Other·August 28, 2017

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY from 7/10/17 to 7/14/17. Representing the California Department of Public Health: Health Facilities Evaluator Nurses #37797, #38322, #38335 and Nutrition Consultant #17065. Entity Reported Incidents (ERIs) CA00542297, CA00534344 and CA00494256 were investigated during the survey and were substantiated with no regulatory violations. An intent to cite was issued to the Administrator on 7/27/17 (see F-314)

F241 SS=E DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 08/30/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to care for one of 11 sampled residents (Resident 8) with dignity and respect when it applied a physical barrier across the doorway of his room restricting his ability to leave his room. This failure limited Resident 8's freedom of movement, enjoyment LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 1 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of common areas of the facility, socialization with staff and other residents and the exercise of his activity preferences. Findings: A review of Resident 8's "Admission Record" dated 4/7/09 indicated Resident 8 was admitted to the facility with a primary diagnosis of chronic obstructive pulmonary disease and additional diagnoses of difficulty walking, muscle weakness, nicotine dependence and others. On 7/26/16 the facility created a care plan (a document directing staff how to care for residents) for Resident 8 focused on supervising Resident 8 due to his "erratic, often violent and disruptive behaviors, poor safety awareness, recent decrease in number and severity of behaviors." The care plan directed staff to deploy an "Alarmed stop sign at door when resident is in his room." Resident 8's annual MDS (Minimum Data Set an assessment tool), dated 2/21/17, indicated Resident 8 had intact cognition (Brief Interview for Mental Status score of 15) and had exhibited verbal but not physical behavioral symptoms towards others. In the MDS the facility noted that it was very important for Resident 8 to go outside and get fresh air, weather permitting. In the MDS the facility also noted it was "somewhat important" for Resident 8 to "do things with groups of people". During an observation on 7/12/17 at 12:55 p.m., an alarm sound was heard coming from a nearby room. Registered Dietician H walked over to Resident 8's room and attached a net/mesh to the room's doorway. On 7/12/17 at 1 p.m., Resident 8 was was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 2 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observed in his room. The door was open. A net measuring approximately three feet wide and 10 inches in height was attached to the doorway frames at a height of approximately three feet from the floor. The net was connected to alarm devices at both ends. On the net a red sign read "Stop". Resident 8 was in a wheelchair alone in his room. A consumed lunch tray was on his bedside table. Resident 8 was asked what the net over his doorway was for. Resident 8 answered: "It is to keep me in." Resident 8 stated he liked to go out of his room but the net prevented him. He was asked if he was able to remove the net and he answered yes. He was asked if he would like to go out of his room now. He answered yes but would not because when he removed the net "it makes a loud noise and the nurses come put me back in." During an observation, on 7/12/17 at 2:05 p.m., Resident 8 was in his room. The door was open and the net was applied to the doorway. Resident 8 was alone in his room in a wheelchair. He was asked how often the net was applied to his doorway. He answered: "It is on all the time." Resident 8 also stated the net had been there "For a long time." Resident 8 was asked how he liked to stay in his room and not go out. Resident 8 answered: "I don't like it." Resident 8 was asked how did it make him feel not being able to leave his room. He answered: "Not so good." During an observation on 7/12/17 at 5:40 p.m., Resident 8 ate dinner alone in his room. The net was applied to the doorway. During an observation, on 7/13/17 at 9:15 a.m., Resident 8 was alone in his room sitting in his wheelchair staring at the wall. The net was applied to the doorway. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 3 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 7/13/17, at 11:20 a.m., Resident 8 was observed alone in his room. He sat in his wheelchair behind the net applied to his doorway and looked toward the hallway. Resident 8 was asked if everything was well with him. He replied: "I hate this thing," pointing to the net across his doorway. On 7/13/17, at 1:20 p.m.., Resident 8 was observed eating lunch alone in his room. The net was applied to the doorway. On 7/13/17 at 3:20 p.m., the Social Services Director (SSD) and the Director of Nursing (DON) were interviewed about Resident 8. The SSD stated the net/stop sign to Resident 8's room had been applied since 7/28/16 when Resident 8 started exhibiting behaviors such as screaming, striking out and throwing objects at staff. The SSD stated initially the facility placed Resident 8 on a one-to-one supervision (when a staff member remains with the resident at all times). The SSD stated this made Resident 8 upset. The SSD stated the facility then discontinued the constant supervision and replaced it with staff checks every 15 minutes. The SSD stated this intervention proved successful in controlling Resident 8's behavior and the facility replaced it with staff checks every 30 minutes. The SSD stated this intervention also proved successful and the facility replaced it with staff checks every 45 minutes and that this intervention was also successful. The SSD stated the facility then replaced the staff checks every 45 minutes with the net/stop sign connected to alarms so Resident 8 could be without constant supervision. The SSD stated Resident 8 was able to remove the net/stop sign whenever he wanted. The SSD stated the purpose of the net/stop sign was not to keep Resident 8 in his room but to alert staff when he left his room so staff could escort him to wherever he wanted to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 4 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE go. Facility policy titled "Resident Rights - Dignity and Respect", revised 01/2016, stated:: "It is the policy of this facility that all residents be treated with kindness, dignity and respect." "Schedules of daily activities allow maximum flexibility for residents to exercise choices about what they will do and when they will do it. Residents' individual preferences regarding such things as menus, clothing, religious activities, friendships, activity programs, and entertainment are elicited and respected by the facility." Facility policy "Resident Bill of Rights", dated 5/11, stated: "Patients shall have the right: (15) to meet with others and participate in activities of social, religious and community groups."

