Health inspection·March 27, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to hold quarterly care conferences for one of three residents (Resident 16). This failure prevented Resident 16's Responsible Party to be involved in Resident 16's care plans. Findings: A review of Resident 16's facesheet indicated he was admitted to the facility on [DATE] and had a Responsible Party (RP) (a person responsible for making healthcare decisions on behalf of the resident). During an interview on 3/21/23, at 10:50 a.m., Resident 16's RP stated she had not been invited to attend care conferences for Resident 16. Resident 16's RP stated she would like to participate in Resident 16 care conferences. During an interview on 3/24/23, at 9:35 a.m., the Director of Nursing (DON) stated the facility's policy was to have resident care conferences upon admission and quarterly thereafter or upon a change in condition. The DON stated the resident, or their responsible party, were invited to participate in the care conferences. During a concurrent record review, the DON reviewed Resident 16's record and stated the last care conference for Resident 16 was held on 8/23/22. The DON confirmed Resident 16 had not had a care conference in seven months and should have had one during the interim. A review of facility policy and procedure titled Care Plans, Comprehensive Person-Centered, Revised December 2016, indicated care planning conferences are held at least quarterly and the residents or their responsible parties are invited to attend. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 2 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for two out of three residents (Resident 8 and Resident 26) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications. Findings: The controlled medication CDR for three random residents receiving as needed controlled medications were requested for review during the survey. During an interview on 3/21/23, at 9:44 a.m., with Licensed Nurse 2 (LN 2), LN 2 stated whenever a controlled medication was administered to a resident, the dose was to be documented in both the CDR and the MAR. He stated it was important for documentation to be in both places to know when a dose was last administered. During an interview on 3/21/23, at 10:22 a.m., with Director of Nursing (DON), DON stated the expectation of nursing staff was whenever a controlled medication was administered to a resident, they were to validate the tablet count, then document the given dose on the CDR and the MAR. 1a. Resident 26 had a physician's order for hydrocodone/APAP (a medication used to treat pain) 5/325 milligram/milligram (mg, a unit of measurement), dated 2/28/23. During a concurrent interview and record review on 3/21/23, at 10:25 a.m., with DON, a review of Resident 26's 3/2023 MAR indicated nursing staff removed 1 tablet on 3/13/23 from the medication cart and documented on the CDR without documenting the respective administration on the MAR. DON verified the finding. 1b. Resident 8 had a physician's order for lorazepam (a medication used to treat anxiety) 0.5 mg, 1 tablet every 4 hours as needed for anxiety, dated 2/11/23. During a concurrent interview and record review on 3/21/23, at 10:27 a.m., with DON, a review of Resident 8's CDR for lorazepam and 2/2023 through 3/2023 MARs indicated nursing staff removed the following from the medication cart and documented on the CDR without documenting the respective administration on the MAR: 1 tablet on 2/23/23, 1 tablet on 3/6/23, and 1 tablet on 3/19/23. DON confirmed the findings and stated, I don't see anything charted. During a review of the facility's policy and procedure titled, Preparation and General Guidelines, dated 10/2019, indicated, When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and/or the medication administration record (MAR): 1. Date and time of administration. (MAR, Accountability Record) 2. Amount administered. (Accountability Record) 3. Remaining quantity (Accountability Record) 4. Signature of the nurse administering the dose on the accountability record at the time the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 3 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 medication is removed from supply 5. Initials of the nurse administering the dose, completed after the medication is actually administered (MAR). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 4 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure discontinued medications were removed from stock according to facility policy and procedure (P&P), medications were appropriately labeled with a pharmacy label identifying which resident they were for, and expired medications were not available for resident use. The deficient practices had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency from being used past their discard date. Findings: On 3/20/23 at 11:14 a.m., an inspection of the Medication Storage Room alongside Licensed Nurse 1 (LN 1) identified two Mounjaro (an injectable medication used to treat diabetes) 2.5 milligram/0.5 milliliter (mg/ml, a unit of measurement) pens. One pen was inside a clear bag with a pharmacy label on the outside for Resident 4. The second pen was unlabeled with a pharmacy label and was not in any other packaging identifying which resident it was for. LN 1 stated all medications should have a pharmacy label affixed to the medication or packaged inside a bag with a label on the outside to identify which resident it was for. She stated Resident 4's order for Mounjaro had been discontinued and the pen should have been discarded in the discontinued medications bucket (DC bucket, a container designated for discontinued or expired medications). Further inspection identified two amber prescription vials sitting on top of the counter for Resident 27. One vial contained omeprazole (a medication used to treat acid reflux) 20 mg capsules and the second contained nitrofurantoin (an antibiotic used to treat infection) 100 mg capsules. LN 1 stated both vials should have been placed in the DC bucket because the resident was no longer taking those medications. During the same inspection, one Eliquis (a medication used to prevent blood clots) 2.5 mg tablet inside plastic strip packaging expired 9/19/22, was identified inside a cabinet. LN 1 stated the tablet was expired and should have been discarded in the DC bucket. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 8/2019, indicated, All medications dispensed by the pharmacy are stored in the box, bag or other container with the pharmacy label . During a review of the facility's P&P titled, Disposal of Medications and Medication-Related Supplies, dated 8/2014, indicated, If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose . An inspection of Medication Storage Cart 1, on 3/20/23 at 12:15 p.m., alongside LN 1 identified one calcitonin salmon (a medication used to prevent osteoporosis) 200 units/ml nasal spray, opened 2/5/23. LN 1 reviewed the manufacturer's labeling on the product packaging and stated the nasal spray expired 35 days after opened. LN 1 confirmed the nasal spray had expired 7 days prior. During an interview on 3/21/23, at 10:36 a.m., with Director of Nursing (DON), DON stated the expectation of nursing staff was to remove expired medications from stock and replace with new supply. She stated discontinued medications were to go in the DC bucket and their disposal documented by signatures of two licensed nurses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 5 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Medication Storage in the Facility, dated 8/2019, indicated, Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of accorder to procedures for medication, and reordered from the pharmacy, if a current order exists. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 6 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department and a qualified Dietary Supervisor or fulltime RD was overseeing the day-to-day operations of the kitchen, and evaulating dietary staff for competencies (cross reference F 812). These failures resulted in issues with safe and effective food storage, meal production (cross reference F 804) correct therapeutic diets being plated (cross reference F803) and infection control (cross reference F 812). Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness. Findings: During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. there was no Dietary Supervisor overseeing the kitchen. The Rehabilitation Manager stated she was overseeing the kitchen. The Rehabilitation Manager stated the Dietary Supervisor was on the way. A review of the facility job descriptions titled, Director of Rehabilitation, and Speech-Language Pathologist indicated the Rehabilitation Manager was hired as the Director of Rehabilitation on 12/20/2012. On 12/10/2010, the Rehabilitation Manager was hired in the position of Speech-Language Pathologist. During a concurrent interview and dietary record on 3/22/23 at 8:40 a.m., the Dietary Supervisor stated he had worked at the facility for a year, started as a cook and has been the Dietary Supervisor for the past six months. The Dietary Supervisor stated he was not yet qualified to be a Dietary Supervisor. He had his California Food Handlers Card, but was not a Certified Dietary Manager (CDM). The Dietary Supervisor stated he was still taking the Certified Dietary Manager course. During an interview on 3/22/23 at 3:45 p.m., the Dietary Supervisor stated he was trained by the Rehabilitation Manager, the Dietary Supervisor from the facility's sister facility located in another town, who was a Certified Dietary Manager, and the corporate Registered Dietician (RD) consultant, who came to the facility every few months. The Dietary Supervisor stated he could e-mail and call the corporate RD consultant as well. The Dietary Supervisor stated he trained [NAME] B. The Dietary Supervisor stated he had no training by the facility RD, who came every Thursday. The Dietary Supervisor stated the Dietary Supervisor oversaw the kitchen. The Dietary Supervisor stated he had never seen the RD oversee the kitchen and observe tray line. During an interview on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated the Dietary Supervisor from their sister facility did one inspection of kitchen but technically it did not count because she was not the RD, not part of her job description. The Dietary Supervisor stated the Dietary Supervisor oversaw the cooks. The Dietary Supervisor stated when he was on vacation the Rehabilitation Manager would be checking on the dietary staff to make sure everything was flowing well. The Dietary Supervisor stated the Rehabilitation Manager hired him in the Dietary Supervisor position, and when he was first hired in the cook position. The Dietary Supervisor stated he worked as the Dietary Supervisor on Monday through Thursday, and as a cook on Fridays. During an interview on 3/23/23 at 11:05 a.m., the RD stated she started working at the at the end of August or September 2022. The RD stated she was at the facility once per week and was also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 7 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many available by e-mail and/or phone. The RD stated when she first started, she mainly was in orientation and in October 2022, she started overseeing the operations of the facility's Food Service Department, by doing her monthly inspection of kitchen, and tray line and dining observations. The RD stated she was supposed to do a kitchen inspection monthly, starting October 2022, but she did not know if she had done many kitchen inspections. The RD stated the Rehabilitation Manager was overseeing the kitchen while the RD was orientating. The RD stated she understood and agreed the Dietary Supervisor was not qualified yet to oversee the kitchen. The RD stated she had never met and oversaw [NAME] B and verified [NAME] B's competencies as a cook by demonstration. The RD stated she did not oversee the ordering of food supplies. During a concurrent interview and review of the RD's monthly inspections of the kitchen from 1/2022 through 3/23/23, on 3/23/23 at 11:45 a.m., the Administrator was able to show a kitchen inspection took place by a RD six times. The current RD inspected the kitchen on 11/3/22, 1/27/23, and 2/27/23, the facility's corporate RD consultant inspected the kitchen on 5/2-5/3/22 and another RD inspected the kitchen on 1/21/22 and 8/6/22. The Administrator stated the RD, who inspected the kitchen on 1/21/22 and 8/6/22, used to be the facility's RD for a while and when she left, she was still helping at times. The Administrator stated the current RD started on 8/23/22. The Administrator stated it has been difficult to find a qualified RD to oversee the operations of the facility's Food Service Department and qualified Dietary Supervisor or fulltime RD to oversee the day-to-day operations of the kitchen. During an interview on 3/23/23 at 1:45 p.m., the Administrator stated she hired the Dietary Supervisor in 10/2022 as the Director of Food Services in training. The Administrator stated the corporate RD consultant has been helping at the facility at times. The Administrator stated the RD started in August/September 2022 and was mainly learning the computer, resident assessments and physician dietary orders at first. During an interview on 3/23/23 at 2 p.m., the Rehabilitation Manager stated she was mainly a support for the kitchen. The Rehabilitation Manager stated she was the Director of the Rehabilitation Department. The Rehabilitation Manager stated in her scope of practice, she would be looking at the resident's diet orders, advising the dietary staff in changes to a resident's therapeutic diet, advising if the texture of the resident's pureed diet was not prepared correctly, amongst other things. During an interview on 3/24/23, at 1:26 p.m., the Administrator stated the facility had been without a certified dietary manager (CDM) since July 2021, when the CDM quit. Since then, the Administrator stated, the facility had not been able to hire a CDM. The Administrator stated around October 2022 the facility started training a cook (the Dietary Supervisor) to take on the role as CDM. A review of the RD's New Hire/Employment Record Transfer Form, indicated the RD's hire date was 8/23/22, she was part-time, and her scheduled weekly hours was 16 hours. The facility job description titled, Registered Dietitian, undated, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Plan, develop, organize, implement, evaluate, and direct the Dietary Department, its programs and activities . Make written and oral reports/recommendations to the Food Service Supervisor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 8 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and/or administrator as necessary/required concerning the operations of the Dietary Department . Develop and participate in the