23 at 10:54 a.m. when asked how long she had to wait for her call light to be answered, Resident 27 stated it took 10 to 15 mins before staff gets to her. During an interview with Resident 10 on 3/13/23 at 11:03 a.m., when asked how long she had to wait for her call light to be answered, Resident 10 stated, would not say quickly. Resident 10 stated the facility was short staffed mostly evening shift. During an interview with Resident 248 on 3/13/23 at 11:25 a.m. Resident 248 stated it could take an hour for staff to answer her call light. Resident 248 stated this happened during AM (day) and night shifts. Resident 248 stated she had peed on her pants and her bed was all wet because she could not wait any longer. Resident 248 stated she felt embarrassed when this incident happened. During an interview with Resident 20 on 3/13/23 at 3:41 p.m., Resident 20 stated it took at least 30 minutes for staff to answer his call light, usually nighttime. During an interview with Resident 37 on 3/13/23 at 5:01 p.m., Resident 37 stated her call light was not answered timely. During an observation on 3/14/23 at 9:00 a.m., Resident 33 was in his room calling for Unlicensed Staff P. Resident 33 stated he wanted to go really bad. Observed three unlicensed staff went to check Resident 33; however, they did not assist Resident 33 to go to the toilet. Meanwhile, Resident 33 kept on yelling, please [Unlicensed Staff P], I really need to go, really bad. Observed Unlicensed Staff P entered Resident 33's room at 9:10 a.m. During an interview with Resident 250 on 3/14/23 at 9:27 a.m., Resident 250 stated he had asked for hot milk for about half an hour and was still waiting. Resident 250 turned on his call light again at 9:32 am. At 9:37 a.m., a CNA came to answer Resident 250's call light. Resident 250 again asked the CNA for his milk. During an interview with Resident 250 on 3/14/23 at 10:05 a.m., Resident 250 was asked if he had gotten his hot milk, Resident 250 stated no. During an observation on 3/15/23 at 4:01 Resident 33 was in his room screaming, I need help, naming multiple staff who could help him. Resident 33's call light was not on; however, Resident 33's screaming was loud enough to be heard. Resident 33's room was close to the nurse's station, however, staff who were sitting at the nurse's station did not check Resident 33. During an observation on 3/15/23 at 4:06 p.m. while Resident 33 continued to scream Please I am (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 30 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hurting, Visitor Q was observed entering Resident 33's room. When Visitor Q was asked about her conversation with Resident 33, Visitor Q stated Resident 33 complained of severe back pain. During an interview with Unlicensed Staff J on 3/16/23 at 8:48 a.m., Unlicensed Staff J stated there were days when they were short staffed. Unlicensed Staff J stated she was asked to stay over sometimes to cover a shift. During an interview with Unlicensed Staff E on 3/16/23 at 9:11 a.m., Unlicensed Staff E stated the facility was usually short staffed on NOC (night 11pm-7 am) shift and usually on the weekends. When Unlicensed Staff E was asked about the risks for the residents who had to wait long for their call lights to be answered, Unlicensed Staff E stated, there was a greater risk of falling and serious or deadly injury resulting to lack of oversight. Unlicensed Staff E stated call lights should be answered as soon as possible. During an interview with Licensed Staff F on 3/16/23 at 11:37 a.m. when asked about staff's call light response, Licensed Staff F stated anybody could answer the call light and it should be answered as soon as possible. Licensed Staff F stated resident would put their call light on for anything like needing pain medicine, food when hungry; wanting to go to the bathroom or needing to be cleaned. Licensed Staff F stated risk for residents when waiting too long, would risk for fall, untreated pain, bladder/ bowel accidents and emotional impact to resident like feeling upset/ mad. Review of the Facility policy and procedure titled Call Light/ Bell revised on 2/2023 indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedure indicated, Answer the light/bell within a reasonable time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 31 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to provide pharmaceutical services that meet the needs of their residents as evidence by: Residents Affected - Few 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. Findings: 1. A review on 3/14/23 of the Insulin Lispro manufacturer's insert indicated Administer the dose of insulin lispro .by injection into the subcutaneous tissue of the abdominal wall, thigh, upper arm, or buttocks. To reduce the risk of lipodystrophy, rotate the injection site within the same region from one injection to the next . A review of 3/14/23 of Resident 148's medication