Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Northbrook Healthcare Center during CMS and state inspections, most recent first.
Food was served with poor palatability and improper preparation. A resident on an easy-to-chew diet complained that breakfast potatoes were hard in the center and oatmeal was tasteless, while kitchen observations showed vegetables boiled for an extended time, unseasoned tilapia prepared without tasting, and trays returned with half-eaten or untouched fish. Another resident stated breakfast was disgusting and not appetizing, and only ate a few bites of a grilled cheese substitute.
Unsafe food storage, equipment sanitation, and hand hygiene practices were observed in the kitchen. Clean cups and utensils were stored in soiled racks and a debris-filled utensil tray, the stove had grease and hardened residue, and a cook repeatedly contaminated gloved hands by touching personal clothing and other items before continuing food prep and trayline tasks without washing or changing gloves. Refrigerated ready-to-eat items were also found without required use-by dates.
Pest Control Failure in Kitchen: Two flies were observed in the kitchen during lunch preparation, and the CDM confirmed their presence in the food prep area. The CDM stated the flies may have entered with someone coming in from outside, and no electronic air curtain was noted at the facility entrance.
Food preferences were not honored for multiple residents when trays contained items they disliked or could not tolerate. Two residents were served peas they said they did not like, one resident with a lactose allergy and dislike of milk products and refined sugar was served foods containing cream cheese, powdered sugar, and milk, and another resident reported mushy vegetables, tasteless oatmeal, and difficulty chewing potatoes before receiving a limited substitute meal.
Two residents had care plan failures. One resident admitted with HF and ordered O2 at 1 LPM via NC did not have an oxygen care plan initiated until weeks after admission, even though the MDS showed oxygen therapy was in use and the DON said the plan should have been developed on admission. Another resident with fragile skin and blood thinner use did not receive ordered care plan interventions, including compression stockings and padding for the bedside table, wheelchair armrests, and leg rest pegs, and later developed a facility-acquired wound on the left lateral upper leg.
A resident with diagnoses including esophageal obstruction, muscle weakness, repeated falls, and need for assistance with personal care was observed unkempt, with uncombed hair, dirty fingernails, and BM on her pillowcase, sheets, and bedside table. Staff confirmed the brown substance was BM and acknowledged her call light was out of reach, despite the care plan directing staff to keep the call device within reach and encourage use for assistance.
Dirty Oxygen Concentrator Vent: A resident receiving O2 via NC had visible dust and debris buildup in the vents and internal filter compartment of the oxygen concentrator. The DON, IP, and MNS confirmed the condition during observation, and the IP stated the buildup was unhealthy because dust and debris could be pushed into the resident’s lungs. The MNS said he performed weekly checks, blew out dust with compressed air, and was responsible for cleaning the concentrators and changing filters.
Two residents received their prescribed medications late on two separate days, with multiple medications administered more than an hour past the scheduled time. The DON confirmed that these late administrations did not comply with facility policy, which requires medications to be given within 60 minutes of the scheduled time.
The facility exceeded the acceptable medication error rate when two residents did not receive medications as ordered: one received only half the prescribed doses of aspirin and sennosides-docusate sodium, and another had Bengay cream applied only to the knees instead of both knees and hands. Nursing staff did not follow the required verification procedures, resulting in a 6.98% medication error rate.
The facility did not ensure accurate documentation of medication and treatment administration for two residents, with staff failing to record administered medications in the MAR/TAR and incorrectly transcribing a physician's order for a diuretic in the EHR. Staff interviews confirmed that medications were given but not documented, and that a transcription error occurred regarding blood pressure parameters for holding a medication.
A resident with severe cognitive impairment and a diagnosis of pleural effusion was held down by two CNAs during perineal care, despite his refusal to wear a brief. This action, confirmed by staff and against the facility's abuse prevention policy, left the resident feeling belittled and upset.
