Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ukiah Post Acute during CMS and state inspections, most recent first.
Failure to prevent resident-to-resident abuse: A cognitively intact resident repeatedly accused another resident with impaired cognition of stealing soft drinks, despite staff finding the items in his room and documenting ongoing monitoring. The conflict escalated to threats and a raised fist, and later the resident confronted the other resident again; staff observed the wheelchairs close together and the other resident reported being struck in the arm.
Fall Care Plan Not Followed: A resident with gait instability, weakness, and impaired decision-making had a fall after falling asleep in her wheelchair and was sent to the ER with a nasal fracture. Her care plan included keeping the bed in the lowest position, but during observation the bed was not in the lowest position, and the DON stated the IDT, nurses, and CNAs were responsible for carrying out the fall interventions.
A resident with CVA-related hemiplegia, cognitive communication deficit, DM2, and schizophrenia was dependent on staff for bathing and grooming, but records and observations showed she received only bed sponge baths, had long untrimmed fingernails, and had facial hair on her chin. She stated she had been asking for nail trimming for a month and wanted a shower so her hair could be washed, while CNA skin observation sheets did not document any shower refusal or related education. Interviews with CNAs, LNs, and the DON confirmed the missing documentation and the unmet grooming needs.
A nurse failed to supervise a resident in uncontrolled pain who was performing a risky self-care procedure, left the resident unattended during a meal break, and did not notify the physician or family when the resident called 911 and was transferred to the hospital. The resident, with a history of GI bleeding and anemia, was later found to have severe complications requiring emergency treatment. Facility policy for assessment and notification was not followed.
A resident, fully dependent on staff for bathing, received only one shower during a six-week stay, despite being scheduled for nine opportunities. The resident's care plan highlighted the need for assistance due to weakness and the importance of cleanliness for wound healing. Facility records showed discrepancies in documentation, with multiple instances of the resident being marked as unavailable or refusing a bath. The facility's policy did not specify the frequency of showers, leading to a failure in maintaining the resident's personal hygiene.
The facility failed to ensure meals were prepared and served at appropriate temperatures, affecting several residents who received cold, flavorless, and overcooked food. Observations revealed issues with food preparation methods, such as overcooked chicken and boiling carrots, and inadequate kitchen conditions, including low ambient temperatures and inactive steam wells. Despite resident complaints and discussions by the QAPI Committee, no performance improvement projects were initiated to address these issues.
The facility failed to ensure safe food storage, preparation, and service, with issues including improper hair restraint, glove use, and jewelry worn by staff. Expired food was found, and there was a lack of ambient cooling logs. Soiled equipment and unclean condiment containers were observed, and the resident refrigerator lacked a cleaning process, posing a risk for foodborne illness.
The facility failed to implement an effective QAPI plan to address resident complaints about cold food, bland meals, and cold room temperatures. Residents expressed dissatisfaction with meals, noting that food was often cold and unappetizing. The QAPI Committee had not initiated any performance improvement projects related to these issues, and there was no evidence of audits or monitoring. Staff interviews revealed a lack of awareness and understanding of the QAPI process, and the facility's QAPI plan lacked approval from the governing body.
The facility failed to maintain essential equipment, including a soiled air conditioner in the dry storage room, leaking condenser fans in the walk-in refrigerator, and ice drips in freezer #2. The ice machine cleaning process was unsafe, and a resident refrigerator had a damaged gasket. These issues risked food contamination for all 46 residents.
The facility failed to uphold resident dignity by serving lunch trays late to three residents, causing distress. Although lunch was scheduled for 11:30 a.m., the first food cart arrived at 11:49 a.m., serving only five residents initially. The remaining three residents were served at 12:07 p.m., contrary to the facility's policy of serving all residents at the same table simultaneously. A resident expressed sadness over the delay, and previous Resident Council Meeting Minutes noted similar concerns.
A facility failed to administer medications timely for three residents, leading to increased health risks. Residents with conditions like hypertension and dysphagia received medications, including insulin and antihypertensives, late. Interviews confirmed the delays, and staff acknowledged the importance of timely administration within the prescribed time frame.
The facility failed to ensure sufficient and competent staff in the food and nutrition service, affecting meal delivery timeliness and sanitizing procedures. Only two staff members worked the tray line, contrary to the required four, leading to delays. A dietary aide demonstrated inadequate knowledge of sanitizing solution testing, and pureed food presentation was unappetizing, not meeting facility guidelines.
