Inspection·January 24, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility allowed one out of two sampled residents (Resident 11) to self-administer medications without the Interdisciplinary Team (IDT, a collaborative approach that combines data, techniques, and perspectives from multiple disciplines) determining if self-administration was clinically appropriate for Resident 11. Residents Affected - Few This failure was a safety issue which could lead to dosing errors and ineffective symptom management. Findings: A review of Resident 11s face sheet (demographics) indicated an admission date of 10/25/24 with a diagnoses of Weakness, Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, high levels of fat particles (lipids) in the blood. During a concurrent observation and interview on 1/22/25 at 10:36 a.m., there was a medicine cup with 4 ½ tablets noted on top of Resident 11's overbed table. Resident 11 stated the morning nurse left it there. Resident 11 could not recall the name of the pills but knew one of them was tramadol (opioid analgesic and had high potential for misuse and abuse). Resident 11 stated nurses occasionally would leave medications at her bedside and allowed her to self-administer her medications. Resident 11 stated staff did not perform any assessments to determine whether it was safe and appropriate for her to self-administer her medications. During an interview on 1/22/25 at 11:21 a.m., when shown a photograph of the medication cup containing 4 ½ tablets on top of Resident 11s overbed table, Registered Nurse (RN) I verified these medications were Resident 11s medications and the 1/2 pill was tramadol. RN I stated she could not recall why the medications were left at Resident 11s overbed table. RN I stated leaving medications at bedside should not happen and was a safety issue as other residents may accidentally take the medications, residents may not take the medications and could end up having pain. RN I could not recall whether an assessment was done to check if Resident 11 was safe to self-administer her medications. During an interview on 1/22/25 at 12:07 p.m., the Director of Nursing (DON) stated medications should not be left at bedside if they did not have an order and if they did not have an assessment indicating they were safe to self-administer their medications. The DON stated leaving medications at bedside was a safety issue and could lead to other residents accidentally ingesting medications not meant for them. During an interview on 1/24/25 at 9:10 a.m., the DON verified there were no assessment done to determine if Resident 11 was safe to self-administer her medications. The DON verified there were no IDT assessment or progress note that would indicate Resident 11 was assessed for safety and appropriateness to self-administer her medications. A review of the facility's policy and procedure (P&P) titled Self-Administration of Medication, revised 8/2024, the P&P indicated .if a resident desires to participate in self administration, the IDT will assess and periodically re-evaluate the resident based on change in resident status . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 2 of 28 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 01/24/2025 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure medications were administered timely for three out of three sampled residents (Residents 11, 32 and 45). Residents Affected - Some This failure put Residents 11, 32 and 45 at significantly increased risk of worsened health condition, untreated symptom, and complications from untreated symptoms. Findings: A review of Resident 11s face sheet indicated an admission date of 10/25/24 with a diagnoses of Weakness, Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, high levels of fat particles (lipids) in the blood. Resident 11s BIMS dated 11/19/24 score was 15 indicating intact cognition. A review of Resident 11s MAAR indicated 2 medications were administered late on 1/19/25: Insulin injection scheduled time was 6:30 a.m. and was not administered until 8:15 a.m. and Insulin injection scheduled time was 4:30 p.m. and was not administered until 5:41 p.m., A review of Resident 11s MAAR indicated at least 2 medications were administered late on 1/21/24: Vasoconstrictor scheduled time was 6:30 a.m. and was not administered until 08:25 a.m., and Insulin injection scheduled time was 6:30 a.m. and was not administered until 8:19 a.m. A review of Resident 32s face sheet indicated an admission date of 8/17/23 with a diagnoses of Weakness, HTN, and HLP. Resident 32s BIMS dated 11/7/24 score was 15 indicating intact cognition. A review of Resident 32s MAAR indicated 2 medications were administered late on 12/6/24: 2 antidiabetic medications were scheduled at 7:00 a.m. but was not administered until 8:07 a.m. A review of Resident 45s face sheet indicated an admission date of 12/23/24 with a diagnoses of Dysphagia (difficulty swallowing), Insomnia (a sleep disorder where a person have trouble falling asleep, staying asleep, or both). Resident 45s BIMS dated 12/30/24 score was 12 indicating moderately impaired cognition. A review of Resident 45s MAAR indicated at least 8 medications were administered late on 1/19/25: Insulin injection scheduled time was 8:00 a.m. and was not administered until 12:10 p.m., 2 Antihypertensive medication scheduled time was 8:00 a.m. 1 was not administered until 12:16 p.m. and the other was not administered until 12:17 p.m., Antiarrhythmic medications (used to treat abnormal heart beats) medication scheduled time was 8:00 a.m. and was not administered until 12:16 p.m., Blood thinner medication scheduled time was 8:00 a.m. and was not administered until 12:16 p.m., water pill medication scheduled time was 8:00 a.m. and was not administered until 12:16 p.m., The afternoon medications potassium supplement scheduled time was 4:00 p.m. and was not administered until 6:41 p.m., Antihypertensive medication scheduled time was 4:00 p.m. and was not administered until 6:41 p.m., A review of Resident 45s MAAR indicated at least 6 medications were administered late on 1/20/25: 2 Antihypertensive medication scheduled time was 8:00 p.m. and was not administered until 9:48 a.m. and 9:49 a.m., water pill medication scheduled time was 8:00 a.m. and was not administered until 9:49 a.m., Potassium supplement scheduled time was 8:00 a.m. and was not administered until 9:46 a.m., blood thinner scheduled time was 8:00 p.m. and was not administered until 9:49 a.m., Antiarrhythmic medication scheduled time was 8:00 a.m. and was not administered until 9:49 a.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 3 of 28 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 01/24/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/23/25 at 10:15 a.m., Resident 45 stated staff were usually late in administering her medications. Resident 45 stated she wished staff were more cognizant of giving her medications timely. During an interview on 1/22/25 10:36 a.m., Resident 11 stated staff would give her medications late most of the time. Resident 11 stated it was important for her to receive her medications timely. Residents Affected - Some During a concurrent interview and Residents 11, 32 and 45s MAAR record review on 1/23/25 at 2:14 p.m., the Director of Nursing (DON) verified there were medications that were administered late for Resident 11 on 1/19/25 and 1/21/25, Resident 32 on 12/6/24 and Resident 45 on 1/19/25 and 1/20/25. The DON stated it was important to follow the physician's orders and to administer medications on time to prevent medication errors and for residents' safety. The DON stated to consider a medication was administered timely, a medication should be given within 1 hour before and 1 hour after the scheduled time. During an interview on 1/23/25 at 2:10 p.m., Licensed Nurse (LN) K stated, in order for a medication to be administered timely, the medications should be administered 1 hour before up to 1 after the scheduled time. LN K stated it was important to follow this time frame because it was a physician's order and for residents' safety. LN K also stated giving the medications timely reduced the risk of error in drug administration. A review of the facility's policy and procedure (P&P) titled Medication Administration-Oral, revised 11/2019, the P&P indicated . the purpose was to ensure safe, accurate, and effective administration of medication while maintaining compliance with state, federal including California Department of Health guidelines .no medication is to be administered without a physician's written order .Accurate and timely administration according to MD (physician) order is essential. California Advocates for Nursing Home Reform (CANHR), published on 10/24/22 indicating the time frame for medication administration. It stated A drug, whether prescribed on a routine, emergency, or as needed basis, must be provided in a timely manner. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. https://canhr.org/nursing-home-care-standards/# FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 4 of 28 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 01/24/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interviews and record reviews, the facility failed to ensure: Residents Affected - Few 1. the opthalmic (eye) suspension medication of one out of two sampled residents (Resident 4) was labeled properly when the physician's order had changed. 2. the discontinued level II-V medications (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) were stored in a permanently affixed compartment prior to destruction. These failures had the potential to cause medication errors and/or lead to drug diversion. 1. Findings: A review of Resident 4s face sheet (demographics) indicated an admission date of 3/17/23 with a diagnoses of Low Back Pain and Weakness. A review of Resident 4s Physician Order Summary (POS, a written physician order/instruction for staff to follow) indicated an order of ophthalmic (eye) suspension 1 percent (%, one part in every hundred) instill 1 drop (gtt) in left eye two times a day dated 1/20/25 for herpes viral keratitis (infection of the eye caused by the herpes simplex virus (HSV). During a concurrent observation and interview on 1/22/25 at 9:38 a.m., Registered Nurse (RN) I confirmed the label on the ophthalmic suspension 1% indicated to instill 1 gtt on left eye three times daily. RN I stated this label was inaccurate since the order was changed to instill 1 gtt in left eye two times daily with a start date on 1/21/25. RN I confirmed the label for the ophthalmic suspension 1% was incorrect. During an interview on 1/22/25 at 11:21 a.m., RN I stated the medication orders in the POS, electronic medication administration record (EMAR, digital version of the traditional paper medication administration records) and the medication label should all match to prevent confusion and medication error. During an interview on 1/22/25 at 12:00 p.m., the Infection Preventionist (IP) stated labels on medications including instructions should match what was on EMAR and POS to ensure safe medication administration, to ensure right dose was being administered to the resident and to prevent medication error. During an interview on 1/22/25 at 12:06 p.m., the Director of Nursing (DON) stated medication labels should match the POS and EMAR to prevent medication error and to ensure residents were receiving the correct medication and dose. A review of the facility's policy and procedure (P&P) titled Medication Ordering and Receiving From Pharmacy updated 9/2019, the P&P indicated .only the dispensing pharmacy /registered pharmacist can modify, change or attach prescription labels .if the physician's directions for use have changed, the nurse may place change of order- check chart label on the container indicating there is a change in directions for use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 5 of 28 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 01/24/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 2. During a concurrent observation and interview on 1/23/25 at 8:34 p.m. it was noted the discontinued controlled drugs/narcotics were stored in a safe not permanently affixed to a compartment. The Director of Nursing (DON) verified the discontinued controlled drugs were kept in this safe. The DON confirmed the safe was not in a permanently affixed compartment. A review of the Comprehensive Drug Abuse Prevention and Control Act of 1976 indicated the facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II and other drugs subject to abuse. Event ID: Facility ID: 055734 If continuation sheet Page 6 of 28 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 01/24/2025 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 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review the facility failed to ensure sufficient and competent staff were scheduled to carry out the functions of the food and nutrition service safely when: Residents Affected - Some 1. Two staff members worked tray line affecting timeliness of meal delivery. 2. One dietary aide (DA B) could not verbalize or demonstrate proper method to check sanitizing solution. 3. Presentation of pureed food was not appetizing. Findings: 1. During an observation on 1/21/25 at 10:00 a.m., a posted sign at the nursing station 2 read: breakfast served at 7:30 a.m., lunch at 11:30 a.m. and dinner at 5:30 p.m. daily. During an observation on 1/21/25 at 11:49 a.m., a food cart arrived in the dining room. Five residents seated at different tables were served and started eating. The second cart arrived at 12:07 p.m. During an observation on 1/22/25 at 12:11 p.m., the lunch food cart was delivered to nursing station 2. During an observation on 1/22/25 at 7:15 a.m., breakfast trayline was in progress. [NAME] (CK) C plated entrees and sides while Dietary Aide (DA) B placed drinks, condiments, extra items and silverware on tray. During an observation on 1/23/25,dietary leadership assisting with the following tasks: At 10:28 a.m., Dietary Services Supervisor (DSS) held strainer for CK 3 allowing meat juice to be strained. At 10:32 a.m., Registered Dietitian (RD) retrieved an ivory scoop for CK 3. At 10:57 a.m., RD washed Robo Coupe bowl for CK 3. At 11:03 a.m., DSS placed rice and beans in oven. At 11:10 a.m., RD washed blender. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 7 of 28 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 01/24/2025 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 At 11:23 a.m., DSS made gravy on stovetop from strained meat juices. RD washed teal scoop. Level of Harm - Minimal harm or potential for actual harm At 11:46 a.m., DSS plated Caeser Salad during trayline. RD replaced sanitizer bucket. Residents Affected - Some During an interview on 1/23/25 at 2:58 p.m., CK B stated there are normally only 2 dietary personnel to plate all meals with no additional help from dietary leadership. During an interview on 1/23/25 at 3:01 p.m., RD confirmed there are normally only 2 people on trayline for all meals. She stated she is not normally the runner or helper during trayline. During a record review of a document titled Trayline Setup Procedure: Breakfast, Lunch, Dinner dated 2023, a diagram depicts 4 dietary staff for trayline. 