administration record for Insulin Lispro indicated the following location of administrations that were not rotated as required by the manufacturer: *3/13/23 1106 Abdomen LLQ administered by Licensed Nurse A *3/13/23 0652 Abdomen LLQ administered by Licensed Nurse A *3/12/23 12:26 Abdomen RLQ administered by Licensed Nurse B *3/12/23 08:53 Abdomen RLQ administered by Licensed Nurse B *3/11/23 18:01 Abdomen RLQ administered by Licensed Nurse C *3/11/23 1155 Abdomen RLQ administered by Licensed Nurse B *3/11/23 0810 Abdomen RLQ administered by Licensed Nurse B *3/10/23 1751 Abdomen RLQ administered by Licensed Nurse C *3/10/23 11:32 Abdomen RLQ administered by Licensed Nurse A During an interview on 3/14/23 at 1:51 p.m., the Consultant Pharmacist stated that he was the facility pharmacist. He also stated that he did an in-service all the nurses on rotating the injection site for subcutaneous insulin. He said that the insulin for Resident 148 should have been rotated and he did not know why the nurses did not rotate the injection site. 2. A review on 3/13/23 of the facility policy entitled Emergency Pharmacy Service and Emergency (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 32 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Kits indicated If exchanging kits, opened kits are replaced with sealed kits within (72 hours) of opening. Level of Harm - Minimal harm or potential for actual harm During an observation on 3/13/23 at 2:38 p.m. at nursing station 1 medication room, there were two oral emergency kits (e-kits) that were opened. The outside of the e-kits was labeled ORAL EMERGENCY DRUG SUPPLY *PLEASE NOTIFY PHARMACY BEFORE OPENING*. There were two oral e-kits and each had a e-kit log which indicated: Residents Affected - Few *PO EKIT #50 first opened date on log 02/15/23 *PO EKIT #14 first opened date on log 02/28/23 The above indicated that the two kits should have been replaced by 2/17/23 and 3/3/23 which is 72 hours from when it was opened on 2/15/23 and 2/28/23. The kit was still not replaced by 3/13/23. A review on 3/13/23 of the oral e-kits logs indicated the following medications were taken from the kit: *2/16/23 Potassium 20 meq 1 quantity *2/24/23 Sodium Polystyrene Sulfonate Suspension 2 quantity *2/25/23 Azithromycin 250 mg 1 quantity *2/28/23 Cephalexin 500 mg 2 quantity *3/03/23 Azithromycin 250 mg 2 quantity *3/11/23 Ciprofloxacin 250 mg 2 quantity During an interview on 3/13/23 at 3:15 p.m., the Director of Nursing (DON) stated that the oral e-kits were supposed to be used up until 3/08/23 and then the Cubix (automated dispensing unit-medications are dispensed through vending type machine). She said that the e-kits should now be removed, and she acknowledged that the e-kits should have been replaced within 72 hours as required by facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 33 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based 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. Findings: During an initial observation of the kitchen on 3/13/23 at 11:15 a.m., Dietary Staff L was asked what type of dishwasher she used. Dietary Staff L stated a low-pressure dishwasher. Dietary Staff L was asked to check the chlorine of the dishwater. Dietary Staff L took an ECO lab (brand name) chloride test strip and held the strip in the water for approximately 30 seconds and read the results at above 100. When asking Dietary Staff L how long to keep the test strip in the water she stated about 30 seconds. Review of the manufactures directions for using the Eco Lab chlorine test strip indicated, to dip the test strip into the water and remove immediately. When asking Dietary Staff L if the chloride test was done following the directions, she stated, No. During an observation of the kitchen on 3/13/23 at 2:00 p.m., a small freezer chest contained frozen chubs of beef and meats and contained two thermometers with broken mercury lines. The temperature log on the outside of the freezer chest indicated the recorded AM and PM temperatures for the month of March were 35 degrees Fahrenheit. During an interview on 3/13/23 at 2:30 p.m., [NAME] M was asked the temperature of the small freezer chest. [NAME] B reviewed the thermometers and stated 20 degrees. When asked if the thermometers were accurate, he stated he was not sure. [NAME] M stated he knew the temperature of the freezer should be 0 degrees. A copy of the temperature log was requested. During a review of the small freezer chest temperature log on 3/14/23, the AM and PM temperatures were changed to 0 degrees. [NAME] M was asked why the temperatures were changed on the log, he stated the thermometers were broken. During a food preparation observation on 3/15/23 at 11:30 a.m., egg salad was observed in the refrigerator with a prepared date of 3/14/23 and use by date of 3/15/23. When asking [NAME] N and the Dietary Manager if a cool down log for potentially hazardous foods (foods prepared at