The facility failed to accommodate resident food preferences and offer snacks, leading to dissatisfaction and potential nutritional issues. Residents reported limited and unappealing meal options, with substitutions often restricted to cheese-based items. Snacks were not routinely offered, and some residents were promised snacks that were never delivered. Staff indicated that snacks were available upon request, but this was not effectively communicated to residents.
A facility failed to ensure staff followed Enhanced Barrier Precaution (EBP) protocols and proper hand hygiene (HH) practices. A resident with a feeding tube was administered medication without the nurse wearing a gown, violating EBP guidelines. Additionally, a nurse was observed not performing HH between glove changes. These actions were confirmed by staff interviews as necessary for infection control.
A resident was allowed to self-administer medications without an IDT assessment to determine clinical appropriateness. Medications, including tramadol, were left at the bedside, and the resident reported no safety assessment was conducted. The RN and DON confirmed the lack of assessment and acknowledged the safety issue, which violated the facility's policy requiring IDT evaluation for self-administration.
A facility failed to properly label ophthalmic suspension medication for a resident, resulting in a discrepancy between the physician's order and the medication label. The medication was ordered to be administered twice daily, but the label indicated three times daily, leading to potential medication errors. Additionally, discontinued controlled drugs were stored in a safe that was not permanently affixed, violating regulations. These issues were confirmed by staff and had the potential to cause medication errors and drug diversion.
The facility failed to ensure adequate staffing levels, leading to delays in care and potential neglect. Additionally, the facility's Abuse Policy and Procedure were not updated, resulting in inconsistent understanding among staff about reporting guidelines. These deficiencies posed significant risks to resident safety and well-being.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when it did not effectively respond to an escalating conflict between two residents. One resident had diagnoses including vascular parkinsonism and major depression and was cognitively intact with a BIMS score of 15. The other resident had diagnoses including COPD, peripheral vascular disease, major depression, anxiety disorder, and schizophrenia, and had a BIMS score of 7, indicating moderately impaired cognition. The conflict began when the cognitively intact resident repeatedly accused the other resident of stealing soft drinks, even after staff investigated and found the soft drinks in his room and determined the allegation was unfounded. Despite ongoing accusations documented in nursing notes and behavior monitoring records, the situation escalated. On 5/30/26, the resident verbally threatened to fight the other resident and raised his fist toward him while again accusing him of stealing. Management and the physician were notified, and the DON stated the physician ordered the residents to be kept apart. However, the facility later documented that on 6/01/26 the resident again confronted the other resident, with staff observing the wheelchairs positioned extremely close together. The other resident reported that he was struck in the arm, and the resident involved stated, "I tried," when asked whether he struck him.
Fall Care Plan Not Implemented as Written
Penalty
Summary
The facility failed to implement a comprehensive person-centered fall care plan for one resident after a fall incident. The resident’s face sheet listed diagnoses including difficulty walking, unsteadiness on feet, need for assistance with personal care, muscle weakness, and abnormalities of gait and mobility. Her order summary indicated she lacked capacity to make her own decisions and that her daughter was her decision maker. Progress notes dated 5/24/26 documented that the resident was sitting in her wheelchair in the hallway at Station 1, fell asleep, fell face forward to the floor, and was sent to the ER for evaluation. The resident’s comprehensive person-centered care plan noted that she had a fall on 5/24/26 and sustained a nondisplaced fracture of the left nasal bone. The care plan goal stated she would resume usual activities without further incident through the review date, and one intervention listed was to keep the bed in the lowest position. During a concurrent observation and interview on 5/29/26, CNA 1 stated the resident’s bed was not in the lowest position and demonstrated this using the bed controls. LN 1 stated it was her expectation that the fall intervention requiring the bed to be in the lowest position should be followed. The DON stated she created the fall care plan on 5/24/26 and that the IDT, nurses, and CNAs were responsible for implementing the interventions; she also stated that if the interventions were not implemented, the resident might fall again and could potentially sustain another injury.