2. During a record review of document titled Verification of Job Competency dated August 2024, DA B was granted competency of Sanitizing Solution; test concentration and record results; when to replace solution by demonstration and verbalization. During a concurrent observation and interview on 1/22/25 at 8:50 a.m., Dietary Aide (DA) B stated the cleaning procedure in the kitchen consisted of washing, rinsing and sanitizing. DA B then demonstrated testing of sanitizer solution. DA B held the strip for four seconds, when RD corrected DA B by stating to hold the strip for 10 seconds. DA B repeated the demonstration a second time with a new testing strip, holding it in the sanitizer solution for 7 seconds. DA B was unable to verbalize proper test result range of strip or demonstrate proper testing method of sanitizer solution despite showing competency on his job competency checklist. During a record review of document titled Job Description: Dietary Aide dated 2023, a duty and responsibility of the DA is cleaning as assigned on cleaning schedule. During a record review of document titled AM Dietary Aide, undated, a posted sign in the kitchen indicates at 5:30 a.m., the dietary aide is assigned to prepare the quat bucket, use the quat strip to test the ppm. During a record review of the Food and Nutrition Department Cleaning Schedule (undated), sanitizing the tray carts had been assigned to dietary aide. During a document review from Ecolab titled Oasis 146 Multi-Quat Sanitizer dated 2016 indicated the testing strip is to be held in the sanitizer solution for 10 seconds. Result range for testing solution should be between 150-400 ppm. 3. During an observation on 1/23/25 at 9:47 a.m., in the kitchen, CK C pureed Caeser salad. Excess dressing added to the mixture resulted in a runny texture. CK C added croutons and stated he would check before serving the salad to ensure proper consistency. Pureed Caeser salad was not rechecked prior to trayline start. The texture was observed to be not fully formed. During an observation on 1/23/25 at 10:50 a.m., CK C pureed carrots with parsley by adding ¾ (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 8 of 28 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 01/24/2025 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 cup warmed milk. The texture was observed to be not fully formed. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/23/25 at 11:05 a.m., CK C pureed rice and beans, then added ½ cup warm milk. The texture was observed to be not fully formed. CK C stated that Rice is tricky. It looks right but then it seizes up when it sits. Residents Affected - Some During an observation on 1/23/25 at 12:15 p.m., the pureed test tray was inspected. Pureed rice & beans and pureed carrots spread across plate due to thin consistency. During a record review of a document titled Regular Pureed Diet/IDDSI Level #4, dated 2024 indicated the texture of pureed food items should .hold their shape .and should not weep. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 9 of 28 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 01/24/2025 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 During an interview on 1/23/25 at 10:40 a.m., Operations Manager stated the Quality Assurance Performance Improvement (QAPI) Committee met in January and had had discussed resident dissatisfaction with meals. He stated QAPI had a plan to test meal trays and audit resident meals. He stated QAPI had not started the process yet and there were no performance improvement projects that included resident food palatability, temperature of food or temperature of the ambient temperature of facility areas. Residents Affected - Many A review of the Resident Council meeting minutes from 10/24 indicated resident grievances included the resident rooms temperatures were cold for rooms 1, 2, 3, 9, 11, 15, 19, 24, 27, 28, 30. Grievances from resident included complaints that food temperatures were cold. The Resident Council meeting minutes from 11/24 did not indicate follow up from the facility administration for the grievances that included cold resident rooms and cold meals. Review of the minutes for the last year indicated resident complaints about their rooms being cold were discussed at Resident Council on 1/24, 2/24, 4/24, 6/24, 10/24, 11/24 and 12/24. Based on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition, palatability and served at an appetizing temperature when eight out of 46 residents (Resident 4,Resident 11, Resident 253, Resident 29, Resident 35, Resident 154, Resident 36, Resident 1) received meals that were cold, flavorless and overcooked. This failure had the potential to decrease nutritive content and decrease meal intake by the residents eating meals served by the kitchen and adversely affecting their health. Findings: During a concurrent observation and interview on 1/21/25 at 11:59 a.m., in the dining room, Resident 4 stated the chicken served for lunch was too dry, she couldn't chew it and didn't want it. Chicken was observed partially cut up on Resident 4's plate and appeared dry. Resident 4 stated they do not provide gravy for chicken. She asked for some refried beans in place of chicken. During a concurrent observation and interview on 1/22/25 at 11:53 a.m., in residents' room, Resident 11 was just served her lunch tray. Resident 11 had only eaten approximately 25% of her lunch. She stated that lunch was cold and that meals were frequently delivered cold, and that she would not be eating a lot of the food that was served to her for lunch. She also stated the eggs are terrible. She had informed the RD of the issues with the food but had not seen any changes. She further stated she liked everything about the facility except the food. During a concurrent observation and interview on 1/22/25 at 12:05 p.m., in residents' room, Resident 253 was just served her lunch tray. Resident 253 had only taken a few bites and stated she was finished. She stated the food was bland and cold and she was not interested in any of the alternate meal choices. During an interview on 1/21/25 at 9:56 a.m., Resident 29 stated the meals were not like home cooking. During an interview with Resident 35 on 1/21/25 at 12:10 p.m., she stated her meals were not like home cooking. She stated the food was bland and did not taste as good as it could. She stated cold (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 10 of 28 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 01/24/2025 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 food was Not very appetizing. Level of Harm - Minimal harm or potential for actual harm During an interview with Resident 4, on 1/21/25 at 12:22 p.m., she stated she was the president of the Facility Resident Council, and consistent issues brought up by residents was dissatisfaction with meal menus and the temperature of food. She stated her meals are never served hot and were warm at best. Residents Affected - Many During an interview on 1/21/25 at 3:54 p.m. , Resident 154 stated the food at the facility was not very good. She stated substitutions were limited to cheese based options that did not taste good and was served cold. She stated too much cheese created a constipation problem. Cold food is not appetizing and not like home cooking. She stated it made her feel like the food was from an institutional cafeteria. During an observation and interview on 1/22/25 at 8:21 a.m., Resident 154 and Resident 36 both stated the room felt cold. Resident 154 stated breakfast was French Toast, and it was cold and tough. She stated she did not finish her breakfast, and her plate was observed to have 25% of her French Toast not eaten. She stated she lost her desire to eat when food is cold and tough. Resident 36 stated her French Toast was cold and tough. She stated she did not have teeth, and it was difficult to chew. She pointed to her breakfast plate that indicated she had eaten 25% and stated she missed hot food, and the meals were not like being at home. She was observed to be tearful