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 08/14/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide services meeting professional standards of quality for one of 11 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 5 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sampled residents (Resident 5) when Resident 5's medical record did not contain documentation of physician notification of abnormal blood sugar levels per physician's order. This failure placed Resident 5 at risk of having uncontrolled blood sugar levels. Findings: On 7/12/17 at 10:05 a.m., Resident 5's medical records were reviewed with the Director of Nursing (DON). A review of Resident 5's physician's orders indicated an order, dated 3/13/16, directing staff to check Resident 5's blood sugar levels before breakfast and to notify the physician if the blood sugar level was lower than 70 or greater than 300 mg/dl (milligram per deciliter). A review Resident 5's Medication Administration Record for June 2017 indicated on 6/13/17 Resident 5's blood sugar level was 368 and on 6/17/17 it was 353 mg/dl. A review of Resident 5's Medication Administration Record for July 2017 indicated on 7/8/17 Resident 5's blood sugar level was 312 and on 7/9/17 it was 466 mg/dl. During a concurrent interview, the DON was asked for documentation in the clinical record Resident 5's physician was notified of the abnormal blood sugar levels on 6/13/17, 6/17/17, 7/8/17 and 7/9/17. This documentation was not found in Resident 5's clinical record. According to the California Healthcare Foundation, "Nursing homes must communicate abnormal laboratory results to the clinicians who order them..." (Resources for Nursing Home Professionals, California Healthcare Foundation, 2006, available at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 6 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE http://www.chcf.org/~/media/MEDIA%20 LIBRARY%20Files/PDF/PDF%20F/PDF%20 FFLabResultNotifications.pdf). Facility policy titled "Change of Condition Reporting", revised 05/2016, stated: "All symptoms and unusual signs will be communicated to the physician promptly." "All attempts to reach the physician and responsible party will be documented in the nursing progress notes."

F314 SS=G TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES CFR(s): 483.25(b)(1)

F314 08/30/2017 (b) Skin Integrity (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 6) received the necessary care, consistent with professional standards of practice, to prevent pressure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 7 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ulcers when the facility did not implement a frequent turning and repositioning program to prevent pressure ulcers for Resident 6, whom it had assessed to be at a very high risk for developing pressure ulcers; failed to consistently accurately assess pressure ulcers; and failed to implement the Registered Dietician's initial recommendation for a multivitamin supplement for Resident 6, whom the facility had assessed to be in poor nutrition and at a very risk for pressure ulcers. Resident 6 developed two pressure ulcers, including a Stage 4 pressure ulcer. Findings: According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is "localized damage to the skin and underlying soft tissue usually over a bony prominence... the injury can present as intact skin or an open ulcer ... the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear" (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or "staged" according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as "unstageable", which occurs when the wound is covered by slough or eschar (dead tissue). "If slough or eschar is removed, a Stage 3 or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 8 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Stage 4 pressure injury will be revealed." (http://www.npuap.org/resources/educationaland-clinical-resources/npuap-pressure-injurystages/ (2016) and www.npuap.org/wpcontent/uploads/2012/02/Shear_slides.pdf). Review of Resident 6's "Admission Record", dated 7/11/17, indicated Resident 6 was admitted to the facility on 9/27/16 with diagnoses that included Parkinson's disease (a progressive movement disorder), dementia (a brain disease that causes a long term and often gradual decrease in the ability to think and remember), aphasia (loss of ability to communicate using speech) and generalized weakness. Resident 6's "Initial Admission Record," dated 9/27/16, indicated Resident 6 was admitted on hospice care (terminal prognosis), had no open skin injuries but had "very fragile skin." During an interview on 7/12/17 at 4 p.m., Resident 6's family member and responsible party stated Resident 6 was immobile and needed complete assistance to turn and reposition but had no skin injuries at the time she was admitted to the facility. The family member stated Resident 6 lived with her prior to admission and family frequently turned and repositioned her at home to prevent skin injuries. A nursing "Admission Note" for Resident 6, dated 9/27/16 at 2:15 p.m. stated: "The resident came from home. The resident has very fragile skin, though in very good shape r/t [related to] the families [sic] ongoing care for her ... No open areas noted." The "Braden Scale for Predicting Pressure Sore Risk" assessment (a pressure