Ukiah Post Acute

F-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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 28 055734 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055734 B. Wing 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 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 Level of Harm - Minimal harm or Resident 1 had told him the breakfast was cold and tough. He stated he did not ask her if she wanted a potential for actual harm substitute breakfast tray or if she wanted him to heat it up for her.

Residents Affected - Many 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 1/22/25 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.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 28 055734 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055734 B. Wing 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 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 Level of Harm - Minimal harm or medication issues. He stated QAPI tracks adverse events by when the Director of Nursing presented them to potential for actual harm 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 Residents Affected - Many 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.

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) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 28 055734 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055734 B. Wing 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46132 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 admitted [DATE REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 28 055734 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055734 B. Wing 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 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 Level of Harm - Minimal harm or devices such as urinary catheters (a tube placed in the body to drain and collect urine from the bladder), potential for actual harm feeding tubes .EBPs apply during device care or handling .gowns and gloves must be worn during all high contact care activities . 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) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 28 055734 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055734 B. Wing 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 43238 potential for actual harm Based on observation, interview and record review, the facility failed to maintain essential patient care Residents Affected - Many equipment in safe operating condition when:

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.

2.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 28 055734 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055734 B. Wing 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 During an interview on 1/21/25 at 2:27 p.m., MND acknowledged condenser fan leaking water and soiled areas of fans. Level of Harm - Minimal harm or potential for actual harm 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 Residents Affected - Many 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 adjusted in accordance with manufacturer's specifications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 28 055734