when she stated she was not able to enjoy her breakfast but all the meals in general. During an observation and interview on 1/22/25 at 8:24 a.m., Certified Nurses Aid (CNA) N was observed to exit Resident 1's room with a breakfast tray that indicated the resident had not eaten anything. He stated Resident 1 had told him the breakfast was cold and tough. He stated he did not ask her if she wanted a substitute breakfast tray or if she wanted him to heat it up for her. During an interview on 1/22/25 at 8:28 a.m., Resident 29 stated her breakfast was French Toast that she never ordered. She stated I have no teeth, and the French Toast was cold and tough. During an interview on 1/23/25 at 9:10 a.m., Resident 29 stated she was very upset about her breakfast. She stated she had requested oatmeal, and they served her cold cream of wheat. She had refused another tray because they told her there was no oatmeal and they would have to cook it for her. She stated she needed her breakfast in the morning because she needed it to take with her morning medications because she could not take them on an empty stomach. She stated when dietary did not serve her food that she requested and that was hot, it made her feel unimportant. She stated this is my home and it is not right. During an observation on 1/23/25 at 9:45 a.m., in the kitchen, carrots were boiling on the stove in a large amount of water. During an observation on 1/23/25 at 10:44 a.m., in the kitchen, carrots were drained. Carrots were pale in color. During a concurrent observation and interview on 1/23/25 at 11:05 a.m., small portions of boneless, skinless chicken breast were removed from the oven. They appeared dry. When [NAME] (CK) D was asked what time they were placed in the oven, he stated I placed the chicken in the oven at 9:45 a.m. During a record review of document titled Recipe: Baked Chicken, dated 2024, indicate that chicken (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 11 of 28 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 01/24/2025 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 breasts should be placed in the oven for 30-40 minutes. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/23/25 at 10:09 a.m., all three steam wells were off. Registered Dietitian (RD) stated that they were usually kept on at a low temperature to keep them warm. Residents Affected - Many During an observation on 1/23/25 at 10:23 a.m., temperature on the wall clock above the window in the kitchen reads 57.3 degrees Fahrenheit (F). Following observations of time and temps follow: 10:57 a.m.: 57.7 degrees F, 11:12 a.m.: 57.9F 11:29 a.m.: 58.2 F 11:43 a.m.: 58.6 F 11:56 a.m.: 59 F. Fans and vents are running the entirety of lunch plating. During an observation on 1/23/25 at 11:43 a.m., plate warmer had 5 plates standing above rim on both sides during trayline service. This left the higher plates to be exposed to the cold air in the kitchen. During an observation of temperatures during test trays on 1/23/25 at 12:15 p.m., the following foods were tested for temperature by RD using facility thermometer: Pureed Regular Roast Beef RD 100.2F RD 118 F Carrots RD 94.6 F RD 107.4 F Rice & Beans RD 95.1 F RD 104.5 F Survey team observed the test trays for taste, palatability and appearance. Pureed carrots and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 12 of 28 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 01/24/2025 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 Residents Affected - Many pureed rice and bean dishes spread across plate due to the thin consistency. Test trays for both regular and pureed meals were lukewarm. Survey team members stated carrots had very little flavor. The carrots are watery. RD stated Our recipes don't use much salt. During a record review of document titled Meal Service dated 2023, food items are recommended to be delivered to the residents at the following temperatures: Hot entrée at or above 120F Starch at or above 120F Vegetables at or above 120F Record review of Resident Council Meeting Minutes, dated 1/20245 to 10/2024, revealed residents voicing concern over vegetables being either overcooked or undercooked, tough meat, and meals that are often served cold. During a record review of Food & Nutrition: Test Tray Evaluation Log, completed independently by RD on 10/16/24, 10/17/24, 10/23/24, 10/31/24 and 1/14/25 indicated a temperature drop from trayline to resident delivery ranging from a 38-degree temperature drop to a 70- degree. Comments from residents included toast was cold.; Weird seasoning on broccoli.; My meat was dry and tough. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 13 of 28 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 01/24/2025 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview and record review the facility failed to accommodate resident food preferences or offer snacks to seven of 46 residents (Resident 154, Resident 36, Resident 1, Resident 3, Resident 27, Resident 11, Resident 29), when alternate menu items were continuously repeated, and snacks were not offered to all residents in the facility. This failure had the potential for residents in the facility to experience weight loss and become malnourished. Findings: During an interview with Resident 154, on 1/21/25 at 3:54 p.m., Resident 154 stated the food at the facility was not very good. She stated substitutions were limited to cheese based options that did not taste good and was served cold. She stated too much cheese created a constipation problem. She stated she was not offered snacks ever. During an interview on 1/22/25 at 8:21 a.m., Resident 154 and Resident 36 stated they were not offered snacks last night. Resident 36 stated the facility had never offered bedtime snacks. During an observation and interview on 1/22/25 at 8:24 a.m., Certified Nurses Aid (CNA) N was observed to exit Resident 1's room with a breakfast tray that indicated the resident had not eaten anything. He stated Resident 1 had told him the breakfast was cold and tough. He stated he did not ask her if she wanted a substitute breakfast tray or if she wanted him to heat it up for her. During an interview on 1/22/25 at 8:39 a.m., Resident 3 stated he was not offered snacks last night. He stated the staff do not provide bedtime snacks. He stated staff have never asked him if he wanted a meal substitution if he did not like something. During an interview on 1/22/25 at 9:09 a.m., Certified Nurse Assistant N stated Resident 27 had refused her breakfast and did not eat anything. He stated he did not offer her another breakfast substitution. During an interview on 1/22/25 at 11:50 a.m., in resident's room, Resident 11 stated that she wants snacks but does not like what they send her, because it is normally a half sandwich. She stated she dislikes sandwiches. She would like to have raw vegetables with hummus for a snack. She stated she often does not like the meat served for meals because it is often dry and tough. The alternate menu for meals is never different, always sandwiches. She stated that she is hungry all the time, and that the facility does not give them very much to eat. During an interview on 1/23/25 at 9:10 a.m.,Resident 29 stated last night the nurse promised her a bag of chips but she never got it. She stated she was mad because they never offer snacks before bed. She stated she was really excited about the snack of chips and then mad because she never got them. During an interview on 1/22/25 at 2:33 p.m., Registered Nurse (RN) I stated that resident snacks come out in between meals. Snacks consists of half sandwiches, juices, cheese and crackers. All snacks come out from the kitchen with a name label. She stated that nursing staff do not go around and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 14 of 28 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 01/24/2025 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 0806 offer snacks to resident and that they can request to be placed on a snack list through the kitchen. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/22/25 at 2:35 p.m., the Registered Dietitian (RD) stated that upon admission the resident can request to have snacks ,choose what they want to eat, and they can update as needed. Residents who wish to change their snack or wish to begin receiving a snack would tell their CNA, Nurse or contact the RD. Residents Affected - Some During a record review of the Meal Service Alternatives choices for Spring 2024, Summer 2024 and Fall 2024, a grilled cheese sandwich (or ungrilled) is offered on each menu. Fall 2024 has 2 sandwich options: grilled cheese or turkey. Winter 2024-2025 has 2 sandwich options: grilled ham and cheese or tuna salad. During a record review of responses to facility document Resident Council, an email, dated 6/24/24, was sent to RD stating that residents are requesting more drinks and snacks to the day room. Record review of Resident Council meeting minutes dated 9/20/24 , indicated they would like to switch alternating meals. Minutes from 10/15/24 indicate that residents would like to add resident choice meal to the calendar, and to replace the set menu. A review of a facility minutes document titled Resident Council, dated 12/7/24, indicated Department: Dietary Issues: More fresh fruit, too much pork, protein substitution/not grilled cheese, alternative always out . Record review of a document titled Food Preferences, dated 2023, indicated resident's food preferences will be adhered to within reason. Record review of document titled Food Substitutes for Residents who Refuse the Meal, dated 2023, indicated residents will be provided a suitable nourishing alternate meal after the served planned meal has been refused. According to this document, nursing staff would ask those residents who refused the meal why they are not eating, and offer a food substitution in accordance with the resident's diet order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 15 of 28 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 01/24/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when: Residents Affected - Many 1. Kitchen staff improperly restrained facial hair and hair net use. 2. Kitchen staff Improperly used gloves. 3. Dietary staff observed to wear jewelry while at work in the kitchen. 4. Kitchen staff did not monitor ambient food cooling. 5. Expired food found in the reach in refrigerator and dry storage area. 6. Condiment containers found with drip residue in caps and along sides of containers. 7. Soiled equipment observed in a food prep area. 8. Resident refrigerator did not have a cleaning process. 9. Cross contamination of products in the resident refrigerator in the nutrition room. These failures posed the risk for food borne illness for 46 of 46 residents that resided in the facility and consumed food prepared in the kitchen. Findings: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 16 of 28 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 01/24/2025 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 During an observation on 1/21/25 at 11:06 a.m., in the kitchen, Dietary Aide (DA) A wore a baseball cap with hair restraint underneath that did not cover the entirety of his hair. During an observation on 1/21/25 at 2:00 p.m., in the kitchen, [NAME] (CK) B wore a hair restraint on his beard. His mustache was not covered. Residents Affected - Many During an observation on 1/22/25 at 7:15 a.m., in the kitchen, CK D wore a baseball cap with no hair restraint underneath. His hair was curling up over the bottom of the cap. During an observation on 1/22/25 at 2:48 p.m., in the kitchen, CK B wore a baseball cap with no hair restraint underneath. The hair at the back of the head was exposed. A beard restraint was worn. His mustache was exposed. During an observation on 1/23/25 at 8:30 a.m., in the kitchen, DA F had hair protruding from the bottom of the hair restraint around her entire head. During an interview on 1/23/25 at 3:01 p.m., Registered Dietitian (RD) stated she would look at the policy regarding hair restraint use. During an observation on 1/23/25 at 9:44 a.m., in the kitchen, a sign posted by the handwashing sink stated that hairnets and beard coverings must be worn while in the kitchen. During a record review facility policy titled Dress Code, dated 2023, indicated that if hair is short, staff may wear a hat that completely covers the hair. If hair is long, use hair restraint. Staff with beards and mustaches (any facial hair) must wear beard restraint. According to FDA Food Code 2022 2-402.11 (A) showed Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. 2. During an observation on 1/21/25 at 2:00 p.m., in the kitchen, CK B opened the kitchen entry door with gloved hand and resumed cooking without washing hands and changing gloves. During an observation on 1/22/25 at 7:15 a.m., DA E retrieved an item from freezer #2 with gloved hands. Did not change gloves or wash hands before resuming plating items for trayline. During a record review of facility policy titled Glove Use Policy dated 2023, employees need to wash their hands and change their gloves when starting a different task and/or when touching non-food items. According to the FDA Food Code 2022, Section 2-301.14 Food employees shall clean their hands and exposed portions of their arms .(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms and (E) After handling soiled equipment or utensils. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 17 of 28 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 01/24/2025 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 During an observation on 1/23/25 at 8:30 a.m., in the kitchen, DA C wore nose piercings, ear piercings, necklace and a large, loose ring during meal prep and trayline. During an interview on 1/23/25 at 3:12 p.m., RD stated that she would have to review the policy regarding jewelry in the kitchen. Residents Affected - Many During a record review of document titled Dress Code, dated 2023, indicated no facial jewelry no excessive jewelry. According to FDA Food Code 2022, Section 2-303.11, Jewelry indicates that except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 4. During a concurrent observation and interview on 1/21/25 at 10:28 a.m., in the walk-in refrigerator, prepared tuna salad was observed in a container labeled made on 1/21/25. When asked for a cooling logs, Registered dietitian (RD) stated the facility did not use cooling logs for ambient foods. We pull everything from the can at room temp and stick it right in the refrigerator. During an interview on 1/22/25 at 2:55 p.m., Dietary Services Supervisor (DSS) confirmed that no ambient cooling logs were kept because mayonnaise and pickles were pulled from the refrigerator. He acknowledged tuna is pulled from dry storage and is at room temp when made. During a record review of facility policy titled Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, indicated, PHF (Potentially Hazardous Food) or TCS (Time/Temperature Control for Safety) food shall be cooled within 4 hours to 41 degrees or less, if prepared from ingredients at ambient temperature, such as reconstituted food and canned tuna. According to FDA Food Code 2022, 3-501.14 Cooling. (B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna. 5. During a concurrent observation and interview on 1/21/25 at 10:28 a.m., in the reach in refrigerator 2 bowls of soup were found, labeled Prepared 1/12/25. Use by 1/15/25. RD confirmed these were expired and should have been thrown out. During a concurrent observation and interview on 1/21/25 at 10:48 a.m., in the dry storage area, a container of sesame oil with expiration date of 11/24 was seen. RD confirmed this was expired and should have been thrown out. The facility did not have a policy regarding expired foods. 