ulcer assessment scale) dated 9/27/16, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 9 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 6 was bedfast (confined to bed), completely immobile, did not make even slight position changes in body or extremity without assistance and had very poor nutrition. The assessment indicated a score of 9, corresponding to a "very high risk" of developing pressure ulcers. Resident 6's record contained a care plan, dated 9/27/16, for Resident 6's potential for skin injuries related to her fragile skin and poor nutrition. The goal of the care plan was to keep Resident 6 free of skin injuries. The care plan contained interventions such as the use of an alternating pressure mattress and the application of barrier creams to at risk areas. The care plan did not contain interventions to turn and reposition Resident 6. A second care plan for Resident 6, dated 9/28/16, focused on self-care performance of activities of daily living related to Resident 6's disease processes, limited mobility, pain and dementia. This care plan noted Resident 6 was "totally dependent on staff for repositioning and turning in bed." This care plan did not include any intervention for turning and repositioning Resident 6. A review of Resident 6's physician orders, the "Order Summary Report," for September 2016 through April 2017, revealed no physician orders for turning and repositioning Resident 6. Resident 6's Admission MDS (Minimum Data Set - an assessment tool), dated 10/3/16, indicated Resident 6 had no pressure ulcers but was at risk for developing them. In the Admission MDS the facility selected pressure reducing device for bed (pressure redistribution mattress) and application of ointments/medications as interventions for preventing/treating skin injuries. The facility did FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 10 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE not select turning and repositioning Resident 6, an available intervention in the MDS. On 10/4/16, at 8:22 a.m., the IDT (Interdisciplinary Team) convened to review Resident 6's conditions and care plans. The "IDT/Care Conference Note" dated 10/4/16, documented Resident 6 had poor food intake, ate 35-40% of meals, and needed extensive staff assistance with bed mobility. The IDT team made no recommendation to update Resident 6's care plans to include turning and repositioning Resident 6. According to the Wound, Ostomy and Continence Nurses Society, avoidable pressure ulcers can occur when the provider does not "define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate." (Wound, Ostomy and Continence Nurses Society, 2017. WOCN Society Position Paper: Avoidable vs. Unavoidable Pressure Ulcers/Injuries. Mt. Laurel, NJ: Author.) According to the U.S. National Library of Medicine Pubmed Health Service, frequent repositioning is a key intervention in preventing pressure ulcers: "Even if certain mattresses and overlays have been shown to lower the risk of pressure sores ... reducing pressure through movement and repositioning is still the most important way to prevent pressure ulcers." (https://www.ncbi.nlm.nih.gov/pubmedhealth/P MH0079409/). The facility's policies and procedures recommended repositioning to prevent pressure ulcers. The policy titled "Pressure Ulcers - Care and Treatment", revised 05/2016, indicated, under "Prevention Measures": "B. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 11 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Repositioning". Licensed Nurse A documented in a "Progress Note", dated 10/4/16 at 11:48 p.m., Resident 6 had a skin injury to her right hip classified as a possible deep tissue injury (a form of pressure ulcer where the outer skin is intact but the underlying tissue is injured) measuring 3 centimeters (cm) length by 1 cm width. A "Nursing Summary - Weekly", dated 10/5/16, contained documentation that Resident 6 had a pressure ulcer to the right hip area. There was no documentation of the stage or a measurement of the pressure ulcer. On 10/11/16 Registered Dietician G completed Resident 6's admission nutrition assessment. In the "RD - Nutrition Risk Review - Admission" assessment, dated 10/11/16, Registered Dietician G documented Resident 6 ate 50% of her meals, had a pressure injury to the right hip and had "insufficient recorded [food] intake to support healing of wound and maintain weight." Registered Dietician G recommended Resident 6 receive a multiple vitamin with minerals supplement. A review of physician orders for Resident 6, "Order Summary Report", for October, November, and December 2016, revealed no orders for a multiple vitamin with minerals supplement for Resident 6. Vitamin supplements for Resident 6 were ordered starting on 1/19/17. During an interview on 7/13/17 at 9:45 a.m., Registered Dietician H stated the dietician's recommendations were usually communicated to the resident's physician the same day. Registered Dietician H also stated a multiple vitamin with minerals supplement would have assisted in the prevention and healing of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 12 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure ulcers for Resident 6. On 7/14/17 at 8:25 a.m., Resident 6's nutrition assessments, physician orders and other clinical records were reviewed with the Director of Nursing (DON). The