ambient temperatures) was recorded for prepared salads such as (egg, chicken, and tuna), [NAME] N stated we do not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 34 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some use a cool down log. The Dietary Manager stated we do not use a cool down log because we do not keep leftovers. Review of the kitchen policy and procedure titled Food Preparation RDs for Healthcare, Inc. dated 2018, indicated, Special Cool Down Log Use for potentially hazaradous food prepared from ingredients at ambient temperature (room temperature) such as canned tuna and macroni salad. Review of the kitchen recipe titled Classic Egg Salad Sandwich Healthcare Menus Direct, LLC, indicated, allow filling time to cool (Need to utilize cool down log). Temp sandwiches and if higher than 41 Degrees Fahrenheit start a cool down log. During an interview on 3/16/23 at 2:00 p.m., Dietary Aid O was asked what her responsibilities were for the kitchen. She stated she was a dietary aid and now was a CNA that helped in the kitchen when needed. Dietary Staff C stated she washed dishes, poured drinks, and cleaned the kitchen. When asked if she was trained on the kitchen skills she stated she was trained awhile ago. During an interview on 3/17/23 at 3:00 p.m., the dietary manager was asked if she conducted in-services for the dietary staff. She stated she would be conducting in-services for the staff once she had completed orientation. The dietary manager showed the in-service binder to the surveyor and stated Healthcare Menus Direct, LLC. provides the facility with a list and outline of in-services availalbe for the kitchen staff. A review of kitchen competencies and annual reviews for dietary staff showed, no competencies or annual review for Dietary Aid O. The competeny check lists were incomplete and not signed-off and no annual reviews were observed for the dietary support staff. Review of the in-service manual for the dietary staff showed in-services were not current and attended by all dietary staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 35 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Some Findings: Dining observations and interviews from 3/13/23 to 3/16/23 included: On 03/13/23 at 2:44p.m., Resident 34 stated the food was terrible, had lost 65 lbs, couldn't get real food, and the pancake were hard. On 03/13/23 at 3:41 p.m., Resident 20 stated the was food terrible, the toast was burnt, and a little bit of egg for breakfast. On 03/13/23 at 5:01 p.m., Resident 37 didn't like the food. Stated it doesn't have any flavor, had lost weight about 40 pounds since admission. On 03/14/23 at 10:30 a.m., Resident 35 stated the food was icky it did not have any flavor, was not cooked well, and was sometimes cold. On 3/14/23 at 11:00 a.m., Resident 32 stated the food was yucky, it had no flavor, was not cooked well, and had too much white pepper. On 03/15/23 at 08:46 a.m., Resident 248 stated she did not like the food, she only ate waffle. She stated her daughter brings her smoothies to keep her strong. On 03/15/23 at 8:38 a.m. Resident 251 stated breakfast was terrible; had a bite cold waffle. Had one piece of waffle, a piece of sausage, a bowl of cereal. On 03/16/23 at 5:15 p.m., Resident 148 made a face and stated to the assistant no more, I don't like that. During an observation and concurrent interview on 3/15/23 at 9:30 a.m., [NAME] N was preparing chicken for the day's lunch. [NAME] N took frozen chicken breasts from the freezer and put them on a prepared baking pan and placed into the oven. At 10:30 a.m., [NAME] N removed the chicken form the oven and temped the chicken and rice on the stove. The chicken was prepared and set back in the oven along with the rice. When asking [NAME] N when he temps the food, he stated he temps the food and records the temperatures to ensure the food is cooked, he placed the food back into the oven to keep the food at the cooked temperature. [NAME] N was observed placing food on the steam table and preparing lunch plates during tray line, no tempting of food was observed. During an observation and concurrent interview on 3/15/23 at 1:15 p.m., test trays of the regular and pureed diets contained Chinese chicken, seasoned brown rice, mashed potatoes, and stir fry vegetables. On the regular diet tray the food was lukewarm, the chicken was dry, tough, and had no flavor, the rice was hard and had a sticky texture, the mashed potatoes were bland and gritty, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 36 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm mixed vegetables were bland. On the pureed diet tray, the rice had a glue-like texture, and the pureed vegetables had some flavor. The Dietary Manager stated the pureed vegetables had more flavor. [NAME] N tasted the test tray but did not comment on the food. Temperatures of the food entrees were: Residents Affected - Some Chicken =119.5°F Vegie = 121.6°F Mashed Potato = 126.2°F During a dining observation on 3/16/23, at 5:15 p.m., Resident 148's food tray consisted of Pureed spaghetti with meat sauce, seasoned green beans, garlic bread, nilla banana pudding, and nectar thick fluids. The pureed food entrees appeared soup- like on the plate with no distinction between food items. The Infection Preventionist (IP) assisted Resident 148 with eating. The resident made a face and stated to the assistant no more, I don't like that, the assistant encouraged Resident 148 to try something else and gave the resident a spoonful of nectar thick water. Review of facility policy titled Food Preparation, RDs for Healthcare, Inc. 2018, indicated, Food shall be prepared by methods that will conserve nutritive value, flavor and appearance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 37 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. Findings: During an initial observation of the kitchen on 3/13/23 at 11:15 a.m., Dietary Staff-L was asked what type of dishwasher she used. Dietary Staff-L stated a low-pressure dishwasher. Dietary Staff-L was asked to check the chlorine of the dishwater. Dietary Staff-L took an ECO lab chloride test strip and held the strip in the water for approximately 30 seconds and read the results at >100. When asking Dietary Staff-L how long to keep the test strip in the water she stated about 30 seconds. Review of the manufactures directions for using the Eco Lab chlorine test strip indicated, to dip the test strip into the water and remove immediately. When asking Dietary Staff-L if the chloride test was done following the directions, she stated, No. During an observation of the kitchen on 3/13/23 at 2:00 p.m., a small freezer chest contained frozen chubs of beef and meats and contained two thermometers with broken mercury lines. The temperature log on the outside of the freezer chest indicated the recorded AM and PM temperatures for the month of March was 35 degrees Fahrenheit. During an interview on 3/13/23 at 2:30 p.m., [NAME] M was asked the temperature of the small freezer chest. Cook-B reviewed the thermometers and stated 20 degrees. When asked if the thermometers were accurate, he stated he was not sure. [NAME] M stated he knew the temperature of the freezer should be 0 degrees. A copy of the temperature log was requested. During a review of the small freezer chest temperature log on 3/14/23, the AM and PM temperatures were changed to 0 degrees. Cook-M was asked why the temperatures were changed on the log, he stated the thermometers were broken. During a food preparation observation on 3/15/23 at 11:30 a.m., egg salad was observed in the refrigerator with a prepared date of 3/14/23 and use by date of 3/15/23. When asking Cook-N and the Dietary Manager if a cool down log for potentially hazardous foods (foods prepared at ambient temperatures) was recorded for prepared salads such as (egg, chicken, and tuna). Cook-N stated we do not use a cool down log. The Dietary Manager stated we do not use a cool down log because we do not keep leftovers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 38 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the kitchen policy and procedure titled Food Preparation RDs for Healthcare, Inc. dated 2018, indicated, Special Cool Down Log Use for potentially hazaradous food prepared from ingredients at ambient temperature (room temperature) such as canned tuna and macroni salad. Review of the kitchen recipe titled Classic Egg Salad Sandwich Healthcare Menus Direct, LLC, indicated, allow filling time to cool (Need to utilize cool down log). Temp sandwiches and if higher than 41 Degrees Fahrenheit start a cool down log. Event ID: Facility ID: 055734 If continuation sheet Page 39 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The 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: Residents Affected - Few 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). Unsanitary transport and processing of residents' washables increased the potential of cross-contamination, and the use of undated oxygen equipment, unverifiable of its replacement date, had the potential for buildup of harmful bacteria which may then be inhaled by Resident 248. Findings: a. During an observation of the laundry room with Unlicensed Staff H on 3/15/23 at 9:30 a.m., Therapy Assistant I walked into the room's clean linen area, held up a plastic bag, and stated a resident's splints (a device used to protect a broken bone or injury) needed to be washed. Unlicensed Staff H stopped, pointed to the other side of the room, told Therapy Assistant I to leave and stated, You can't be in here. During a concurrent interview, Unlicensed Staff H stated Therapy Assistant I should not have gone to the clean area with items from the residents' rooms. Unlicensed Staff H stated, Dirty items only in the dirty room, never in the clean area. During an interview on 3/16/23 at 9:51 a.m., Therapy