Inspection·March 27, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide scheduled showers for one resident (Resident 1) of three sampled residents when Resident 1 received one shower or bed bath of nine scheduled opportunities while in the facility. Residents Affected - Few This failure increased the potential for delayed wound healing of Resident 1's wounds due to poor personal hygiene (the practice of maintaining cleanliness of the body to promote comfort, health, and well-being). Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility in January 2025 with diagnoses including fracture of right femur (bone in upper part of leg), orthopedic (related to bones or muscles) aftercare, contusion (bruise) of scalp, pain in right knee, presence of right artificial knee joint, weakness, and need for assistance with personal care. A review of Resident 1's Minimum Data Set (MDS– a federally mandated resident assessment tool) Section GG – Functional Abilities, dated January 11, 2025, indicated Resident 1 was fully dependent (staff does all of the effort and resident does none of the effort to complete the activity) for showering/ bathing and personal hygiene. A review of Resident 1's care plan dated 1/6/25, indicated, has actual impairment to skin integrity related to surgical wound . ADL [Activities of Daily Living] self-care performance deficit related to weakness, impaired balance, pain, and poor endurance .[Interventions included] .requires one staff participation with bathing. During an interview on 3/25/25 at 4:25 p.m., Resident 1 stated he received only one shower during his six weeks in the facility. Resident 1 stated he did not receive any bed baths during that time. During a concurrent interview and record review on 3/27/25 at 10:50 a.m., Certified Nurse Assistance (CNA) A stated a binder which stored resident shower sheets (documentation of skin assessments and shower/bed bath refusals) was located at each nurse station. A review of the shower schedule, located at the nurse station in a binder, indicated each resident was scheduled for a shower twice per week. CNA A stated residents received a shower at least twice per week unless they requested a third shower day. During an interview on 3/27/25 at 3:05 p.m., the Medical Records Director (MRD) stated she was unable to locate any shower sheets for Resident 1. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055734 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055734 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2025 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)