DON verified the dietician's recommendation on 10/11/16 for a multiple vitamin with minerals supplement for Resident 6 was not followed. She stated she believed the reason was Resident 6 was on hospice care with a terminal prognosis. The DON verified Resident 6's clinical condition eventually improved and Resident 6 was subsequently taken out of hospice care in November 2016. The DON stated after Resident 6 was taken out of hospice care in November 2016 a multiple vitamin with mineral supplements would have helped improve Resident 6's nutrition and prevent skin wounds. The National Pressure Ulcer Advisory Panel (NPUAP) recommends vitamin supplements to people at risk for or with pressure ulcers and nutritional deficiencies. According to the NPUAP providers should "provide/encourage an individual assessed to be at risk of a pressure ulcer to take vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected". The NPUAP has the same recommendation for individuals with confirmed or suspected pressure injuries. (National Pressure Ulcer Advisory Panel, Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, 2014, available at http://www.npuap.org/). The facility's policies and procedures recommended improved nutrition for pressure ulcer prevention and treatment. Facility policy titled "Pressure Ulcers - Care and Treatment", revised 05/2016, indicated "Maintain or improve nutrition or hydration status" as a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 13 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure ulcer preventing and treatment measure. A Change of Condition MDS assessment for Resident 6, dated 11/11/16, indicated Resident 6 had no current pressure ulcers, but was at risk for developing them. In the MDS the facility selected several interventions for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS. The IDT documented in the "IDT/Care Conference Note" dated 11/16/16, Resident 6 needed extensive assistance with bed mobility. The IDT Team did not recommend or update Resident 6's care plans to include frequent turning and repositioning. A "Braden Scale for Predicting Pressure Sore Risk" assessment, dated 11/25/16, noted Resident 6 had a score of 12 corresponding to a "high risk" for developing pressure ulcers. A "Change of Condition" note, dated 1/10/17 at 6:33 a.m., contained documentation that Resident 6's right hip wound had reappeared. No staging or measurements of the wound were documented. A "Nursing Summary - Weekly", dated 1/11/17, documented Resident 6's right hip wound was a pressure ulcer, but there was no documentation of the staging or measurement of the wound. On 1/17/17, Physician C wrote treatment orders for Resident 6's right hip pressure ulcer. Resident 6's "Order Summary Report", dated 1/31/2017, contained the following order, dated 1/17/17: "Cleanse pressure injury to right hip with DWC [Dermagran Wound Cleanser], and pat dry. Apply Santyl [an ointment] to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 14 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE necrotic/slough [dead tissue] to wound bed (indicating at least a Stage 3 pressure ulcer per NPUAP). Cover with calcium alginate and foam dressing as needed for pressure injury if soiled or dislodged." In a "Change of Condition" note, dated 1/21/17 at 9:53 p.m., Licensed Nurse J documented Resident 6 had a sheared (stress / deformation of the skin from movement) area to right buttock area. In an "Incident Note", dated 1/24/17 at 10:29 p.m., Licensed Nurse A documented Resident 6 had a reddened "skin tear" to her right buttock measuring 3 cm x 2 cm. A new skin care plan, dated 1/24/17, noted Resident 6 "Has actual impairment to skin integrity r/t [related to] Stage 4 pressure injury on right ischial tuberosity [the sit bone]." The new skin care plan did not include turning and repositioning interventions for Resident 6. During an interview on 7/12/17 at 4:25 p.m., Licensed Nurse B stated Resident 6's right buttock pressure ulcer was first identified by the facility as a Stage 4 pressure ulcer in the last week of January 2017. She stated the wound evolved very quickly from a skin tear to a Stage 4 pressure ulcer. She stated the wound location had been referred by facility staff as either right buttock or right ischial tuberosity, with both names referring to the same pressure ulcer. A review of Resident 6's nutrition assessments revealed no assessments of Resident 6's nutritional status by a Registered Dietician following the detection of her Stage 4 pressure ulcer on 1/24/17. During a review of Resident 6's records on 7/13/17, at 9:45 a.m., Registered Dietician H verified Resident 6 had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 15 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE been assessed by a Registered Dietician on 1/18/17 and again on 3/30/17. She stated, in her professional opinion, a new assessment of Resident 6's nutritional status should have been made by a registered dietician following the identification of Resident 6's Stage 4 pressure ulcer on 1/24/17. The facility policy, "Nutrition", revised 1/2014, stated: "Each resident's nutritional status is assessed by the Registered Dietician or his/her designee on admission and at least quarterly thereafter, and following a change in condition." A "Skin Pressure Ulcer Weekly" assessment, dated 2/3/17, noted Resident 6's right