Inspection·December 10, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some LN 1 stated she left Resident 1, while she was performing this procedure, and clocked out for her meal period, without having another Licensed Nurse check on Resident 1 during her break. LN 1 stated that during her lunch period, a Certified Nursing Assistant (CNA) alerted her Resident 1 had blood on her fingers and hands. LN 1 stated she told the CNA that she was not surprised because Resident 1 has been doing fecal disimpaction on herself for about 30 minutes with her long fingernails. LN 1 stated the CNA told her (LN 1) Resident 1 was going to call 911 to get help, but by the time she clocked back from lunch and was about to check on Resident 1, the CNA told her Resident 1 had already called 911 herself. LN 1 stated emergency medical services arrived at the facility and took Resident 1 to the GACH. LN 1 then stated that she, totally dropped the ball on facility protocol, and did not notify Resident 1's family or attending physician that she had been transferred to a GACH by emergency services. LN 1 also admitted that she did not report to the next shift's charge nurse that Resident 1's family had not been notified of her emergency transfer to the hospital. A review of Resident 1's Medication Administration Record (MAR) for the month of November, 2025, indicated a documented pain level assessment of four out of ten (a pain scale from zero to ten, in which zero indicates no pain, and ten is the worst pain experienced during a person's lifetime), followed by an administration of two tablets of Acetaminophen 325 mg (mg = milligram; a unit of measure) to Resident 1 at 11:31 p.m. which resulted in ineffective, pain control as documented by LN 1. Resident 1's MAR also indicated LN 1 administered the medication Zofran (a prescription medication used to prevent nausea and vomiting) 4 mg tablet to Resident 1 at 11:39 p.m. The Zofran order indicated it was ordered by Resident 1's physician on 11/10/2025 for nausea and vomiting. Resident 1's MAR did not contain a physician order for the medication Milk of Magnesia, or any documentation it was administered to Resident 1.A review of a progress noted dated 11/29/25 at 2:11 a.m., documented by LN 1 indicated, pt [patient] c/o [complained of] abd [abdominal] discomfort, stated she had been nauseous all day administered PRN [as needed] APA [acetaminophen] 325 x2 tabs, prn [as needed] ondansetron [generic name for Zofran], pt c/o [complained of] constipation and requested a suppository this nurse explained 2 bm's [bowel movements] charted and administered MOM [milk of magnesia], pt requested bowel sweep [fecal disimpaction] LN [licensed nurse] explained cannot perform that request, pt then self-administered bowel sweep stating it's right there. LN advised to drink more water and allow the medication to work, pt now stating that she's going to call an ambulance, will notify MD. call light within reach.A review of a facility document provided by the Director of Nursing (DON) indicated LN 1 clocked out for her meal period on 11/29/25 at 2:46 p.m. and clocked back in after her meal period at 3:17 a.m.A review of a progress note dated 11/29/25 at 3:31 a.m., documented by LN 1 indicated, pt called 911 for herself, pt left facility in fire department ambulance/transport on transfer from bed to gurney without complications/4 medics present/via ambulance to [name of GACH].During an interview on 12/10/25 at 10:19 a.m., the DON acknowledged it was a failure on the facility's part to not notify Resident 1's family when she was transferred to the hospital by emergency medical services, and not to communicate this information to the charge nurse on the next shift.During a second interview on 12/10/25 at 3:30 p.m., the DON stated that when LN 1 saw Resident 1 performing a fecal disimpaction on herself, she (LN 1) should have told her (Resident 1) to stop, educated her, explained the risks, assessed her, stayed with her, and called the doctor. The DON confirmed in this instance, it was not appropriate for LN 1 to clock out for a meal period while she knew Resident 1 was having this issue with constipation and attempting to disimpact herself. The DON acknowledged that during the time LN 1 was clocked out for her meal period, there was no other licensed nurse to cover, and continue the responsibility of caring for Resident 1. The DON confirmed the process for notifying the attending physician of a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055734 If continuation sheet Page 2 of 3 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 12/10/2025 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete resident's change in condition, or to obtain a new physician order in the middle of the night, was to simply call the physician. The DON stated the people LN 1 was supposed to notify in this situation were, the doctor, the family, the hospital to call and give report, the administrator, the DON, and to endorse the information to the next shift charge nurse. Additionally, according to the DON, due to Resident 1's follow up pain level assessment of six out of ten on 11/29/25, after the administration of Acetaminophen for pain, LN 1 should have called the doctor to report the worsening pain, or to request an order for an alternate pain medication to treat Resident 1's high pain level.During a phone interview with Resident 1's family member (FM) on 12/16/25 at 2:01 p.m., FM confirmed there was no notification made to Resident 1's emergency contacts, her spouse, her daughter, or her family that she was emergently transferred to the hospital from the staff at the facility on 11/29/25. FM stated the first notification Resident 1's family received regarding her GACH admission on [DATE], was from a GACH physician calling Resident 1's daughter, to obtain an emergency consent for Resident 1 to undergo a surgical procedure.A review of Resident 1's GACH emergency department report dated 11/29/25, documented by Emergency Physician 1 (EP 1) indicated, [Resident 1] Presented with abdominal pain and constipation .tachycardic [heart rate greater than 100 beats per minute; normal heart rate is 60-100 beats per minute] on arrival .Found to have emphysematous cystitis [a serious rare urinary tract infection where gas producing bacteria create bubbles in the bladder wall] and an obstructing left ureteral stone [A kidney stone inside the tube that connects the kidney to the bladder] .Blood cultures [tests used to detect bacteria or other organisms growing in a person's blood] positive for Klebsiella Pneumoniae [a type of bacteria that can cause infection] .Upon my evaluation, this patient had a high probability of imminent or life-threatening deterioration due to sepsis [a life threatening medical emergency where the body's overwhelming response to an infection damages its own tissues and organs], hypotension [lower than normal blood pressure] requiring pressor [emergency medication used to increase blood pressure] support.A review of the facility policy and procedure (P&P) titled, Significant Change in Condition, Response, undated, indicated, The nurse will perform and document the assessment and identify the need for additional interventions considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR (Situation, Background, Assessment, Recommendation: a standardized communication tool used for clear, concise handoffs and critical patient updates) or similar process to obtain new orders or interventions .The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report .There will be certain circumstances where immediate attention will be warranted and nursing will be responsible for notifying the appropriate department for evaluation. The nurse will use .her clinical judgment and shall contact the physician based on the urgency of the situation .The resident representative will be notified of the change in condition and any changes in the resident's medical or nursing care. Event ID: Facility ID: 055734 If continuation sheet Page 3 of 3