planning, conducting, and scheduling of timely in-service training that ensure a well-educated competent dietary services department . Monitor dietary services to assure that all residents' dietary needs are being met . A review of the Dietary Supervisors New Hire/Employment Record Transfer Form, indicated the Dietary Supervisor was hired on 9/23/21 and his job title was cook. A review of the facility job description titled, Director of Food Services, indicated the Dietary Supervisor took the title as Director of Food Services on 10/1/22, and under Education, written next to qualifications, the Dietary Supervisor was In Training, dated and signed on 10/1/22. The facility job description titled, Director of Food Services, signed by the Dietary Supervisor on 10/1/22, indicated: Purpose of Your Job Position: The primary purpose of your job position is to assist the Dietician in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations, governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: Assist in planning, developing, organizing, implementing, evaluating and directing the Dietary Department, its programs and activities . Personnel Functions: . Review and check competence of dietary personnel and make necessary adjustments/corrections as required or that may become necessary . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . Equipment and Supply Functions: . Ensure that stock levels of staple/non-staple food, supplies, equipment, etc. are maintained at adequate levels at all times . Assist in the purchase of food services supplies, equipment, etc., as required . Education: . Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association . Handwritten next to qualification: In Training, signed and dated, 10/1/22 . Specific Requirements: Must be registered as Food Service Director in this state . Note there has not been a qualified certified dietary manager (CDM) since July 2021. The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not a Certified Dietary Manger/had not completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to sanitation inspections . and enforcement/education of State, County and Federal regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 9 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietary observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members were not: 1) following recipes for a.spinach and b. meatloaf 2) following therapeutic diets when a. portion sizes were not plated correctly, meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed properly, and b.mash potatoes were not fortified 3) qualified to oversee the day-to-day operations of the kitchen and 4) qualified to evaluate cooks for competences. Failure to ensure staff competency could result in decreased food distribution and food production systems to ensure food palpability and nutritional content, which could result in decreased dietary intake that did not meet individual resident nutritional requirement. This could result in weight loss and further compromise resident medical status. Findings: 1a) During an observation on 3/22/23 at 9:05 a.m. [NAME] B placed two frozen bags of spinach in a pot of water and started cooking the frozen spinach on the stovetop. During an observation on 3/22/23 at 9:15 a.m., the two bags of spinach were submerged in boiling water. During an observation on 3/22/23 at 10:10 a.m., the spinach was still cooking on the stovetop. During a concurrent observation and interview on 3/22/23 at 11:20 a.m. the spinach with added margarine and Swiss cheese was on the steam table. When [NAME] B was asked if he had baked the Spinach after adding the margarine and Swiss cheese per the Spinach Au Gratin recipe, [NAME] B stated, No, he first drained the spinach, added the spinach to the pan, placed the pan on the steam table and then added the margarine and Swiss cheese while in the pan on the steam table. The spinach had been cooking in boiling water for over two hours prior to placing the spinach on the steam table. During an observation during tray line on 3/22/23 at 12:20 p.m., [NAME] B was using a slotted serving spoon (spoon with holes) to plate the Spinach Au Gratin, which was very watery. [NAME] B tapped the spoon on the side of the serving pan five times to drain off the excess water before plating the spinach. A review of the recipe titled, Spinach Au Gratin, indicated: 1. [NAME] spinach in enough water to cover. Drain well. Place in baking pan, 2. Add margarine and cheese and mix well, 3. Bake at 325 degrees Fahrenheit for 10-15 minutes, until cheese is melted . 1b) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 10 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3/22/23 at 9:45 a.m., [NAME] B chopped carrots, onions and celery, but did not chop the mixed colored bell peppers, one of the ingredients needed. [NAME] B placed the carrots, celery and onions in the Robot Coupe (food processor used to dice, mince, grind, puree, slice, shred, etc.), blended the vegetables, and drained the excess water. When [NAME] B was asked why he blended the vegetables, [NAME] B stated it made it easier to mix all the ingredients together. The recipe indicated: Heat margarine or oil in skillet and sauté vegetables and Italian seasonings until vegetables are tender, approximately 3 to 5 minutes. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. [NAME] B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how [NAME] B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated [NAME] B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. [NAME] B then added the pound of ground turkey to the hamburger mix. This occurred after the surveyor had to cue the Dietary Supervisor about not having enough hamburger to serve 30 residents. The Dietary Supervisor was overseeing [NAME] B. [NAME] B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., [NAME] B added the one pound of ground turkey to the already mixed meatloaf. [NAME] B added chopped carrots, celery and onion. When [NAME] B was asked why he did not put the additional raw chopped vegetables in the food processor, [NAME] B stated to give the meatloaf a variation of cut vegetables. When [NAME] B was asked what additional ingredient he added to the bowl, which had the meatloaf mix, ground turkey, and raw vegetables, he stated he added a 1/4 cup of Italian seasoning. When asked if the recipe asked for a ¼ cup of Italian seasoning, [NAME] B said, Yes. Surveyor asked [NAME] B to look at the recipe. [NAME] B stated he read the Garden Fresh Meatloaf recipe wrong. [NAME] B stated he was supposed to add 1/4 teaspoon (tsp) to the one pound of additional ground turkey. [NAME] B was observed taking a handful of the Italian Seasoning off the top of the ground turkey with his gloved hand. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., [NAME] B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties, each in a baking dish, placed on the top oven rack, baking at 400 degrees Fahrenheit. When [NAME] B was asked why he was cooking the meat at 400 degrees instead of following the recipe, which indicated: Bake at one and a half hours to two hours at 325 degrees, [NAME] B stated to speed up the process. During a concurrent observation and interview on 3/22/23 at 11:25 a.m., [NAME] B pulled the meat out of the oven to check the temperature. [NAME] B stated the meatloaf temperature was at 135.4 degrees. [NAME] B placed the meatloaf back in the oven to continue cooking. During a concurrent observation and interview on 3/22/23 at 11:30 a.m., when [NAME] B was asked what the other pan on the top oven rack was, [NAME] B stated a veggie patty. The two 4-ounce hamburger patties had been cooking on the top oven rack for one hour. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 11 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The facility Policy/Procedure (P/P) titled, Food Preparation, dated 2018, indicted: Policy: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedure: . 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. The facility P/P titled, Menu Planning, dated 2020, indicated: . Procedures: . 4. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. 2a) During an observation on 3/22/23 at 11:45 a.m., [NAME] B had placed a slice of meatloaf on a medal spatula and placed the spatula with the meat on the kitchen food scale. He was measuring the meat for the pureed diets. [NAME] B then pureed the meat using low sodium broth. During an observation during tray line on 3/22/23 at 12:20 p.m., one slice of meatloaf (regular portion size) was seen on the shelf above steamtable. During a concurrent observation and dietary record review on 3/22/23 at 12:30 p.m., the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated a small portion of meatloaf should weigh three oz and a regular or large portion of meatloaf should weigh 4 oz. Plating the residents lunch meal ended at 12:30 p.m. and there was one of four loaves of meatloaf left in the baking pan, which was full of grease. The grease had not been drained from the baking pan before plating the meatloaf. There was six pounds (96 oz) of hamburger and one pound (16 oz) of ground turkey, total of 112 oz of meat used to serve 30 residents. A review of the residents Lunch Meal Cards, indicated 118 oz of meat was needed to serve 30 residents, based on portion size. [NAME] B was short six oz of meat before he started plating the meatloaf and hamburger patties.There was a loaf of meatloaf left over after the last slice of meatloaf was plated. During an interview on 3/23/23 at 8:00 a.m., the Dietary Supervisor stated he did not see [NAME] B weigh the meatloaf periodically. The Dietary Supervisor stated [NAME] B did have a slice of meatloaf on the shelf above the steam table for an example of the portion size he needed to slice. The Dietary Supervisor stated [NAME] B was slicing the meatloaf as he was periodically eyeballing the example of meatloaf portion size. The Dietary Supervisor stated to accurately weigh meat [NAME] B should have used cellophane to cover the scale, placed the slice of meat on the scale, and then weigh the meat. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. When asked how the Dietary Supervisor measured out meat, the Dietary Supervisor stated he usually sliced and measured a few pieces of meat. The Dietary Supervisor stated he would then eyeball the slices of meat he sliced against the meat he had weighed for his portion size example to make sure he was plating the correct portion size. The Dietary Supervisor stated if he felt he had not sliced enough meat he would remeasure a slice of meat to make sure he was slicing the correct portion size. The Dietary Supervisor stated [NAME] B felt rushed because he had to place the meatloaf back in the oven, because it was not cooked. The Dietary Supervisor stated [NAME] B did not measure the meat out like he would normally. The facility P/P titled, Food Preparation: Portion Control, dated 2018, indicated: Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food . 3. A diet scale should be used to weigh meats . It is not always necessary to weigh every slice of meat, but test weighing should be done (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 12 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 periodically to ensure accuracy. Level of Harm - Minimal harm or potential for actual harm The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Serve meals in accordance with established portion control procedures . Ensure that food and supplies for the next meal are readily available . Residents Affected - Many 2b) During an observation on 3/22/23 at 12:20 p.m., [NAME] B was fortifying the meatloaf with gravy and extra liquid butter on the spinach for residents on a Fortified diet. During an interview on 3/22/23 at 1:20 p.m., [NAME] B stated the gravy on the meatloaf was for the Fortified diets. [NAME] B stated per the Fortified instructions, he should have fortified both the meatloaf and the mashed potatoes with gravy and fortified the spinach with additional butter. [NAME] B stated he missed putting gravy on the mash potatoes. A review of the dietary document titled, Fortified Lunch dated Spring 2023 Week 3, indicated for Wednesday's lunch, the mashed potatoes needed 2 oz of gravy and the Spinach needed ½ oz melted margarine. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed and CCHO (Controlled Carbohydrate include sugars, fibers and starches) diet were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Fortified Diet, dated 2020, indicated: Description: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional Breakdown: The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day . Sample Fortified Meal Plan: . Lunch: Extra sauce or gravy on meat, extra margarine on potatoes, rice or paste . The facility P/P titled, Section 1: Purpose, dated 2018, indicated: .Therapeutic diets shall be prepared and served in accordance with the physician diet order . The facility job description titled, Registered Dietitian, undated, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . 3) During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. there was no Dietary Supervisor overseeing the kitchen. The Rehabilitation Manager stated she was overseeing the kitchen. The Rehabilitation Manager stated the Dietary Supervisor was on the way. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 13 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent interview and dietary record on 3/22/23 at 8:40 a.m., the Dietary Supervisor stated he had worked at the facility for a year, started as a cook and has been the Dietary Supervisor for the past six months. The Dietary Supervisor stated he was not yet qualified to be a Dietary Supervisor. He had his California Food Handlers Card, but he was not a Certified Dietary Manager (CDM). The Dietary Supervisor stated he was still taking the Certified Dietary Manager course. The Dietary Supervisor was asked to show where the carton of liquid eggs was kept. The Dietary Supervisor stated there was no liquid eggs used to cook omelets and scrambled eggs. The Dietary Supervisor stated he did the ordering for the kitchen but had missed ordering the cartons of liquid eggs. The dietary menu titled Good For Your Health Menus, dated 3/20/23-3/26/26, indicated the residents were going to be served a Denver Omelet on Thurs (3/23/23) and scrambled eggs on Friday (3/24/23). When the Dietary Supervisor was asked how the scrambled eggs for Friday was going to be made, the Dietary Supervisor stated he would normally go to the grocery store and buy a cartoon of liquid eggs. During an interview on 3/22/23 at 3:45 p.m., the Dietary Supervisor stated he was trained by the Rehabilitation Manager, the Dietary Supervisor from the facility's sister facility located in a nearby town, who was a Certified Dietary Manager, and the corporate Registered Dietician (RD) consultant, who came to the facility every few months. The Dietary Supervisor