Ukiah Post Acute: Fall Care Plan Ignored After Fracture - CA
That was May 24. Five days later, a state inspector found her bed was not in the lowest position, the one intervention her care plan specifically required to keep her from falling again.
Resident 1 is a woman with difficulty walking, unsteadiness on her feet, muscle weakness, and abnormal gait. She cannot make her own decisions. Her daughter speaks for her. The fall care plan created for her after the wheelchair incident set a goal that she would "resume usual activities without further incident" through a target date of August 16, 2026. The single documented intervention: bed in lowest position.
On May 29, at 3:40 in the afternoon, an inspector stood in Resident 1's room alongside a certified nursing assistant identified as CNA 1. The CNA did not dispute what the inspector was seeing. She demonstrated it herself, using the bed's own controls to show the bed was raised. The inspector photographed the different positions.
CNA 1 did not explain why the bed had been left up.
Twenty minutes later, a licensed nurse told the inspector it was her expectation that if the care plan said lowest position, staff should follow it. That was the extent of her response.
The Director of Nursing, interviewed three days after the inspection, said she had personally created the fall care plan on the same day as the fracture, May 24. She said responsibility for carrying out its interventions fell to her, the interdisciplinary team, the nurses, and the CNAs. Then she said the quiet part plainly: if the interventions were not implemented, Resident 1 might fall again and could sustain another injury.
She was describing exactly what the inspection had just documented.
The care plan's goal, the one about resuming usual activities without further incident, had a target date nearly three months out. The intervention designed to support that goal was not being followed within the first week.
Resident 1's face sheet listed her diagnoses in plain terms. Difficulty walking. Unsteadiness. Need for assistance with personal care. Muscle weakness. Abnormal gait and mobility. These are not subtle or unpredictable risk factors. They are the documented, known reasons a woman falls asleep in a hallway and cannot catch herself.
The facility's own fall prevention policy, written in November 2020, states its purpose as investigating the circumstances of each fall and implementing actions to reduce additional falls and minimize injury. The care planning policy, updated in December 2023, defines interventions as actions designed to meet an objective.
Keeping a bed at its lowest position is among the most basic fall-prevention measures in a nursing facility. It requires no equipment, no medication, no clinical skill. It requires only that the person adjusting the bed leave it where the care plan says to leave it.
Nobody had.
The inspection was classified as a complaint survey. The violation was cited at minimal harm, meaning inspectors determined no additional injury had yet occurred. But the Director of Nursing's own words framed the stakes: another fall, another injury, a woman who already went to the emergency room once and came back with a broken nose.
Resident 1's daughter is her decision maker. The inspection report does not say whether she knew her mother's care plan was not being followed. It does not say whether she was told.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ukiah Post Acute from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
UKIAH POST ACUTE in UKIAH, CA was cited for violations during a health inspection on May 29, 2026.
Resident 1 is a woman with difficulty walking, unsteadiness on her feet, muscle weakness, and abnormal gait.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.