Food was served with poor palatability and improper preparation
Penalty
Summary
The facility failed to ensure that food was prepared by methods that preserved nutrition and palatability when three residents received meals that were described as flavorless, difficult to chew, and overcooked. During a concurrent interview and observation in a resident’s room, the resident complained that the cubed breakfast potatoes were pale, hard in the center, and too difficult to chew, and stated the oatmeal was tasteless and never eaten. The Certified Dietary Manager confirmed the potatoes were hard and reviewed the tray ticket showing the resident was ordered an easy-to-chew diet. Kitchen observations showed broccoli and carrots placed in steam table pans with water to boil on the stove, with a total cooking time of 1.5 hours, and the carrots were not observed to have any seasoning added. Frozen tilapia was placed on heated sheet pans without seasoning, then baked and later plated with an unmeasured amount of Italiano sauce; the staff member was not observed tasting the entree to ensure it was palatable. After lunch, trays were observed with half-eaten or untouched tilapia. Another resident stated breakfast was disgusting and did not look appetizing, and was observed eating only a few bites of a grilled cheese substitute. The facility’s recipes directed specific seasoning and cooking methods for broccoli with garlic and Fish Italiano, and the facility policy stated food shall be prepared by methods that conserve nutritive value, flavor, and appearance.
Unsafe Food Storage, Equipment Sanitation, and Hand Hygiene
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards in the facility kitchen. Clean plastic cups were observed stored in soiled, heavily scratched plastic racks, and clean eating utensils were stored in a utensil tray that contained accumulated food debris under dirty protective netting. The Certified Dietary Manager confirmed the racks were visibly scratched and soiled and confirmed the utensil storage condition posed a risk for contamination of the clean utensils. The front of the stove was observed to be stained with old grease drippings, and the stovetop was encrusted with hardened black residue in between and in the burners. The Certified Dietary Manager confirmed the stove was soiled and stated the equipment must be clean and ready to use. The facility’s sanitation policy stated that equipment shall be maintained as necessary, and the FDA Food Code cited cleaning requirements for cooking and baking equipment and non-contact food surfaces. During meal preparation and trayline, Cook 1 repeatedly contaminated his gloves by touching his pants, shirt, watch, a wall chart, a scale, and other kitchen items, then continued handling food without changing gloves or washing his hands. In addition, refrigerated ready-to-eat items were found without use-by dates, including a carton of soy milk and a bottle of vegetable juice, and the Certified Dietary Manager confirmed both needed to be discarded because they had expired. The facility policy required commercially processed ready-to-eat foods stored cold for more than 24 hours to be marked with a use-by date, and the FDA Food Code required refrigerated ready-to-eat TCS foods held more than 24 hours to be clearly marked with the date by which they must be consumed or discarded.
Pest Control Failure in Kitchen
Penalty
Summary
The facility failed to maintain an environment free of pests when two flies were observed in the kitchen during lunch preparation for 38 residents. During a concurrent observation and interview in the kitchen, the Certified Dietary Manager confirmed the presence of flies in the food preparation area and stated the flies may have come in with someone entering the building from outside. The observation also noted there was no electronic air curtain at the facility entrance. The facility's Pest Control policy stated that pesticides are to be used in a safe and efficient manner to control pests and that storage and food preparation areas are to be kept clean. The FDA 2022 Food Code cited in the report states that premises shall be maintained free of insects and that insect presence shall be controlled through routine inspection of food and supply shipments and the premises for evidence of pests.
Food Preferences Not Honored During Meal Service
Penalty
Summary
The facility failed to ensure food preferences were honored for four residents when meals were served that included foods they disliked or could not tolerate. During observation and interview, two residents were eating lunch with untouched peas on their plates, and both stated they did not like peas; their tray tickets also listed peas as disliked. Another resident stated she would not eat the peas served at lunch because she preferred her vegetables cooked al dente and said the vegetables were usually served too mushy. Her tray ticket listed a lactose allergy, dislike of milk and milk products, dislike of refined sugar, and a preference for al dente broccoli and cauliflower when available on the menu. The same resident also reported that she had become sick and had diarrhea after being served scrambled eggs made with milk in the past. Her lunch tray later contained a cherry square made with cream cheese and canned cherries on a graham cracker crust, which she said was too sweet; the CDM confirmed the recipe contained powdered sugar and cream cheese and stated she should have been served applesauce with cinnamon instead. On another occasion, her tray contained green beans she described as overcooked and mushy, and later she received apple pie despite requesting no foods made with refined sugar. A fourth resident stated his oatmeal was tasteless and he could not chew his potatoes, and after requesting more food because he was still hungry, he was served one fried egg and one piece of dried toast without butter.
