Health 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. Page 1 of 2 055734 055734 03/27/2025 Ukiah Post Acute 1349 South Dora St. Ukiah, CA 95482

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 3/27/25 at 3:40 p.m., the MRD stated a facility record titled ADL indicated what type of bathing was completed for Resident 1 from 1/6/25 through 2/7/25. The ADL record indicated Resident 1 received a shower on 1/12/25, refused a bath on 1/17/25, 2/4/25, and 2/7/25, and was unavailable for bath on 1/21/25 and 2/7/25. The ADL record indicated Resident 1 was scheduled to receive a shower/bath on Tuesdays and Fridays. The ADL record indicated NA (Not Applicable) for Resident 1's scheduled shower dates of: 1/7/25, 1/10/25, 1/14/25, 1/24/25, 1/28/25, and 1/31/25. During a concurrent interview and record review on 3/27/25 at 3:45 p.m., CNA B confirmed the document titled, ADL indicated Resident 1 was given one shower on 1/12/25, refused bathing on 1/17/25, 2/4/25, and 2/7/25 in the morning, and was unavailable for bathing on 1/21/25 and 2/7/25 in the afternoon. CNA B stated he charted NA if it was not an assigned resident's shower day, or they were unavailable for a shower. CNA B reviewed the abbreviations used for the ADL sheet and indicated the following were used when CNAs charted what type of bathing activity was completed: SH for a shower given, FB for a full body bath, SB for sponge bath, RU for resident unavailable, RR for resident refused, and NA for not applicable. The charting on the ADL document included only the abbreviations for the bathing type completed and did not include any details. During a concurrent interview and record review on 3/27/25 at 4:30 p.m., the Director of Nursing (DON) verified the document titled, ADL indicated Resident 1 was given one shower on 1/12/25, refused bathing on 1/17/25, 2/4/25, and 2/7/25 in the morning, and was unavailable for bathing on 1/21/25 and 2/7/25 in the afternoon. During a concurrent interview and record review on 4/7/25 at 1:43 p.m., the Director of Staff Development (DSD) stated the residents in the facility were scheduled to receive showers at least two times per week. Residents could have requested more showers, but the minimum had been two times per week. The DSD stated the facility had a policy and procedure for baths and showers, but it did not indicate the frequency of baths or showers. The DSD stated the scheduling of twice per week bathing was a standard of care at the facility. The DSD also stated cleanliness was very important for wound healing. 055734 Page 2 of 2