Failure to Provide and Document Hygiene Care
Penalty
Summary
Resident 31, admitted in September 2016, had diagnoses including cerebral infarction with left-sided hemiplegia and hemiparesis, cognitive communication deficit, type 2 diabetes mellitus, and schizophrenia. Her MDS dated 12/8/25 showed a BIMS score of 14 and indicated she was dependent on staff for transfers to the tub/shower. Her care plan identified an ADL self-care performance deficit related to hemiplegia, fatigue, impaired balance, and pain, and directed staff to assist with bathing/showering and to check nail length and trim and clean nails on bath day and as necessary. A later care plan also addressed resistance to care related to schizophrenia and directed staff to maintain consistency in timing of ADLs, caregivers, and routine. During observation on 2/10/26, Resident 31 stated she had been asking staff to trim her nails for a month, and the surveyor observed that her fingernails were long and needed trimming. On 2/12/26, the surveyor again observed that her fingernails were still untrimmed and that she was growing facial hair on her chin. Resident 31 stated her last bed bath was a week ago and that she did not want a bed bath; she wanted a shower so her hair could be washed. Review of CNA skin observation sheets for January and February 2026 showed Resident 31 received only sponge baths in bed on 1/27/26, 1/30/26, 2/3/26, and 2/6/26. The sheets did not document whether she refused a shower or bath in the shower room, and on several entries CNAs noted that her nails needed clipping. Interviews with CNAs and LNs confirmed that Resident 31 was dependent on staff for shaving and nail care, that refusal of a shower should have been documented, and that the records did not show any documented refusal or education about the consequences of refusing showers. The DON reviewed the records and acknowledged that the refusals were not documented and that the resident's nails were still untrimmed.
Failure to Provide Nursing Supervision and Timely Notification During Resident Medical Emergency
Penalty
Summary
A licensed nurse failed to provide appropriate nursing services to a resident experiencing uncontrolled pain and performing a risky self-care procedure. The nurse administered acetaminophen and Zofran for the resident's complaints of abdominal pain, nausea, and constipation, but did not obtain a physician's order for Milk of Magnesia, which was reportedly given. The resident, dissatisfied with the interventions, began to perform fecal disimpaction on herself. The nurse left the resident unattended during this procedure to take a meal break, without arranging for another licensed nurse to supervise or monitor the resident during her absence. During the nurse's break, a certified nursing assistant observed the resident with blood on her hands and fingers and informed the nurse, who did not immediately intervene. The resident subsequently called 911 herself to obtain emergency medical services and was transferred to a general acute care hospital. The nurse did not notify the resident's physician or family of the transfer, nor did she communicate the need for family notification to the oncoming nurse at shift change. The resident's medical history included acute post hemorrhagic anemia, ulcerative proctitis with rectal bleeding, and gastrointestinal hemorrhage, placing her at high risk for complications. Upon arrival at the hospital, the resident was found to have emphysematous cystitis, an obstructing ureteral stone, and sepsis requiring emergency intervention. Facility policy required nurses to assess changes in condition, notify physicians and family, and document interventions, which were not followed in this case.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident who was fully dependent on staff for bathing and personal hygiene. The resident, admitted with multiple diagnoses including a fracture of the right femur and a surgical wound, was scheduled to receive showers twice a week. However, during a six-week stay, the resident received only one shower and no bed baths, despite being scheduled for nine opportunities. The resident's care plan indicated a need for assistance with personal care due to weakness, impaired balance, pain, and poor endurance, and emphasized the importance of cleanliness for wound healing. Interviews and record reviews revealed discrepancies in the documentation of the resident's bathing schedule. Certified Nurse Assistants (CNAs) and the Medical Records Director were unable to locate complete shower sheets for the resident, and the ADL records showed multiple instances where the resident was marked as unavailable or had refused a bath. The facility's Director of Staff Development confirmed that residents were expected to receive showers at least twice a week, but the facility's policy did not specify the frequency of baths or showers. This lack of adherence to the scheduled bathing routine increased the potential for delayed wound healing due to poor personal hygiene.