Failure to Develop and Follow Care Plans for Oxygen Therapy and Skin Protection
Penalty
Summary
The facility failed to develop and implement care plans for two residents. One resident was admitted with heart failure and had a physician order for oxygen at 1 LPM via nasal cannula, and the MDS indicated oxygen therapy was being provided on admission and during the stay. During observation, the resident was seen receiving oxygen via nasal cannula, but the care plan for oxygen therapy was not initiated until 26 days after admission. The DON confirmed the oxygen care plan had not been started until that date and stated it should have been developed upon admission because care plans drive resident care. The facility also failed to implement interventions in another resident’s care plan related to skin impairment risk. That resident had a care plan identifying fragile skin and blood thinner use, with interventions including padding the bedside table and wheelchair armrests, and later a revision requiring compression stockings to be applied in the morning and removed at bedtime. During observation, the resident was not wearing the ordered compression stockings, and the bedside table, armrest area, and wheelchair leg rest pegs were not padded. The wound nurse stated the resident’s prior blister had resolved, but a new wound had developed on the left lateral upper leg, and the wound lined up with the wheelchair leg rest pegs. The skin issues assessment documented the new wound as facility-acquired and measured 5 cm by 2.5 cm with a light amount of sanguinous drainage.
Resident Found Unkempt With BM on Linens and Call Light Out of Reach
Penalty
Summary
The facility failed to ensure Resident 3, who was admitted with diagnoses including esophageal obstruction, need for assistance with personal care, muscle weakness, and repeated falls, received proper grooming and had her call light within reach. Resident 3’s care plan identified her as at risk for falls and for self-care deficits, and staff were expected to keep the call light within reach and encourage her to use it for assistance. During observation, Resident 3 was found scrunched down in bed with her shirt above her breasts and nothing covering her breasts, with uncombed hair, long fingernails with brown debris underneath, and dirty linens and surfaces in her room. Surveyors observed a dark thick brown substance on Resident 3’s pillowcase and bedside table, and large brown streaks on the sheets; CNA 2 identified the substance as bowel movement and stated the streaks on the sheets were also BM. Resident 3’s call light was observed on the floor and later looped over the bedside table drawer, both times out of her reach. CNA 1 acknowledged the resident could not reach the call light, CNA 3 verified the call light was out of reach and noted the resident’s long, jagged fingernails with debris, and the Infection Prevention Nurse confirmed debris under the fingernails and stated BM on the tray table posed an infection control risk.
Dirty Oxygen Concentrator Vent
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to ensure respiratory equipment was clean and in a usable state for one resident. Resident 20 was admitted with a diagnosis of heart failure and had physician orders for oxygen at 1 LPM via nasal cannula. The resident’s MDS indicated she was receiving oxygen therapy upon admission and while residing in the facility. During an observation on 1/27/26 at 11:18 a.m., the outside vent on Resident 20’s oxygen concentrator had visible dust buildup. During a concurrent observation and interview at 11:45 a.m., the DON, Infection Preventionist, and Maintenance Supervisor confirmed dust buildup on the oxygen concentrator’s vent, and the compartment holding the internal filter was also observed to have dust buildup. The Infection Preventionist stated the dust buildup was not good for Resident 20 and was surprised by how much had accumulated. The Maintenance Supervisor stated he performed weekly checks on each oxygen concentrator in use, blew out dust with a compressed air canister, owned all of the facility’s oxygen concentrators, and was responsible for cleaning the oxygen concentrators of debris and changing the filters. During an interview on 1/30/26 at 10:10 a.m., the Infection Preventionist stated the dust buildup would be unhealthy for Resident 20 because dust and debris in the vents could be pushed into the resident’s lungs, placing her at risk for a lung infection such as pneumonia or bronchitis. The oxygen concentrator instruction guide stated the air filter should be cleaned at least once a week and the exterior cabinet should be cleaned with a damp cloth or sponge and mild household cleaner. The facility’s Oxygen Therapy policy stated it was the policy of the facility to administer oxygen in a safe manner.