6. During an observation on 1/21/25 at 10:25 a.m., in the kitchen, a container of BBQ sauce had dried drips of sauce on the outside of the container. The cap of the container had residue on the outside (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 18 of 28 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 01/24/2025 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 of the container rim. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/21/25 at 10:26 a.m., in the dry storage area, a container of vanilla had dried drips of contents on the outside of the container. RD confirmed risk of bacteria growth and stated she would clean off the container. Residents Affected - Many According to the FDA Food Code 2022, 4-601.11 (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. 7. During an observation while on initial tour of kitchen on 1/21/25 at 10:15 a.m., the following equipment was observed to be soiled: grill has black residue; slotted compartment under griddle has debris and dust; stovetop has black residue and debris in burner wells; ovens have black residue; blender base was not clean; top of dishwasher has tan, flaky debris; dishwasher has hard, white buildup on corners and crevices; silverware dispenser was not clean; can opener was not clean. During an interview on 1/21/25 at 10:15 a.m., CK D stated he cleans the grill portion of the stove after every use. During a record review of document titled Food Nutrition Department: Cleaning Schedule dated from October 2024 to January 22, 2025, indicates all equipment named above is listed and assigned to dietary staff. According to the FDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces, and utensils shall be clean to sight and touch, (B) The food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.(C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 8. During an observation on 1/21/25 at 2:50 p.m., the resident refrigerator in nutrition room had brown residue in crevices of door gasket. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 19 of 28 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 01/24/2025 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 - Many During an interview on 1/22/25 at 9:18 a.m., Housekeeping Tech (Hskg) M stated that she does not clean the resident refrigerator in the nutrition room. She only mops the floor in the nutrition room. She stated the kitchen clean the resident refrigerator. During an interview on 1/22/25 at 2:50 p.m., RD stated that the cooks spot clean the resident refrigerator and monitors the temperatures. Housekeeping helps with cleaning and deep cleaning of the refrigerator. On 1/22/25 at 3:50 p.m., a schedule or a log of cleaning and deep cleaning the resident refrigerator in the nutrition room was requested from RD and Maintenance Director (MND). During an interview on 1/23/25 at 12:45 p.m., MND stated there was not a deep cleaning or cleaning schedule for the resident refrigerator in the nutrition room, and that it was done on an as needed basis only. According to the FDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces, and utensils shall be clean to sight and touch, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 9. During an observation on 1/21/25 at 2:52 p.m., in the nutrition room, Certified Nurse Assistant (CNA) H removed a half gallon of milk from the resident refrigerator, dated and labeled the milk and handed to a family member of Resident 12. Milk was observed to be poured into a glass for resident and left on the bedside table with resident's other personal belongings. During an observation on 1/21/25 at 3:00 p.m., the opened half gallon of milk remains on bedside table of Resident 12. During an observation on 1/21/25 at 4:00 p.m., the opened half gallon of milk was placed back in resident refrigerator. Facility did not have policy regarding food removed and returned to the resident refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 20 of 28 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 01/24/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review the failed to ensure a Quality Assurance Performance Improvement (QAPI) plan that resolved consistent complaints from residents about environmental temperatures, food temperatures, food palatability, and food preferences. This failure resulted in the lack of a systematic approach to determine underlying causes of problems impacting temperature of the environment, food palatability, medication errors; and no guidance on how the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. Findings: (Reference F837, F804, F806) During an interview on 1/21/25 at 9:56 a.m., Resident 29 stated the meals were not like home cooking. During an interview with Resident 35 on 1/21/25 at 12:10 p.m., she stated her meals were not like home cooking. She stated the food was bland and not taste as good as it could. She stated cold food was Not very appetizing. During an interview with Resident 4, on 1/21/25 at 12:22 p.m., She stated she was the president of the Facility Resident Council, and consistent issues brought up by residents was dissatisfaction with meal menus and the temperature of food. She stated her meals are never served hot and were warm at best. During an interview with Resident 154, on 1/21/25 at 3:54 p.m. , Resident 154 stated the food at the facility was not very good. She stated substitutions were limited to cheese based options that did not taste good and was served cold. She stated too much cheese created a constipation problem. Cold food is not appetizing and not like home cooking. She stated it made her feel like the food was from an institutional cafeteria. During an observation and interview on 1/22/25 at 8:21 a.m., Resident 154 and Resident 36 both stated the room felt cold. Resident 154 stated breakfast was French Toast, and it was cold and tough. She stated she did not finish her breakfast, and her plate was observed to have 25% of her French Toast not eaten. She stated she lost her desire to eat when food is cold and tough. Resident 36 stated her French Toast was cold and tough. She stated she did not have teeth, and it was difficult to chew. She pointed to her breakfast plate that indicated she had eaten 25% and stated she missed hot food, and the meals were not like being at home. She was observed to be tearful when she stated she was not able to enjoy her breakfast but all the meals in general. During an observation and interview on 1/22/25 at 8:24 a.m., Certified Nurses Aid (CNA) N was observed to exit Resident 1's room with a breakfast tray that indicated the resident had not eaten anything. He stated Resident 1 had told him the breakfast was cold and tough. He stated he did not ask her if she wanted a substitute breakfast tray or if she wanted him to heat it up for her. During an interview on 1/22/25 at 8:28 a.m., Resident 29 stated her breakfast was French Toast that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 21 of 28 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 01/24/2025 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 0867 she never ordered. She stated I have no teeth, and the French Toast was cold and tough. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/22/25 at 2:41 in the back hallway nursing station, License Nurse I stated she did not know much about QAPI except that they meet on Mondays. She stated she was not aware of any performance improvement projects or what QAPI does. Residents Affected - Many During an interview on 1/23/25 at 9:10 a.m., Resident 29 stated she was very upset about her breakfast. She stated she had requested oatmeal, and they served her cold cream of wheat. She had refused another tray because they told her there was no oatmeal and they would have to cook it for her. She stated she needed her breakfast in the morning because she needed it to take with her morning medications because she cannot take them on an empty stomach. She stated when dietary does not serve her food that she requested that was hot made her feel unimportant. She stated this is my home and it is not right. During an interview and record review on 1/23/25 at 10:40 a.m., Operations Manager stated the Quality Assurance Performance Improvement (QAPI) Committee met in January and had had discussed resident dissatisfaction with meals. He stated QAPI had a plan to test meal trays and audit resident meals. He stated QAPI had not started the process yet and there were no performance improvement projects that included resident food palatability, temperature of food or temperature of the ambient temperature of facility areas. Operations Manager was asked to provide the policy and procedures for the QAPI Committee. He stated everything for QAPI was in the 2024 Quality Assurance and Performance Improvement (QAPI) Plan. During a review of the document he stated there were no policy and procedures for QAPI. He stated he did not know what Appendix PP (Appendix PP to a section within the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), which provided detailed guidance that outlined the standards and expectations for nursing homes facilities. Nursing homes needed to be familiar with the guidelines in Appendix PP to ensure they are operating in compliance with CMS standards.) was or how to access the regulations. He stated QAPI was going to start a process to improve resident satisfaction with meal preferences. He stated there was no documentation that a performance improvement plan (PIP) had started yet. He stated there were no PIP's for resident complaints for consistent resident complaints about the cold temperatures in the facility or cold food. He stated he was unsure if QAPI had monitored any pharmacy or resident medication issues. During a phone interview on 1/23/25 at 1:07 pm Administrator stated Operations Manager was not a licensed Skilled Nursing Home Administrator. Administrator stated There is no governing body. He stated he lived in Southern California. During an interview on 1/24/25 at 10:00 a.m., Operations Manager stated there was no documentation of any audits or monitoring. He stated he was unsure if the QAPI had monitored any pharmacy or resident medication issues. He stated QAPI tracks adverse events by when the Director of Nursing presented them to the QAPI and then she would investigate and present her findings at the meeting. He stated there was no QAPI policy and procedures for root cause analysis or investigation of adverse events. When asked how those processes occurred he stated the Director of Nursing was responsible. Operations Manager stated there were only two PIPs; one for resident falls and one for wound care documentation. He stated the PIPs collection of data was from informal observations and not on a documentation form. He stated the Director of Nursing was responsible for collecting and calculating everything. He stated the 2024 QAPI plan was not approved by the Governing Body. A request at the survey entrance for the QAPI minutes and membership was made 1/21/25. No QAPI policy and procedures, QAPI minutes, QAPI Agendas were provided by the end of survey. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 22 of 28 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 01/24/2025 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A review of the Resident Council meeting minutes from 10/24 indicated resident grievances included the resident rooms temperatures were cold for rooms 1, 2, 3, 9, 11, 15, 19, 24, 27, 28, 30. Grievances from resident included complaints that food temperatures were cold. The Resident Council meeting minutes from 11/24 did not indicate follow up from the facility administration for the grievances that included cold resident rooms and cold meals. Review of the minutes for the past year indicated resident complaints about their rooms being cold were discussed at Resident Council on 1/24, 2/24, 4/24, 6/24, 10/24, 11/24 and 12/24. A review of a facility document titled 2024 Quality Assurance and Performance Improvement (QAPI) Plan, indicated The Administrator has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. QAPI Governance: The governing body is ultimately responsible for overseeing the QAPI Committee. At a minimum, the QAPI Committee will report the progress on the established QAPI goals and current data trends to the following: Governing Body . The QAPI Committee, which includes the Medical Director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction. A review of a facility document titled 2024 Quality Assurance and Performance Improvement (QAPI) Plan, indicated QAPI PLAN REVIEWED & APPROVED BY: Governing Body-Member _____ Sginature__________ Date______. The two Governing Body-Member signature lines indicated no signature. A review of a facility document titled 2024 Quality Assurance and Performance Improvement (QAPI) Plan, indicated REFERENCES: CMS QAPI Website: quality Assurance & Performance Improvement. Effective QAPI programs are critical to improving the quality of life, and quality of care and services delivered in nursing homes. https://www.cms.gov/medicare/provider-enrollment-and-certifications/qapi/downloads/qapifiveelements.pdf. Element 5: Systematic Analysis and Systemic Action The facility uses a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change. The facility uses a thorough and highly organized/ structured approach to determine whether and how identified problems may be caused or exacerbated by the way care and services are organized or delivered. Additionally, facilities will be expected to develop policies and procedures and demonstrate proficiency in the use of Root Cause Analysis. Systemic Actions look comprehensively across all involved systems to prevent future events and promote sustained improvement. This element includes a focus on continual learning and continuous improvement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 23 of 28 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 01/24/2025 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 Based on observations, interviews and record reviews, the facility failed to ensure: Residents Affected - Some 1. Staff were following the Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when administering medications via feeding tube (tube inserted into the stomach to provide a patient with enteral nutrition, used when someone is unable to eat or drink safely by mouth). This failure could lead to spread of infection, increased complications and adverse events. 