stated he could e-mail and call the corporate RD consultant as well. The Dietary Supervisor stated he trained [NAME] B. The Dietary Supervisor stated he had no training by the facility RD, who came every Thursday. The Dietary Supervisor stated the Dietary Supervisor oversaw the kitchen. The Dietary Supervisor stated he had never seen the RD oversee the kitchen and observe tray line. During an interview on 3/23/23 at 8:00 a.m. the Dietary Supervisor stated the Dietary Supervisor from the facility's sister facility and the Rehabilitation Manager taught him how to purchase food service supplies/kitchen supplies. The Dietary Supervisor stated there was hamburger in the freezer for the meatloaf, but the cook forgot to pull the hamburger out to thaw in time to make the meatloaf. The Dietary Supervisor stated he did not catch [NAME] B not cutting up mixed colored bell peppers for the Garden Fresh Meatloaf. The Dietary Supervisor stated the RD came every Thursday mainly to do her resident assessments. The Dietary Supervisor stated he could not recall the RD overseeing the kitchen in the past six months, since the Dietary Supervisor went from being a cook to being the Dietary Supervisor. The Dietary Supervisor stated the RD was new. During an interview on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated he oversaw the cooks and when he went on vacation the Rehabilitation Manager would be checking on the kitchen and dietary staff. The Dietary Supervisor stated the Rehabilitation Manager hired him in this position, and when he was first hired in the cook position. The Dietary Supervisor started the Dietary Supervisor from the facility's sister facility did the dietary staff competencies. The Dietary Supervisor stated he worked as the Dietary Supervisor Monday through Thursdays and a cook on Fridays. During an interview on 3/24/23, at 1:26 p.m., the Administrator stated the facility had been without a certified dietary manager (CDM) since July 2021. Since then, the Administrator stated, the facility had not been able to hire a CDM. The Administrator stated around October 2022 the facility started training a cook (the Dietary Supervisor) to take on the role as CDM. A review of the dietary training document titled, Food and Nutrition Service In-Service, dated 1/19/23, indicated the Dietary Supervisor, who was not a CDM, had given an In-Service (training) on Review of Spread Sheets. A review of the dietary training document titled, Dietary In-service, dated 12/5/22, indicated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 14 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Dietary Supervisor, who was not a CDM, had given an In-Service on Menu Changes and Substitutions. Level of Harm - Minimal harm or potential for actual harm A review of the Dietary Supervisor's employee file indicated Dietary Supervisor was hired as a cook on 9/23/21 and started in the job position of Director of Food Services on 10/1/22. Residents Affected - Many The facility job description titled, Director of Food Services, signed by the Dietary Supervisor on 10/1/22, indicated: Purpose of Your Job Position: The primary purpose of your job position is to assist the Dietician in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations, governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Equipment and Supply Functions: . Ensure that stock levels of staple/non-staple food, supplies, equipment, etc. are maintained at adequate levels at all times . Assist in the purchase of food services supplies, equipment, etc., as required. Education: . Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association . Handwritten next to qualification: In Training, signed and dated, 10/1/22 . Specific Requirements: Must be registered as Food Service Director in this state . 4) During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. The Dietary Supervisor stated he did in-services for the dietary staff, one per month. The Dietary Supervisor stated the Dietary Supervisor from the facility's sister facility would do an in-service when she came up to the facility. The Dietary Supervisor stated he would do the competencies on the dietary staff including the cooks as did the Dietary Supervisor from the facility's sister facility. The Dietary Supervisor stated if he had questions, he would e-mail the Dietary Supervisor from the sister facility. The Dietary Supervisor stated he would watch [NAME] B to see if he was doing the dietary processes correctly, such as following a recipe, in order to see if [NAME] B was competent in meal production, amongst other things. The Dietary Supervisor stared [NAME] B came in one day before being hired and shadowed (observed) him. The Dietary Supervisor stated [NAME] B shadowed him for two weeks while the Dietary Supervisor did the cooking. The Dietary Supervisor stated during those two weeks, he would ask [NAME] B to do various kitchen tasks. The Dietary Supervisor stated he oversaw [NAME] B for one to two months. During an interview on 3/23/23 at 2 p.m., the Rehabilitation Manager stated she was [NAME] a support for the kitchen. The Rehabilitation Manager stated she was the Director of the Rehabilitation Department. The Rehabilitation Manager stated in her scope she would be looking at the resident's diet orders, advising the dietary staff in changes to a resident's therapeutic diet, advising if the texture of the resident's pureed diet was not prepared correctly, amongst other things. A review of the Dietary Supervisor's Equipment Competency-Complete with New Employees and Annually, dated 3/1/22, indicated the Rehabilitation Manager signed off on the Dietary Supervisor's competencies, whose dietary position was a cook at the time, under DSS (Dietary Service Supervisor)/Manager signature title. A review of the Dietary Supervisor's Verification of Job Competency Demonstration - Cook, dated 7/27/22, indicated the Rehabilitation Manager signed off on the Dietary Supervisor's competencies, who was in the Dietary Supervisor In Training position. During a concurrent interview and review of dietary staff competencies on 3/24/23 at 3:45 p.m., the DON (Director of Nursing) was shown and asked why [NAME] B's, competencies titled, Verification of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 15 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Job Competency Demonstration - Cooks, in his employee file had no date of completion of competencies for the Cook position. but the same competency document for [NAME] B handed to surveyor on 3/23/23, was dated 10/13/22, indicated [NAME] B was signed off on all competencies for Cooks in one day. The DON stated she saw the issue but did not have an answer. She said, I see that. A review of the Rehabilitation Manager's employee file indicated she was hired on 12/20/10 in the job position of Speech-Language Pathologist and hired on 12/20/12 in the job position of Director of Rehabilitation. The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Review and check competencies of dietary personnel and make necessary adjustments/corrections as required or that may become necessary . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: . Make written and oral reports/recommendations to the Food Service Supervisor and/or administrator as necessary/required concerning the operations of the Dietary Department . Develop and participate in the planning, conducting, and scheduling of timely in-services training that ensure a well educated competent dietary services department, as well as for other facility departments . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . 29. Fulltime FNS (Food and Nutrition Service Manager) credentials meet Title 22/CMS regulations, posted. 30. FNS manager has a current food safety certificate and is posted . Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct food and portion. 4. Fortified foods guides used and are prepared and severed accordingly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 16 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to prepare a meal tray with 1) the individual therapeutic portion size for 30 out of 33 residents, when 30 residents' meatloaf portion size was not followed per the residents' lunch meal card, and 2) 13 out of 13 residents on a Fortified diet did not have their mash potatoes fortified with one oz of gravy per Spring 2023 Week 3 Fortified Lunch. These failures to ensure nutritional content could result in decreased dietary intake and resulted in less calories and protein, which may result in weight loss and further compromise resident medical status. Findings: 1) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. [NAME] B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how [NAME] B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated cook B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. [NAME] B then added the pound of ground turkey to the hamburger mix. This occurred after surveyor had to cue the Dietary Supervisor about there not being enough hamburger. The Dietary Supervisor was overseeing [NAME] B. [NAME] B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., [NAME] B added the one pound of ground turkey to the already mixed meatloaf. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., [NAME] B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties were each in a baking dish placed on the top oven rack, baking at 400 degrees Fahrenheit. During an observation on 2/22/23 at 11:45 a.m., [NAME] B had placed a slice of meatloaf on a medal spatula and placed the spatula with the meat on the food scale. He was measuring the meat for the pureed diets. [NAME] B then pureed the meat using low sodium broth. During an observation during tray line on 2/22/23 at 12:20 p.m., one slice of meatloaf ( regular portion size) was seen on the shelf above steamtable. During a concurrent observation and dietary record on 3/22/23 at 12:30 p.m., the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the small portion of meatloaf should weigh three oz and the regular or large portion of meatloaf should weigh 4 oz. Plating the residents lunch meal ended at 12:30 p.m. and there was one of four loaves of meatloaf in the baking pan, which was full of grease. Grease had not been drained from then baking pan before plating the meatloaf. There was six pound (96 oz) of hamburger and one pound (16 oz) of ground turkey, total of 112 oz of meat used to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 17 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many serve 30 residents. A review of the residents Lunch Meal Card, indicated 118 oz of meat was needed to serve 30 residents, based on portion size. [NAME] B was short 6 oz of meat before he started plating the meatloaf and hamburger patties. There was a loaf of meatloaf leftover after the last slice of meatloaf was plated. During an interview on 3/23/23 at 8:00 a.m., the Dietary Supervisor stated he did not see [NAME] B weigh the meatloaf periodically. The Dietary Supervisor stated [NAME] B did have a slice of meatloaf on the shelf above the steam table for an example of the portion size he needed to slice. The Dietary Supervisor stated [NAME] B was slicing the meatloaf as he was periodically eyeballing the portion size example of meatloaf. The Dietary Supervisor stated to accurately weigh meat [NAME] B should have used cellophane to cover the scale, placed the slice of meat on the scale, and then weigh the meat. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. When asked how the Dietary Supervisor measured out meat, the Dietary Supervisor stated he usually sliced and measured a few pieces of meat. The Dietary Supervisor stated he would then eyeball the slices of meat he sliced against the meat he had weighed for his portion size example to make sure he was plating the correct portion size. The Dietary Supervisor stated if he felt he had not sliced enough meat he would remeasure a slice of meat to make sure he was slicing the correct portion size. The Dietary Supervisor stated [NAME] B felt rushed because he had to place the meatloaf back in the oven because it was not cooked. The Dietary Supervisor stated [NAME] B did not measure the meat out like he would normally. The facility Policy/Procedure titled, Food Preparation: Portion Control, dated 2018, indicated: Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food . 3. A diet scale should be used to weigh meats . It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy. 2) During an observation on 3/22/23 at 12:20 p.m., [NAME] B was fortifying the meatloaf with gravy and extra liquid butter on the spinach for residents on a Fortified diet. During an interview on 3/22/23 at 1:20 p.m., [NAME] B stated the gravy on the meatloaf was for the Fortified diets. [NAME] B stated per the Fortified instructions, he should have fortified both the meatloaf and the mashed potatoes with gravy and fortified the spinach with additional butter. [NAME] B stated he missed putting gravy on the mash potatoes. A review of the dietary document titled, Fortified Lunch dated Spring 2023 Week 3, indicated for Wednesday's lunch, the mashed potatoes needed 2 oz of gravy and the Spinach needed ½ oz melted margarine. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed and CCHO (Controlled Carbohydrate include sugars, fibers and starches) diet were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Fortified Diet, dated 2020, indicated: Description: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 18 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many their weight or nutritional status. Nutritional Breakdown: The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day . Sample Fortified Meal Plan: . Lunch: Extra sauce or gravy on meat, extra margarine on potatoes, rice or paste . The facility P/P titled, Section 1: Purpose, dated 2018, indicated: .Therapeutic diets shall be prepared and served in accordance with the physician diet order . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor: Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct food and portion. 4. Fortified foods guides used and are prepared and severed accordingly The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided at all times. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Serve meals in accordance with established portion control procedures . Ensure that food and supplies for the next meal are readily available . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 19 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food production observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: Residents Affected - Some 1) holding time for Penne pasta, green beans, and turkey and gravy was over 1 hour prior to the beginning of meal service, 2) frozen spinach was cooked on the stovetop for over two hours prior to placing on the steam table, 3) recipes were not followed, 4) two out of 12 Sampled Residents (Resident 2 and Resident 33) and three Unsampled Residents (Resident 1, Resident 4, and Resident 86) did not like the food and/or had issues with the temperature of the food, the texture of food items, quality of the food or taste of the food, and 5) test tray evaluation of noon meal tray on 3/22/23 at 1 p.m. found to have meat that was dry, lacked flavor and greasy tasting, spinach needed seasoning/lacked flavor, mashed potatoes were bland, and pureed meat and spinach were cold. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake, which may result in weight loss and further compromise resident medical status. Findings: 1) During the initial tour of the kitchen on 3/20/23 at 11:20 a.m., lunch foods (turkey with [NAME] sauce, Penne pasta, and green beans) were on the steam table. During an interview on 3/20/23 at 11:45 a.m., [NAME] B was asked when the lunch foods were placed on the steam table. [NAME] B stated the Penne pasta and green beans were placed on the steam table at 10:30 a.m. & the turkey and gravy were placed on steam table at 10:45 a.m. During an observation on 3/20/23 at 11:47 a.m., [NAME] B started plating the lunch. The lunch foods had been warming on the steam table for over one hour. During concurrent interview and observation on 3/20/23 at 12:54 p.m., Resident 4 stated the pasta was Horrible, no taste. Resident 4 stated there was nothing she liked on her plate, and the pasta was cold. Resident 4 could not eat her pasta. Resident 4 stated she ate the turkey because she was hungry but if she was blindfolded, she would not know what she was eating. Resident 4 had been served one slice of turkey with a little gravy. Resident 4 stated she finished the slice of turkey in four and a half bites. 2) During an observation on 3/22/23 at 9:05 a.m. [NAME] B placed two frozen bags of spinach in a pot of water and started cooking the frozen spinach on the stovetop. During an observation on 3/22/23 at 9:15 a.m., the two bags of spinach were submerged in boiling water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 20 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During an observation on 3/22/23 at 10:10 a.m., the spinach was still cooking on the stovetop. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 3/22/23 at 11:20 a.m. the spinach with added margarine and Swiss cheese was on the steam table. When [NAME] B was asked if he had baked the Spinach after adding the margarine and Swiss cheese per the Spinach Au Gratin recipe, [NAME] B stated, No, he first drained the spinach, added the spinach to the pan, placed the pan on the steam table and then added the margarine and Swiss cheese while in the pan on the steam table. The spinach had been cooking in boiling water for over two hours prior to placing the spinach on the steamtable. Residents Affected - Some During an observation of tray line on 3/22/23 at 12:20 p.m., [NAME] B was using a slotted serving spoon (spoon with holes) to plate the Spinach Au Gratin, which was very watery. [NAME] B tapped the spoon on the side of the serving pan five times to drain off the excess water before plating the spinach. A review of the recipe titled, Spinach Au Gratin, indicated: 1. [NAME] spinach in enough water to cover. Drain well. Place in baking pan, 2. Add margarine and cheese and mix well, 3. Bake at 325 degrees Fahrenheit for 10-15 minutes, until cheese is melted . The facility Policy/Procedure titled, Food Preparation, dated 2018, indicated: Policy: Food shall be prepared by methods that conserve nutritive value, flavor. And appearance. Procedure: . 11 Do not use steamtable to cook food. 3) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 9:45 a.m., [NAME] B chopped carrots, onions and celery, but did not chop he mixed colored bell peppers, one of the ingredients needed. [NAME] B placed the carrots, celery and onions in the Robot Coupe (food processor used to dice, mince, grind, puree, slice, shred, etc.), blended the vegetables, and drained the excess water. When [NAME] B was asked why he blended the vegetables, [NAME] B stated it made it easier to mix all the ingredients together. The recipe indicated: Heat margarine or oil in skillet and sauté vegetables and Italian seasonings until vegetables are tender, approximately 3 to 5 minutes. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. [NAME] B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how [NAME] B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated cook B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. [NAME] B then added the pound of ground turkey to the hamburger mix. This occurred after surveyor had to cue the Dietary Supervisor about there not being enough hamburger. The Dietary Supervisor was overseeing [NAME] B. [NAME] B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., [NAME] B added the one pound of ground turkey to the already mixed meatloaf. [NAME] B added chopped carrots, celery and onion. When [NAME] B was asked why he did not put the additional raw chopped vegetables in the food processor, [NAME] B stated to give the meatloaf a variation of cut vegetables. When [NAME] B was asked what he added to the bowl (meatloaf mix, ground turkey, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 21 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm raw vegetables), he stated he added a 1/4 cup of Italian seasoning. When asked if the recipe asked for a ¼ cup of Italian seasoning, [NAME] B said, Yes. Surveyor asked [NAME] B to look at the recipe. [NAME] B stated he read the Garden Fresh Meatloaf recipe wrong. [NAME] B stated he was supposed to add 1/4 teaspoon (tsp) to the one pound of additional ground turkey. [NAME] B was observed taking a handful of the Italian Seasoning off the top of the ground turkey with his gloved hand. Residents Affected - Some During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., [NAME] B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties were each in a baking dish placed on the top oven rack, baking at 400 degrees Fahrenheit. When [NAME] B was asked why he was cooking the meat at 400 degrees instead of following the recipe, which indicated: Bake at one and a half hours to two hours at 325 degrees, [NAME] B stated to speed up the process. During concurrent observation and interview on 3/22/23 at 11:25 a.m., [NAME] B pulled the meat out of the oven to temp. The meatloaf temperature was at 135.4 degrees. [NAME] B placed the meatloaf back in the oven to continue cooking. During a concurrent observation and interview on 3/22/23 at 11:30 a.m., when [NAME] B was asked what the other pan on the top rack in the oven was, [NAME] B stated a veggie patty. The two 4-ounce hamburger patties had been cooking on the top oven rack for one hour. The facility Policy/Procedure (P/P) tilted, Food Preparation, dated 2018, indicated: Policy: Food shall be prepared by methods that conserve nutritive valve, flavor and appearance. Procedure: . 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 3. Prepared food will be sampled . 4. Poorly prepared food will not be sampled. 5. Prepare foods as close as possible to serving time in order to preserve nutrition, freshness and to prevent overcooking . 7. Holding foods prior to service for as short a time as practical. A maximum 1 hour holding time is recommended . The facility P/P titled, Menu Planning, dated 2020, indicated: . Procedures: . 4. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. 