Deficiency in Meal Preparation and Service
Penalty
Summary
The facility failed to ensure that meals were prepared and served in a manner that preserved nutrition, palatability, and temperature, affecting eight out of 46 residents. Observations and interviews revealed that residents received meals that were cold, flavorless, and overcooked. Specific instances included a resident receiving dry chicken without gravy, another resident receiving cold and bland food, and several residents expressing dissatisfaction with the taste and temperature of their meals. The issues were consistently reported by residents, including the president of the Facility Resident Council, who noted that meal temperature and menu dissatisfaction were common complaints. Further observations in the kitchen revealed that food preparation methods contributed to the deficiencies. Carrots were observed boiling in a large amount of water, resulting in a pale color, and chicken was overcooked, having been left in the oven for too long. The steam wells, which were supposed to keep food warm, were turned off, and the kitchen's ambient temperature was notably low, ranging from 57.3 to 59 degrees Fahrenheit. These conditions led to meals being served at temperatures below the recommended 120 degrees Fahrenheit for hot entrees, starches, and vegetables. The facility's Quality Assurance Performance Improvement (QAPI) Committee had discussed resident dissatisfaction with meals but had not yet implemented any performance improvement projects related to food palatability or temperature. Resident Council meeting minutes from the past year indicated ongoing grievances about cold meals and room temperatures, with no documented follow-up from facility administration. The lack of action and oversight contributed to the continued dissatisfaction and inadequate meal service experienced by the residents.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served safely in accordance with professional standards of food service. Observations revealed that kitchen staff did not properly restrain facial hair and hair net use, with several staff members having exposed hair or facial hair not covered by appropriate restraints. This was in violation of the facility's dress code policy and the FDA Food Code 2022, which requires food employees to wear hair restraints to prevent hair from contacting exposed food and clean equipment. Additionally, the facility did not adhere to proper glove use protocols. Staff members were observed handling non-food items and then resuming food preparation without washing hands or changing gloves, contrary to the facility's Glove Use Policy and FDA Food Code 2022 requirements. Furthermore, dietary staff were seen wearing jewelry, including nose and ear piercings, necklaces, and large rings, during meal preparation, which is against the facility's dress code and FDA guidelines that restrict jewelry to prevent contamination. The facility also failed to monitor ambient food cooling, with no cooling logs maintained for foods prepared from ambient temperature ingredients, such as tuna salad. Expired food items were found in storage areas, and there was no policy regarding expired foods. Observations of soiled equipment and unclean condiment containers further highlighted lapses in maintaining cleanliness. The resident refrigerator lacked a cleaning process, and there was evidence of cross-contamination, with food items being removed and returned without proper handling. These deficiencies posed a risk for foodborne illness to all residents consuming food prepared in the facility's kitchen.
Failure to Implement Effective QAPI Plan for Resident Complaints
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) plan to address consistent resident complaints regarding environmental temperatures, food temperatures, food palatability, and food preferences. Interviews with residents revealed dissatisfaction with meals, noting that food was often cold, bland, and not like home cooking. Residents expressed that the cold food was unappetizing and difficult to eat, especially for those without teeth. Additionally, residents reported that their rooms were cold, further contributing to their discomfort. The QAPI Committee, responsible for addressing these issues, had not initiated any performance improvement projects related to food palatability, food temperature, or ambient temperature of facility areas. The Operations Manager admitted that there were no documented policies or procedures for QAPI, and the committee had not started any systematic approach to resolve these issues. Furthermore, the QAPI plan lacked approval from the governing body, and there was no evidence of audits or monitoring to track the effectiveness of any improvement activities. Interviews with staff, including a Licensed Nurse and the Operations Manager, revealed a lack of awareness and understanding of the QAPI process and its responsibilities. The facility's QAPI plan was not effectively implemented, as evidenced by the absence of documented performance improvement plans and the lack of follow-up on resident grievances. The Administrator, who was not present at the facility, also failed to provide oversight, leaving the facility without a governing body to ensure compliance with federal and state requirements.
Facility Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain essential patient care equipment in safe operating condition, as observed during a survey. The air conditioner in the dry storage room was found to be soiled with black and brown grime, and food was stored beneath it despite a sign advising against it. The walk-in refrigerator had condenser fans dripping soiled water onto a box of sliced cheese, and the fans themselves were covered in brown grime. Additionally, freezer number 2 had ice drips hanging from the ceiling, indicating a need for maintenance. The ice machine cleaning process was deemed unsafe as the Maintenance Director used only a sanitizer for cleaning, contrary to the documented procedure that required a cleaner before the sanitizer. Furthermore, the resident refrigerator in the nourishment room had a damaged gasket, which the Maintenance Director was unaware of. These deficiencies have the potential to contaminate food and pose a risk for foodborne illness for all 46 residents in the facility. The observations were confirmed through interviews with the Maintenance Director, who acknowledged the issues and his responsibility for maintaining the equipment. The report references the FDA Food Code 2022, which mandates that equipment be clean to sight and touch and maintained in a state of repair, highlighting the facility's failure to adhere to these standards.