buttock wound as an unstageable pressure ulcer (unable to determine the stage due to the presence of dead tissue covering the wound) measuring 1.9 cm length x 2.9 cm width. The assessment documented bone was visible in the wound bed. During an interview on 7/14/17, at 8:25 a.m., the Director of Nursing (DON), who stated she was a wound certified nurse, stated pressure ulcers in which it was possible to visualize bone in the wound bed were categorized as Stage 4 pressure ulcers. The "Skin Pressure Ulcer Weekly" assessment, dated 2/3/17, documented Resident 6's right hip wound was a Stage 2 pressure ulcer measuring 0.7 cm x 0.9 cm. A quarterly MDS assessment, dated 2/7/17, indicated Resident 6 had pressure ulcers and was at risk for developing them. In the MDS the facility selected several interventions for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 16 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The "IDT - Care Plan Review", dated 2/7/17, contained no documentation of recommendations to update Resident 6's care plans to include turning and repositioning Resident 6. A Skin Pressure Ulcer Weekly assessment, dated 3/13/17, documented Resident 6' right buttock ulcer was an unstageable pressure injury and Resident 6's right hip pressure injury was healed. "Skin Pressure Ulcer Weekly" assessments, dated 4/13/17 and 5/2/17, documented Resident 6's right buttock wound as a Stage 4 pressure ulcer. A second quarterly MDS assessment, dated 5/2/17, indicated Resident 6 had pressure ulcers and was at risk for developing them. The MDS contained several interventions which were selected for Resident 6 for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS. A physician's order, dated 5/3/17, directed staff to "Turn and reposition resident a minimum of every 2 hours for pressure redistribution." On 5/16/17, Resident 6's care plan for potential skin impairment related to fragile skin and poor nutrition was updated to include the following intervention: "Turn and reposition resident a minimum of every 2 hours for pressure redistribution." During interview and concurrent record review, on 7/13/17 at 5:50 p.m., Resident 6's care plans were reviewed with the Director of Nursing (DON). The DON verified the turn and repositioning intervention for Resident 6 was not present in any of Resident 6's care plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 17 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE until it was added on 5/16/17. The DON stated given Resident 6's high risk for developing pressure ulcers, identified by the facility on 9/27/16, Resident 6's care plans should have included turning and repositioning interventions starting on the day Resident 6 was admitted to the facility on 9/27/16. Review of "Skin Pressure Ulcer Weekly" assessments, dated 6/13/17 and 7/11/17, noted Resident 6' right buttock injury were classified as a Stage 4 pressure ulcer. During an observation, on 7/13/17 at 2:50 p.m., Licensed Nurse B completed a dressing change and wound measurement of Resident 6's Stage 4 right buttock pressure ulcer. The wound measured 2.1 cm length, 2.1 cm width, 2.1 cm depth, and 4.6 cm of tunneling. During interview and concurrent record review, on 7/14/17 at 8:25 a.m., Resident 6's record was reviewed with the Director of Nursing (DON). The DON was asked which interventions the facility implemented to prevent pressures ulcers for Resident 6 after the facility determined Resident 6 to be "very high risk" for pressure ulcers on 9/27/16. The DON stated the facility implemented all the interventions listed in the care plans plus turning and repositioning Resident 6 every two hours. She stated the facility had continuously turned and repositioned Resident 6 every two hours starting from admission on 9/27/16 until the present day. The DON was asked to provide evidence that Resident 6 had been turned and repositioned every two hours. The DON provided copies of Resident 6's "Treatment Administration Record" for May, June and July 2017. The turning and repositioning documentation in these reports consisted of a check mark next to each shift a.m., p.m., and night - confirming Resident 6 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 18 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had been turned and repositioned every two hours during each shift. These reports did not specify the times Resident 6 had been turned and repositioned during each shift. The DON was asked for this information. During interview and concurrent record review, on 7/14/17 at 12 p.m., the DON and Registered Nurse Consultant K provided facility reports titled, "Follow Up Question Report", dated September 27, 2016 to July 14, 2017, which contained documentation of Resident 6's turning and repositioning by the facility's Certified Nursing Assistants (CNAs). These reports contained the question "Did you turn and reposition?" followed by the response, "Yes" and the CNA's name, date and time. Registered Nurse Consultant K stated the date and time recorded on the reports was not necessarily the date and time Resident 6 was turned and repositioned, but the time the CNA recorded it on the computer system. She stated CNAs did not always record care immediately after providing care. Registered Nurse Consultant K was asked if, from the documentation provided, it was possible to determine the times Resident 