Assistant I stated she did not know that she could not go through the laundry's clean area door to drop off items that needed to be laundered. During an interview on 3/17/23 at 9:05 a.m., Infection Preventionist (IP) stated the dirty linen goes through the laundry's dirty area to be washed. IP stated staff should not bring in dirty items directly into laundry's clean area and added that the clean area was only for washed items. A review of a facility policy titled, Infection Prevention and Control Program: Infection Prevention - Linen Management, dated 10/22, indicated, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen . Clean and dirty linen areas should be separate and clearly designated . b. During a record review for Resident 248, the Face sheet (A one-page summary of important information about a resident) indicated Resident 248 was admitted on [DATE] with diagnoses including but not limited to Right Femur Fracture (a break in the thigh bone) and Chronic Obstructive Pulmonary Disease (COPD diseases that cause airflow blockage and breathing-related problems). During an observation in Resident 248's room on 3/13/23 at 11:25 a.m. in Resident 248 was sitting on her wheelchair with oxygen at 2 liter via oxygen concentrator (device that concentrates the oxygen) via nasal cannula The humidifier attached to the oxygen concentrator, and the nasal cannula tubing did not have a date to indicate when the humidifier and cannula tubing was opened. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 40 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation in Resident 248's room on 3/15/23 at 8:46 a.m. Resident 248 was sitting at the edge of her bed with oxygen on via concentrator at 2 liters via nasal cannula. The humidifier attached to the oxygen concentrator, and the nasal cannula was not dated. During an observation in Resident 248's room and concurrent interview with Licensed Staff F on 3/16/23 at 11:11 a.m., Licensed Staff F verified the nasal cannula was not dated. When Licensed Staff F was asked about facility process when to change the cannula tubing and humidifier, Licensed Staff F stated night nurses were responsible to change and date the cannula tubing and humidifier once a week. During an interview with Licensed Staff R on 3/17/23 2:10 p.m. Licensed Staff R stated nurses were to change the cannula tubing and humidifier every week and as needed. Licensed Staff R stated cannula tubing and humidifier were labeled with date, time/, and licensed nurse's initials. Licensed Staff R stated there was no way she could verify if cannula tubing and humidifier were changed if not labeled with date. Licensed Staff R stated risk for not changing cannula tubing and humidifier would be an infection control issue. During an interview with the Infection Preventionist (IP) on 3/17/23 at 2:31 p.m., the IP stated the cannula tubing was changed weekly and as needed for soilage. The IP stated bacteria could grow in the tubing when not changed and had the potential for the resident to breath in the bacteria. Review of the Facility policy and procedure titled Oxygen Therapy revised on 11/2020 indicated, It is the policy of this facility to administer oxygen in a safe manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 41 of 42 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Many Findings: During an observation of room [ROOM NUMBER]'s bathroom on 3/14/23 at 10:36 a.m., a call light button was located on the wall next to the toilet. The button was around elbow-height of a resident sitting on the toilet, easily accessible in said position. The bathroom size was approximately six feet by five feet. An observation of room [ROOM NUMBER]'s bathroom on 3/14/23 at 3:52 p.m. revealed a similarly sized bathroom, call light system, and call button location. During an observation on 3/14/23 at 3:59 p.m., the bathroom between rooms [ROOM NUMBERS] was noticeably bigger, approximately eight feet by 10 feet in size, with a partial wall in the middle separating the toilet and shower areas. A similar call light button was located similarly on the wall next to the toilet. During an interview and concurrent observation on 3/14/23 at 4:06 p.m., Maintenance Director stated the facility has 16 resident bathrooms, with the bathrooms between rooms [ROOM NUMBERS], and rooms [ROOM NUMBERS], being bigger than the other 14. Maintenance Director stated all 16 resident bathrooms were equipped with identical call light systems, comprised of the call button located on the wall next to the toilet. During a simulation of a fall on bathroom in room [ROOM NUMBER], with arms outstretched, the surveyor was unable to reach the call light button from the bathroom floor across the toilet. Maintenance Director stated the call light button cannot be reached from the floor. A review of the facility policy titled, Call Light/Bell, dated, 2/2023, indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 42 of 42