Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 7 | 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 | — | 0 | 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.