Ukiah Post Acute

In the surveyor’s words

From the most serious findings on record at Ukiah Post Acute, in the surveyor’s own words.

• Actual harm, patternF686Mar 20, 2023

  Based on observations, interviews and records review, the facility failed to assess two of twelve sampled residents (Resident 23 and 38) who were identified at risk for pressure ulcer when: 1. The facility did not assess Resident 23's skin integrity under the left lower extremity (part of the body that includes the leg, ankle, and foot) immobilizer (removable devices that maintain stability of the knee) for a period of two weeks when nursing and therapy staff were providing care and treatment. […]

• Actual harm, isolatedF684Mar 20, 2023

  Based on observations, interviews and records review, the facility failed to assess and provide necessary services to one of twelve sampled residents (Resident 38) when the facility did not ensure Resident 38 was free from pain due to left foot pressure ulcer and Deep Vein Thrombosis (DVT - a blood clot forms in one or more of the deep veins in the body, usually in the legs) to left leg. This failure resulted to Resident 38's inability to relax when she repeatedly called out for help and moaned (to make a long, low sound of pain, suffering). […]

• Actual harm, isolatedF689Mar 20, 2023

  Based on observations, interviews, and records review, the facility failed to provide adequate supervision for two of twelve sampled residents (Resident 249 and 38) when: 1. The facility did not follow their Fall Care plan to provide staff supervision to Resident 249 when sitting on his wheelchair. This failure resulted to Resident 249's repeated falls requiring two hospitalization s due to nasal laceration (a deep cut or tear in skin) and bilateral nasal bone fractures (a break in the bone or cartilage over the bridge, or in the sidewall or septum [structure that divides the nostrils] of the nose) to which Resident 249 experienced pain. 2. […]

• No harm, potential for more than minimal, widespreadF804Jan 24, 2025

  Based on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition, palatability and served at an appetizing temperature when eight out of 46 residents (Resident 4,Resident 11, Resident 253, Resident 29, Resident 35, Resident 154, Resident 36, Resident 1) received meals that were cold, flavorless and overcooked. This failure had the potential to decrease nutritive content and decrease meal intake by the residents eating meals served by the kitchen and adversely affecting their health. Findings: During a concurrent observation and interview on 1/21/25 at 11:59 a.m., in the dining room, Resident 4 stated the chicken served for lunch was too dry, she couldn't chew it and didn't want it. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2025

  Based on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when: 1. Kitchen staff improperly restrained facial hair and hair net use. 2. Kitchen staff Improperly used gloves. 3. Dietary staff observed to wear jewelry while at work in the kitchen. 4. Kitchen staff did not monitor ambient food cooling. 5. Expired food found in the reach in refrigerator and dry storage area. 6. Condiment containers found with drip residue in caps and along sides of containers. 7. Soiled equipment observed in a food prep area. 8. Resident refrigerator did not have a cleaning process. 9. […]