Failure to Administer Medications as Ordered, Resulting in Late Doses
Penalty
Summary
The facility failed to administer medications as ordered by the prescriber for two of three sampled residents, resulting in late medication administration on two separate days. For one resident with diagnoses including trigeminal neuralgia and syndrome of inappropriate secretion of antidiuretic hormone, five scheduled medications were administered more than an hour past the prescribed 4 p.m. time on two consecutive days. The Director of Nursing (DON) confirmed that these medications, which included gabapentin, Keppra, Flomax, duloxetine, and lamotrigine, were given late, outside the facility's policy requiring administration within 60 minutes of the scheduled time. Another resident, admitted with bilateral osteoarthritis of the hip, benign prostatic hyperplasia, and atherosclerotic heart disease, also received three scheduled medications late on two consecutive days. The medications, including diclofenac gel, atorvastatin, and tamsulosin, were scheduled for 8 p.m. but were administered more than an hour late. The DON acknowledged that these medications should have been given within the required time frame and confirmed the late administration. Facility policy specifies that medications must be administered as prescribed and within 60 minutes of the scheduled time.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by 3 errors out of 43 observed opportunities, resulting in a 6.98% error rate. Facility policy required staff to review the five rights of medication administration multiple times during the process, including verifying the correct medication, dose, and administration instructions. However, during medication administration observations, staff did not consistently follow these procedures. For one resident with a history of heart failure and atherosclerotic heart disease, a registered nurse administered only one tablet each of aspirin and sennosides-docusate sodium, instead of the two tablets ordered for each medication. In another instance, a resident with a history of joint replacement and osteoarthritis was ordered to receive Bengay cream applied to both knees and hands four times daily, but the nurse applied the cream only to the knees, omitting the hands. Interviews with nursing staff and facility leadership confirmed that staff were expected to follow physician orders and the seven rights of medication administration, but these expectations were not met during the observed medication passes.
Failure to Accurately Document Medication Administration and Transcribe Orders
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) and treatment administration records (TARs) accurately reflected the medications and treatments administered to residents. For one resident with a history of gout and chronic kidney disease, there was no documentation of the administration of prescribed topical treatments and oral medications on specific dates, despite the resident reporting that all medications and treatments were received as ordered. Interviews with nursing staff revealed that medications were administered but not documented due to staff being busy or forgetting to sign off on the MAR or TAR. Additionally, the facility did not ensure that medication orders were correctly transcribed into the electronic health record (EHR) for another resident with heart failure and moderate cognitive impairment. A physician's order for a diuretic medication included specific parameters for holding the medication based on blood pressure readings. However, the order was incorrectly transcribed into the EHR, with one entry instructing staff to hold the medication for a systolic blood pressure greater than a certain value, which was acknowledged as a mistake by the nurse responsible for the transcription. Facility policy required that all medication administrations be documented in the MAR or TAR after administration, and that physician's orders be transcribed accurately. Interviews with the Director of Nursing, Administrator, and Medical Director confirmed expectations for proper documentation and transcription, and staff acknowledged the errors in both documentation and order entry.
Resident Held Down by CNAs During Care
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when two CNAs intentionally held down the resident against his will during perineal care. The resident, who was admitted with a diagnosis of pleural effusion and had a severe cognitive impairment, required assistance with activities of daily living due to generalized weakness. Despite the resident's ability to perform toileting hygiene with partial assistance, the CNAs held him down to change his brief, which he had refused. This action was against the resident's expressed wishes and resulted in him feeling belittled and upset. The incident was confirmed by multiple staff members, including a Licensed Nurse and the Director of Rehab, who reported that the resident described being 'manhandled' and forced to wear a brief. The facility's policy on abuse prevention clearly states that residents have the right to be free from physical abuse, which includes the willful infliction of intimidation or punishment resulting in mental anguish. The Operations Manager confirmed that holding a resident down is considered a form of abuse, highlighting the facility's failure to adhere to its own policies and protect the resident's rights.
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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.
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Nursing homes near Willits
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redwood Cove Healthcare Center | 20.9 mi | ★★★★★ | 18 | 0 |
| Ukiah Post Acute | 21.3 mi | ★★★★★ | 9 | 0 |
| Sherwood Oaks Post Acute Care, Llc | 23 mi | ★★★★★ | 22 | 0 |
| Rocky Point Care Center | 34.4 mi | ★★★★★ | 13 | 0 |
| Lakeport Post Acute | 34.8 mi | ★★★★★ | 1 | 0 |
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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.