Delayed Meal Service Affects Resident Dignity
Penalty
Summary
The facility failed to promote resident respect and dignity by serving lunch trays late to three out of eight residents in the dining room. Observations revealed that while the lunch meal was scheduled to be served at 11:30 a.m., the first food cart arrived at 11:49 a.m., and only five residents were served initially. The remaining three residents were not served until a second food cart arrived at 12:07 p.m. This delay in service was confirmed by Resident 36, who expressed that the wait made her feel sad and bothered her. The facility's policy indicated that all residents at the same table should be served simultaneously, which was not adhered to. Additionally, Resident Council Meeting Minutes from July 2024 documented concerns from residents about the inconsistent timing of meal tray deliveries.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure timely administration of medications for three residents, leading to a significant risk of worsened health conditions and untreated symptoms. Resident 11, diagnosed with weakness, hypertension, and hyperlipidemia, experienced late administration of insulin and vasoconstrictor medications on multiple occasions. Resident 32, with similar diagnoses, also received antidiabetic medications late. Resident 45, who has dysphagia and insomnia, had numerous medications, including insulin, antihypertensives, antiarrhythmics, blood thinners, and potassium supplements, administered late over two consecutive days. Interviews with the residents and staff confirmed the delays in medication administration. Resident 45 expressed dissatisfaction with the timeliness of medication delivery, while Resident 11 emphasized the importance of receiving medications on time. The Director of Nursing and a Licensed Nurse acknowledged the importance of adhering to the prescribed medication schedule, which allows for administration within one hour before or after the scheduled time. The facility's policy and procedure, as well as guidelines from the California Advocates for Nursing Home Reform, emphasize the necessity of timely medication administration to ensure resident safety and compliance with physician orders.
Deficiencies in Food and Nutrition Service Staffing and Competency
Penalty
Summary
The facility failed to ensure sufficient and competent staff were scheduled to carry out the functions of the food and nutrition service safely. Observations revealed that only two staff members were working the tray line, which affected the timeliness of meal delivery. The facility's trayline setup procedure indicated that four dietary staff were required, yet only two were present, leading to delays in meal service. Additionally, dietary leadership was observed assisting with various tasks, indicating a lack of adequate staffing. Interviews confirmed that normally only two dietary personnel were available to plate all meals, contrary to the documented procedure. Furthermore, a dietary aide was unable to properly demonstrate or verbalize the correct method for testing sanitizing solution, despite having been granted competency in this area. The aide incorrectly held the testing strip for an insufficient amount of time and was unable to state the proper test result range. This lack of competency was observed despite the aide's job description and cleaning schedule requiring knowledge of proper sanitizing procedures. Additionally, the presentation of pureed food was not appetizing, with observations noting that the texture of pureed items did not hold their shape as required by the facility's guidelines.
Failure to Accommodate Resident Food Preferences and Offer Snacks
Penalty
Summary
The facility failed to accommodate resident food preferences and offer snacks to several residents, leading to dissatisfaction and potential nutritional issues. Observations and interviews revealed that residents were not provided with adequate meal substitutions or snacks. For instance, one resident reported that the food was unappealing and substitutions were limited to cheese-based options, which were not suitable for her dietary needs. Another resident mentioned that the breakfast served was cold and tough, and no alternative was offered. Additionally, residents expressed that they were not offered snacks, particularly at bedtime, and some were promised snacks that were never delivered. The facility's records and interviews with staff highlighted systemic issues in meal and snack provision. The Registered Nurse and Dietitian indicated that snacks were available but required residents to request them, which was not effectively communicated to the residents. The meal service alternatives were repetitive, often limited to sandwiches, and did not align with residents' preferences as noted in Resident Council meeting minutes. Despite residents' requests for more variety and better meal options, the facility continued to offer limited and unappealing choices, failing to adhere to documented food preferences and substitution policies.