Inspection·April 11, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some breaks down substances called purines) that form in and around the joints. Her MDS, dated [DATE], BIMS score was 15 indicating intact cognition. During an interview on 4/11/24 at 1:09 p.m. Unlicensed Staff A stated the facility was short staff especially on the weekends and she usually had between 8 up to 12 residents to care for in the morning shift. Unlicensed Staff A stated it was hard to finish her task on time. Unlicensed Staff A stated short staffing could lead to residents' neglect, late provisions of care and increased fall incidents and injury. Unlicensed Staff A stated short staffing was a safety risk. During an interview on 4/11/24 at 1:46 p.m., Resident 1 stated he felt the facility could improve their staffing as sometimes staff takes a while to answer calls for help. Resident 1 stated it could be frustrating to wait for a long time when you needed help. Resident 1 stated he was worried nobody would see him and answer his call light on time in case of an emergency. During an interview on 4/11/24 1:58 p.m., Licensed Staff B stated the facility was short staffed when there were call off. Licensed Staff B stated short staffing meant little more time allotted per each resident. Licensed Staff B stated short staffing could lead to late provision of care and wait time for staff to answer residents call light could be longer. Licensed Staff B also stated short staffing was a safety risk for the residents. During an interview on 4/11/24 at 3:20 p.m., Licensed Staff C stated the facility was short staffed. Licensed Staff C stated it would be beneficial for the residents if the facility was adequately staffed. Licensed Staff C stated short staffing made it difficult for her to complete her task safely and timely. Licensed Staff C stated short staffing could lead to late provision of care, care not being rendered at all, residents' change of condition (COC, a change in the residents' health or functioning) could be missed which could be a safety issue for the resident. During an interview on 4/11/24 at 3:23 p.m., Resident 2 stated the facility was short staffed. Resident 2 stated there were not enough staff to care for the residents at the facility. Resident 2 stated during resident council (an independent group of long-term care facility residents who typically meet at a minimum of once a month to discuss concerns and suggestions in the facility and to plan activities that are important to them) meeting, she had also heard residents complained of short staffing and staff taking a long time to answer call lights. Resident 2 stated she felt frustrated and concerned about short staffing. Resident 2 stated despite being discussed in resident council, short staffing was still happening in the facility. During an interview on 4/11/24 at 3:40 p.m., Anonymous 3 stated the facility was short staffed. Anonymous 3 stated she had to wait for 1 up to 2 hours before staff answers her call light. Anonymous 3 stated staffing was bad at nighttime. Anonymous 3 stated about a month ago, she was left soiled on her brief, and it took about an hour for staff to change her brief. Anonymous 3 stated it was embarrassing and frustrating. Anonymous 3 stated she hoped the facility would have adequate staff to care for the residents. During an interview on 4/11/24 at 3:57 p.m., Unlicensed Staff D stated the facility was short staffed. Unlicensed Staff D stated taking care of 12 to 13 residents on morning shift was a lot. Unlicensed Staff D stated short staffing was a safety risk for the residents. Unlicensed Staff D stated short staffing could lead to late provision of care and staff rushing residents to complete their task. During a telephone interview on 4/11/24 at 4:14 p.m., the Interim Director of Nursing (DON) stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 2 of 4 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 04/11/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that at this time the facility was struggling with short staffing. The Interim DON stated some staff had left due to issues with short staffing. The Interim DON stated short staffing could result to decreased quality of care. Based on the staffing documentation provided by the facility, it indicated that on these dates, the CNAs had a higher number of residents to care for on these dates: 3/1/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/2/24, the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/3/24 the facility had a census of 49, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/6/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/10/24 the facility had a census of 49, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/15/16 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/16/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. 3/24/24 the facility had a census of 48, there were only 4 CNAs in the morning shift, indicating the CNAs have about 12 to 13 residents to care for during their shift. A review of the facility's policy and procedure (P&P) titled Staffing, Adequate , revised 1/2024, the P&P indicated it was the policy of the facility to provide adequate staffing to meet the needs of the resident population. B. During an interview on 4/11/24 at 1:14 p.m., Licensed Staff A stated abuse allegation should be reported as soon as possible within 4 hours. Licensed Staff A stated if an abuse allegation was not reported timely, it could lead to continued abuse, further abuse and worst case scenario, injury or death to the resident. During an interview on 4/11/24 at 1:30 p.m., the Occupational Therapist (OT) stated abuse allegations were only reported to the Ombudsman (an independent official who has been appointed to investigate complaints) and should be reported within 24 hours. The OT stated if an abuse allegation was not reported timely, it could result to further abuse, psychological harm and neglect. During an interview on 4/11/24 at 1:44 p.m., Unlicensed Staff A stated abuse allegations should be reported to the Ombudsman (an official who investigates complaints) and State (CDPH, the state (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 3 of 4 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 04/11/2024 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some department responsible for public health in California) within 24 hours. Unlicensed Staff A stated, if an abuse allegation was not reported timely, it could result to ongoing abuse. Unlicensed Staff A stated it was a safety issue to the resident if an abuse allegation was not reported timely. During an interview on 4/11/24 at 2:08 p.m. Licensed Staff B stated abuse allegation should be reported to the Ombudsman, the State and the local police as soon as possible within 24 hours. Licensed Staff B stated if an abuse allegation was not reported to the appropriate agencies and was not reported timely, residents could be at risk for neglect, ongoing abuse. Licensed Staff B stated not reporting an abuse timely was a safety risk, residents would not feel safe in the facility and residents would not feel staff were protecting them. During an interview on 4/11/24 at 2:33 p.m., the Interim DON stated abuse allegations with injury should be reported to the Ombudsman and the CDPH within 24 hours. The Interim DON stated if there was no injury, there would be no need to report the abuse allegation to the local police. The Interim DON stated if an abuse allegation resulted in injury, it should be reported to the Ombudsman, CDPH and the local police within 2 hours. During an interview on 4/11/24 at 3:57 p.m., Unlicensed Staff D stated abuse allegations should be reported to the Ombudsman within 24 hours. Unlicensed Staff D stated if an abuse allegation was not reported timely, it could lead to continued abuse and resident could get hurt. A review of the facility's policy and procedure (P&P) titled Abuse Prevention Program , revised 11/2022, the P&P indicated when an incident or allegation of resident abuse was reported, the allegation will be reported within 24 hours to the appropriate agency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 4 of 4