6 had been turned and repositioned. Registered Nurse Consultant K replied it was not possible to know, stating it was only possible to know the turning and repositioning had been done sometime during the CNA's shift. A review of the turning and repositioning documentation provided by the facility, the "Follow Up Question Reports", from 9/27/16 to 6/30/17, revealed documentation Resident 6 was turned and repositioned an average of once every 8 hours. On several days during the period, such as on 9/28/16, 10/2/16, 11/13/16, 12/11/16, 1/1/17, 2/6/17, 3/3/17, 4/28/17, 5/31/17 and 6/5/17, there were gaps of more than 12 hours without documentation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 19 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 6 being turned and repositioned. The "Follow Up Question Report" for July 2017 documented on 7/11/17 Resident 6 was turned and repositioned a total of three times: at 6:39 a.m., at 11:17 a.m. and at 9:47 p.m.. On 7/11/17 Resident 6 was observed in her room at 9:15 a.m., at 11:15 a.m., at 2 p.m. and at 4 p.m. In all four instances Resident 6 was observed asleep lying on her right side. The "Follow Up Question Report" for July 2017 documented on 7/13/17 Resident 6 was turned and repositioned a total of three times: at 2:10 a.m., at 8:52 a.m., and at 9:51 p.m. On 7/13/17 Resident 6 was observed in her room at 9:10 a.m., and at 11:10 a.m. In both instances Resident 6 was observed asleep lying on her left side. According to the American Association of Family Physicians, "Pressure ulcers may develop in as little as four to six hours" and, "there is also no evidence to suggest an optimal interval at which to reposition patients, although every two hours is recommended based on expert opinion." http://www.aafp.org/afp/2015/1115/p888.html. The National Database of Nursing Quality Indicators, a national nursing quality measurement program, recommends, as pressure injury prevention interventions, "turning immobile patients every 2 hours while in bed as this is a common practice for patients unable to turn/reposition themselves ... Patients who are at higher risk will likely need to be turned/repositioned more frequently than every 2 hours." https://members.nursingquality.org/ndnqipressu reulcertraining/Module3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 20 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE /PressureULcerSurveyGuide_16.aspx. The U.S. National Library of Medicine MedlinePlus Service recommends "changing a patient's position in bed every 2 hours" to prevent pressure ulcers. https://medlineplus.gov/ency/patientinstructions /000426.htm.

F323 SS=E FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 08/14/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 21 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure residents' safety when one housekeeping cart containing hazardous chemicals was found unlocked and unattended. This had the potential to expose residents to the hazardous chemicals inside. Findings: During an observation and concurrent interview with the Maintenance Director on 7/12/17 at 10:05 a.m., a housekeeping cart was observed in the hallway of Station 2 outside of resident Rooms 22 and 23. No staff was observed in the hallway or near the cart. The side of the cart had an unlocked door, which opened to a compartment containing two cans of Ajax (a powdered cleaning product), a spray bottle of Clorox bleach spray, a spray bottle of air freshener, and a spray bottle of disinfectant. The Maintenance Director stated, "Housekeeper F must be around here somewhere." Housekeeper F was found near the nurses' station after walking around a corner and down another hall. During an interview on 7/12/17 at 12:30 p.m., the Maintenance Director stated he had oversight of the housekeeping staff. He stated he informed Housekeeper F in the future he expected Housekeeper F to let him know if the lock was broken on the cart, and not to leave the cart unattended until the lock was fixed. During an interview on 7/13/17 at 8:45 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 22 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Housekeeper F stated the cart was unlocked because the key had broken off in the lock the previous morning. Housekeeper F stated that the lock on the cart had been replaced, and demonstrated that it was functioning by locking and unlocking it. Review of facility policy titled, "Resident Safety" stated, "5. Ensure all medications, chemicals, cleaning supplies and any other potential hazardous materials are kept locked/secured when staff has completed their use and is no longer in attendance." Review of the Material Safety Data Sheet (a fact sheet developed by manufacturers describing the chemical properties of a product) for Ajax states, "If victim is conscious and alert, give 2-3 glasses of water to drink and induce vomiting by touching back of throat with a finger. Do not induce vomiting or give anything by mouth to an unconscious person. Seek immediate medical attention. Do not leave victim unattended. Vomiting may occur spontaneously." Review of the U.S. Department Health and Human Services Household Products Database states the following regarding Clorox bleach spray: "Exposure to vapor or mist may irritate eyes, nose, throat, lungs. Harmful if swallowed. May cause nausea and vomiting if swallowed."