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure that staff adhered to Enhanced Barrier Precaution (EBP) protocols when administering medications via feeding tube, as observed with Resident 45. Resident 45, who was admitted with diagnoses of Dysphagia and Esophagitis, had a feeding tube and was on EBP. During an observation, Licensed Nurse J administered medications to Resident 45 without wearing a gown, which is a requirement under EBP for residents with indwelling medical devices. Interviews with the Registered Nurse, Infection Preventionist, and Director of Nursing confirmed that EBP should be followed to prevent the spread of infection, and Licensed Nurse J acknowledged the failure to adhere to these protocols. Additionally, the facility did not ensure proper hand hygiene (HH) practices were followed by staff. During an observation, Licensed Nurse J was seen removing gloves and donning new ones without performing HH in between. This was acknowledged by Licensed Nurse J as an important step for infection control. Interviews with another Licensed Nurse and the Director of Nursing confirmed that HH should be performed before and after glove use, as recommended by the Centers for Disease Control and Prevention (CDC), to prevent the spread of infection.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility allowed a resident to self-administer medications without the Interdisciplinary Team (IDT) determining if it was clinically appropriate. This was observed when a medicine cup with 4 1/2 tablets was found on the resident's overbed table, and the resident stated that the morning nurse left it there. The resident could not recall the names of the pills but identified one as tramadol, an opioid analgesic with a high potential for misuse and abuse. The resident also mentioned that staff did not perform any assessments to determine whether it was safe and appropriate for her to self-administer her medications. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed that medications should not be left at the bedside without an order and an assessment indicating the resident was safe to self-administer. The RN verified the medications belonged to the resident and acknowledged that leaving them at the bedside was a safety issue. The DON confirmed that no assessment was conducted to determine if the resident was safe to self-administer her medications, and there was no IDT assessment or progress note indicating such an evaluation had been performed. The facility's policy required the IDT to assess and periodically re-evaluate residents who wish to self-administer medications, but this was not followed in this case.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling of ophthalmic suspension medication for one resident, leading to a discrepancy between the physician's order and the medication label. The resident, who was admitted with diagnoses of low back pain and weakness, had a physician's order for ophthalmic suspension to be administered twice daily for herpes viral keratitis. However, the medication label incorrectly indicated administration three times daily. This inconsistency was confirmed by a registered nurse, who acknowledged the potential for medication errors due to the mismatch between the physician's order, the electronic medication administration record (EMAR), and the medication label. Interviews with the infection preventionist and the director of nursing further emphasized the importance of matching medication labels with physician orders and EMAR to prevent errors. Additionally, the facility did not store discontinued controlled drugs in a permanently affixed compartment as required by regulations. During an observation, it was noted that these drugs were kept in a safe that was not permanently affixed, which was confirmed by the director of nursing. This practice was not in compliance with the Comprehensive Drug Abuse Prevention and Control Act of 1976, which mandates that controlled drugs be stored in separately locked, permanently affixed compartments. These failures had the potential to cause medication errors and lead to drug diversion.
Inadequate Staffing and Inconsistent Abuse Reporting
Penalty
Summary
The facility failed to ensure adequate staffing levels, resulting in residents experiencing delays in receiving care. Three residents reported that staff took a long time to answer call lights, leading to feelings of frustration, worry, and potential neglect. Interviews with both licensed and unlicensed staff confirmed that the facility was short-staffed, particularly on weekends, which increased the risk of late provision of care and potential safety issues for residents. Staffing documentation showed that CNAs were responsible for 12 to 13 residents each during their shifts on multiple dates, which is higher than recommended levels. Additionally, the facility did not update its Abuse Policy and Procedure to reflect correct reporting guidelines. Staff interviews revealed inconsistencies in understanding the appropriate agencies to report abuse allegations to and the required reporting time frames. Some staff believed abuse allegations should be reported within 24 hours, while others thought it should be within 4 hours or only if there was an injury. The Interim Director of Nursing also provided conflicting information about the reporting requirements. These deficiencies resulted in residents feeling unsafe and concerned about the quality of care they were receiving. The lack of adequate staffing and inconsistent abuse reporting procedures posed significant risks to resident safety and well-being. The facility's policies and procedures were not effectively implemented, leading to potential neglect and unreported abuse incidents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ukiah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redwood Cove Healthcare Center | 0.3 mi | ★★★★★ | 18 | 0 |
| Lakeport Post Acute | 16.3 mi | ★★★★★ | 1 | 0 |
| Rocky Point Care Center | 16.5 mi | ★★★★★ | 13 | 0 |
| Northbrook Healthcare Center | 21.3 mi | ★★★★★ | 16 | 0 |
| Cloverdale Healthcare Center | 25.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ukiah Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.