2. Staff were performing hand hygiene (HH, cleansing of your hands with soap and water, antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers) prior to donning gloves. These failures could lead to spread of infection, increased complications and other adverse events. Findings: A review of Resident face sheet (demographics) indicated an admission date of 12/23/24 with a diagnoses of Dysphagia (difficulty swallowing) and Esophagitis (an inflammation of the esophagus, the tube that carries food from the mouth to the stomach). Resident 45 had a feeding tube and was on EBP. During an observation on 1/22/25 at 8:09 a.m., Licensed Nurse (LN) J provided Resident 45s medications via feeding tube without wearing a gown. During an interview on 1/22/25 at 11:21 a.m., Registered Nurse (RN) I stated EBP must be followed when giving medications to the residents via feeding tube to protect the staff and the resident. RN I stated it was also to prevent spread of infection at the facility. During an interview on 1/22/25 at 12:05 p.m., the Infection Preventionist stated nurses had to follow the EBP when administering medications to residents via feeding tube. The IP stated this was for infection control and residents' safety to prevent spread of infection. During an interview on 1/22/25 at 12:07 p.m., the Director of Nursing (DON) stated nurses had to follow EBP whenever giving medications to a resident via feeding tube. The DON stated this was an infection control measure and was used to prevent spread of infection. During an interview on 1/23/25 at 10:18 a.m., LN J verified she did not follow the EBP when she administered Resident 45s medications via feeding tube. LN J verified nurses should follow the EBP when administering Resident 45s medications. LN J stated not following EBP when administering medications via feeding tube was an infection control issue. A review of the facility's policy and procedure (P&P) titled Policy on Enhanced Barrier Precaution, effective date 8/2024, it stated EBPs must be implemented for residents who have wounds or indwelling medical devices such as urinary catheters (a tube placed in the body to drain and collect urine from the bladder), feeding tubes .EBPs apply during device care or handling .gowns and gloves must be worn during all high contact care activities . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 24 of 28 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 01/24/2025 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 - Some 2. During a concurrent observation and interview on 1/22/25 at 7:56 a.m., Licensed Nurse (LN) J removed her gloves and wore new gloves with no HH. LN J stated she should have performed HH prior to donning new gloves. LN J stated this was important for infection control and to prevent spread of infection. During an interview on 1/23/25 2:10 p.m., Licensed Nurse (LN) K stated staff were required to perform HH prior to donning gloves and after removing gloves. LN K stated if this was not done, then it was an infection control issue which could lead to spread of infection. During an interview on 1/23/25 at 4:15 p.m., the Director of Nursing (DON) stated staff should be performing HH prior to donning gloves. The DON stated if HH was not done prior to donning gloves, then it was an infection control issue. The DON stated performing HH prior to gloving decreases the risk of spread of infection. The Centers for Disease Control and Prevention (CDC) recommends that healthcare workers (HCWs) wash their hands before and after putting on gloves, and after removing gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 25 of 28 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 01/24/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain essential patient care equipment in safe operating condition when: Residents Affected - Many 1. The air conditioner in dry storage room is soiled. 2. The walk-in refrigerator condenser fans are dripping soiled water on food box. 3. Freezer number 2 had frozen ice drips on ceiling. 4. Ice machine and ice chest cleaning process is unsafe. 5. Resident refrigerator in nourishment room had a damaged gasket. These failures have the potential to contaminate food and pose a risk for food borne illness for 46 of 46 residents that reside in the facility. Findings: 1. During an observation on 1/21/25 at 10:48 a.m., in the dry storage area, the air conditioner had black and brown grime and matter underneath the vent and on the locking mechanism. During the same observation, food was stored beneath the air conditioner. A sign was placed across from air conditioner that stated Do not place objects on shelf under air conditioning unit. During an interview on 1/21/25 at 2:25 p.m., Maintenance Director (MND) stated he was responsible for maintaining and cleaning vents, sprinklers, refrigerator and freezer components. He confirmed the air conditioner could be cleaner. According to FDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces and Utensils (A) Equipment shall be clean to sight and touch. Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. According to FDA Food Code 2017, FDA Food Code 2017 - 6-202.12 Heating, Ventilating, Air Conditioning System Vents; Heating ventilating and air conditioning systems shall be designed and installed so that make-up air intake and exhaust vents do not cause contamination of food, food-contact surfaces, equipment or utensils. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 26 of 28 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 01/24/2025 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 0908 2. Level of Harm - Minimal harm or potential for actual harm During an observation on 1/21/25 at 10:28 a.m., water was dripping from condenser fans in walk in refrigerator making a box bottom of sliced cheese wet. Upon closer observation, the blades of the condenser fans have brown colored grime. Residents Affected - Many During an interview on 1/21/25 at 2:27 p.m., MND acknowledged condenser fan leaking water and soiled areas of fans. According to FDA Food Code 2022, Section 4-601.11, Food Contact Surfaces, Nonfood Contact Surfaces and Utensils (A) Equipment shall be clean to sight and touch. Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. 3. During an observation on 1/21/25 at 10:38 a.m., in the kitchen, ice was observed hanging from the ceiling of freezer #2. During an interview on 1/21/25 at 2:29 p.m., MND stated the filters in the freezer needed to be changed or cleaned. MND acknowledged the presence of ice hanging from the ceiling. 4. During a concurrent observation and interview on 1/21/25 at 2:10 p.m., MND demonstrated and stated the process for cleaning the ice machine. MND provided surveyor with instructions and stated he follows these instructions exactly. MND brought chemical Manitowoc Ice Machine Sanitizer which he stated he uses for entire process, and stated The sanitizer also cleans. MND confirmed he used no other chemicals. He stated after following the cleaning process is completed, he dilutes the sanitizer solution with water and sprays on every inch of ice machine. After machine has air dried, he will spray water on the machine to rinse off the sanitizer. Prior to cleaning process, he stated the current ice is removed into sanitized ice chests. Ice chests are cleaned with facility wide multipurpose sanitizer from Ecolab by first spraying with water, spraying with facility wide sanitizer, then air dry. The final step to clean the ice chests was to rinse off. During a record review of document titled Section 4 Maintenance. Cleaning and Sanitizing dated 4/2014, step 3 indicated when water trough refills, the proper amount of ice machine cleaner is to be added prior to sanitizer solution in step 9. Step 11 of the same document indicated Do not rinse sanitized areas. 5. During an observation on 1/21/25 at 2:50 p.m., resident refrigerator gasket located in nutrition room was pulling away from door at top outer portion of door. During an interview on 1/21/25 at 3:55 p.m., MND stated he was not aware of damaged gasket and will replace soon. According to FDA Food Code 2022, Section 4-501.11, (A) Equipment shall be maintained in a state of repair and condition (B) Equipment components such as doors, seals .shall be kept intact, tight and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 27 of 28 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 01/24/2025 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 0908 adjusted in accordance with manufacturer's specifications. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 28 of 28