F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 08/14/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 23 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observations, interview, and document review, the facility did not ensure safe food services as evidenced by: 1. Dry food products such as powdered potatoes and condiments were stored on shelves in original packaging and packing boxes. 2. Dented cans on a storage shelf with canned food items, 3. Dietary staff did not wear protective barrier for beards and mustaches when washing dishes and plating residents' trays. Failure to ensure safe and effective food service operations that prevent foodborne illness may result in food safety hazards and compromised health status for residents. Findings: 1. During the initial tour of the kitchen on 7/10/17 at 10:15 a.m., dry food products FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 24 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (crackers, peanut butter, jellies) and an opened bag of powdered potatoes in the original package taped closed, were stored on shelves in the "Dry Goods Storage Area". Dry goods were not removed from the original packing boxes or packaging. 2. Two dented cans of beans were observed on a storage shelf in the "Dry Goods Storage Area". During review of the facilities dietary policy, the document titled, "Storage of Food and Supplies" from RDs for Healthcare, Inc., item #6 indicated, dry bulk foods should be stored in seamless metal or plastic containers with tight covers or in bins which are easily sanitized, and item #7 indicated to remove foods from the packing boxes upon delivery; this is to minimize pests. 3. During an observation on 7/11/17 at 08:30 a.m., Unlicensed Dietary Staff L, with an uncropped beard and mustache, did not wear a protective barrier for beards and mustaches while washing dishes. At 11:45 a.m., Unlicensed Dietary Staff L did not wear a protective barrier for beards and mustaches while prepping residents' trays during lunch tray line. During concurrent interview and document review on 7/11/17 at 3:00 p.m., the Dietary Services Supervisor was asked if Unlicensed Dietary Staff L should wear a protective barrier for beards and mustaches when working in the kitchen. The Dietary Services Supervisor stated that for non-closely cropped and trimmed beards a protective barrier for beards and mustaches should be worn. During a review of the facilities "Dress Code for Women and Men", from RDs for Healthcare, Inc., dated 2015, proper dress for men: item #8 states, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 25 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE beards and mustaches which are not closely cropped and neatly trimmed should be covered.

F431 SS=E DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 08/14/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 26 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to label and store drugs and biologicals according to its policies when it did not mark four bulk medication containers with the date they had been opened. This failure placed residents at risk of receiving expired medications. Findings: During an observation of the facility's medication room on 7/14/17 at 10:35 a.m., one bottle of Acidophilus 300mg and one bottle of Acidophilus 500mg (probiotic tablets) had their original seal broken and had no indication on the bottles of the date they had been opened. During an observation of the facility's medication carts on 7/14/17, at 10:45 am, two bottles of milk of magnesia (a laxative) had their original seals broken and had no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 27 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indication on the bottles of the date they had been opened. During concurrent interviews, the Director of Nursing stated bulk medications once opened should be marked with the date opened. Facility policy "Medication Storage in the Facility - Storage of Medications", Revised August 2014, stated: "When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated."

F465 SS=F SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.90(i)(5) 08/14/2017 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to maintain a safe environment when: 1. Dryer exhaust vents were covered with a thick layer of lint in close proximity to highly flammable, dry grass which could potentially FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 28 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cause the building to catch on fire. 2. Six resident rooms and one office had windows with screens that had gaps between the screens and the window frame that could allow insects to enter the building, potentially spreading diseases. 3. A rain gutter was allowed to become clogged with leaves, preventing the drainage of water, which could potentially become a breeding ground for mosquitoes, or the weight of the water could cause the gutter to fall off the building, potentially causing injury to a resident. Findings: 1. During an observation and concurrent interview on 7/12/17 at 9:00 a.m., two dryer exhaust vents, approximately ten inches in diameter, were observed on the outside of the building approximately 12 inches away from a bed of dry, yellow grass. The vents were blowing hot air out of the laundry room, as the clothes dryers were running inside. The wire screens, which covered the outlets of the vents, were coated with a thick layer of lint. The Maintenance Director stated, "I need to clean those off." During an interview on 7/13/17 at 3:15 p.m., a policy or written schedule for cleaning the dryer exhaust vents was requested, but the Maintenance Director stated he could not find a policy or procedure and there was no written schedule. He stated he cleaned off the screens on the openings of the dryer vents on the outside of the building with a wire brush when he noticed a build-up. A review of the U.S Fire Administration National Fire Incident Reporting System FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 29 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Topical Fire Report Series, Volume 13, Issue 7 revealed the following: "Lint is a highly combustible material that can accumulate both in the dryer and in the dryer vent. Accumulated lint leads to reduced airflow and can pose a potential fire hazard. . . A compromised vent will not exhaust properly to the outside. As a result, overheating may occur and a fire may ensue." 2. During an observation and concurrent interview on 7/12/17 at 9:15 a.m., the windows of six resident rooms and one office had screens with gaps between the frame of the screen and the window frame. Gaps were noted on the windows for resident Rooms 3, 5, 15, 22, 23, 25, and the medical records office. When queried, the Maintenance Director stated he thought the gaps were large enough to allow a fly get through. During an interview on 7/14/17 at 1:51 p.m., the Director of Staff Development stated the facility's infection control program did not address mosquito-borne illnesses or insects. She stated pests were controlled according to the pest control plan, that they are monitored for, and addressed as needed. The Centers for Disease Control (CDC) Healthy House Reference Manual indicated, ". . . the house fly is one of the most widely distributed insects, occurring throughout the United States. . . . Because of its close association with people, its abundance and its ability to transmit disease, it is considered a greater threat to human welfare than any other species of nonbiting fly. Each housefly can easily carry more than 1 million bacteria on its body. . ." The CDC also advises, "Protect yourself and your family from mosquito bites. . . Use screens on windows and doors. Repair holes in screens FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 30 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to keep mosquitoes outside." 3. During an observation and concurrent interview on 7/12/17 at 9:30 a.m., a rain gutter was observed to have a steady drip of water onto the cement walkway in the back of the facility. The Maintenance Director stated the water came from the condensation from the air conditioning unit on the roof. An air conditioning unit was noted to be on the roof with a length of pipe coming from underneath it, running along the top of the roof, terminating at the edge of the roof over the gutter. The Maintenance Director climbed up on the roof and reached his arm down into the gutter, which caused water to spill over the top onto the ground. He removed leaves from the gutter above the drainspout, and a large amount of water and many leaves gushed out of the drainspout onto the lawn. During an interview on 7/13/17 at 3:15 p.m., a policy or written schedule for cleaning out the gutters was requested. The Maintenance Director stated he did not have one. The Maintenance Director stated he cleaned them out quarterly, but the large sycamore tree behind the building only had to drop a few leaves in the gutters before they were clogged up again, which made it hard for him to keep up with. A review of the CDC Integrated Mosquito Management indicated, "Everyone can control mosquitoes. . . Removing places where mosquitoes lay eggs is an important step. Mosquitoes lay eggs near water because larvae need water to survive. Professionals and the public can remove standing water. . . Once a week, items that hold water . . . should be emptied. . . ." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 31 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F518 TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2)

F518 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/14/2017 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: Based on observation and interview the facility failed to prepare all staff for an emergency when one of three staff interviewed was unable to correctly demonstrate how to turn the gas shut-off valve. This had the potential to delay or prevent the shutting off of the gas in an emergency situation. Findings: During an observation and concurrent interview on 7/12/17 at 9:20 a.m., the Maintenance Director indicated the location of the gas shutoff valve behind the facility. On observation, the shut-off valve had been painted red and a wrench, also painted red, was against the wall next to it. Above the valve was an arrow, approximately 8 inches long, made out of red and white candy-striped tape. The Maintenance Director explained that the arrow was pointing up so that anyone who needs to turn off the gas will know to pull the wrench handle up. During a record review and concurrent interview on 7/12/17 at 12:25 p.m., the Maintenance Director provided documentation that disaster drills were performed on all shifts every six months. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 32 of 33 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056215 (X3) DATE SURVEY COMPLETED 07/14/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHBROOK HEALTHCARE CENTER 64 Northbrook Way Willits, CA 95490 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an observation and concurrent interview on 7/13/17 at 9:10 a.m., Unlicensed Staff E was asked to demonstrate how to turn off the gas in an emergency. Unlicensed Staff E placed the wrench correctly and then stated she would press down on the wrench handle to turn off the gas. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NRPS11 Facility ID: CA010000047 If continuation sheet 33 of 33