4) During an interview on 3/20/23, at 11:55 a.m., Resident 1 stated, The food is lousy, the vegetables are undercooked, pasta is served all the time, the bread is stale, they serve powdered eggs, the food served is very low quality, the food is really terrible. During an interview on 3/20/23, at 12:20 p.m., Resident 2 stated, The food is really bad, the food all tastes the same, the food is very poor quality. During an observation and concurrent interviews on 3/20/2023 at 12:41 p.m., Resident 86 and Resident 33 were in their room eating lunch. When asked about their meals, Resident 86 stated it was, awful and stated the food was not warm. Resident 33 stated, it's all crap. When asked what she did not like about her food, Resident 33 stated she did not like, all of it. She stated there was no salt or pepper and the food was only, medium warm. During concurrent interview and observation on 3/20/23 at 12:54 p.m., Resident 4 stated all the food served was processed. Resident 4 stated when the kitchen served pizza the residents were only (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 22 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some allowed one piece. Resident 4 stated she was told the kitchen was cutting back because food was being wasted. Resident 4 complained about small meat portions. Resident 4 had been served one slice of turkey with a little gravy. Resident 4 stated she finished the slice of turkey in four and a half bites. During a concurrent interview and dietary record review on 3/22/23 at 8:40 a.m., the Dietary Supervisor was asked to show where the carton of liquid eggs was kept. The Dietary Supervisor stated there was no liquid eggs used to cook omelets and scrambled eggs. The Dietary Supervisor stated he did the ordering for the kitchen but had missed ordering the cartons of liquid eggs. The Good For Your Health Menus, dated 3/20/23-3/26/26, indicated scrambled eggs were going to be served for breakfast on Friday (3/24/23). When the Dietary Supervisor was asked how the scrambled eggs would be made, the Dietary Supervisor stated he would normally go to the grocery store and buy a cartoon of liquid eggs. During a concurrent interview and record on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated he went to the grocery store last night to get the liquid eggs needed to make omelets this morning. The dietary menu titled, Good For Your Health Menus, dated 3/20/23-3/26/23, indicated a Denver Omelet was on the 3/23/23 breakfast menu. The Dietary Supervisor stated he was overseeing the dietary budget and corporate wanted the facility to lower the budget. 5) On 3/22/23 at 1 p.m., a test tray was completed. The Dietary Supervisor tempted the pureed meatloaf at 85 degrees Fahrenheit and the spinach at 95 degrees Fahrenheit. The Dietary Supervisor agreed the hot pureed foods were cold. The pharmacy consultant stated the meatloaf tasted dry and bland. The Dietary Supervisor stated the meatloaf needed salt. The surveyor stated the meatloaf had very little flavor and she could taste the grease. No gravy had been poured over the meatloaf. All tasters agreed the mash potatoes were bland/no flavor. The pharmacy consultant and surveyor stated the spinach was bland, needed seasoning and there was no cheese noted. The survey said the pureed meatloaf and spinach tasted cold and spinach had no flavor/needed to be seasoned. During an interview on 3/22/23 at 1:15 p.m., Resident 4 stated the meatloaf was gross, had no gravy and no flavor. Resident 4 stated the mash potatoes had no flavor and no gravy. Resident 4 stated she would have liked to have had gravy on her meatloaf and mashed potatoes. Resident 4 stated she could not eat the garlic bread; it was soaked in butter and disgusting. A review of Resident 4's Lunch Meal Card for 3/22/23, indicated Resident 4 was on a Regular CCHO (Controlled Carbohydrate (include sugars, fibers and starches) diet. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) and CCHO diets were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Meal Service, dated 2018, indicated: Policy: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. Procedure: . 7. Temperatures of the food when the resident receives it based on palatability. The goal is to serve cold food cold and hot food hot. Hot entrée should be 120 [NAME] Fahrenheit or hotter . The facility P/P titled, Section 1: Purpose, dared 2018, indicated: Food and Nutrition Service (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 23 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some means a service organized, staffed and equipped to assure that the food service to residents is safe, appetizing and provides for their nutritional needs. Policy: It is the policy of this facility to serve nourishing attractive meals to all our residents, to meet the nutritional needs of each individual resident, to totally integrate food and nutrition service polices and procedures with all other resident care policies and procedures, to comply with all federal, state, and local regulations pertaining to food and nutrition services, and to employ an adequate, competent staff, including a registered dietician or dietary consultant, to ensure high quality meals, excellent service and maximum safety of food and nutrition services department. Procedures . Resident's meals shall be prepared from quality food purchases with the food budget. The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided at all times. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Prepare and serve meals that are palatable and appetizing in appearance . Ensure that food and supplies for the next meal are readily available . The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not Certified Dietary Manger/had not completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to . meal service accuracy and enforcement/education of State, County and Federal regulations . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 24 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 food and portion. 7. Temperature retention methods keep hot foods hot and cold foods cold during time of service . 9. Food is placed on steam table less the 30 minutes prior to meal service . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 25 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) frozen vegetables were not sealed, 2) dietary staff did not know quaternary (quat ammonium compounds designed to kill germs) wet time for sanitizer solutions, 3) cook did not sanitize countertop after preparing meat, and 4) the cook was not wearing appropriate aprons for cooking and washing cooking utensils and equipment per the facility's policy/procedure. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal distress, weight loss and in severe instances may result in death. Findings: 1. During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. the frozen corn and frozen peas located in the freezer in the main kitchen area were both stored in unsealed blue bags, which were in open cardboard boxes. During a concurrent observation and interview on 3/22/23 at 8:40 a.m., the frozen corn and frozen cauliflower located in the freezer in the main kitchen area were both stored in unsealed blue bags, which were in open cardboard boxes. The Dietary Supervisor stated the frozen vegetables are delivered in a compressed sealed bag inside a sealed cardboard box, but the frozen vegetables are not tied/sealed after they are opened. The facility Policy/Procedure (P/P) titled, Procedure for Freezer Storage, dated 2018, indicated: Subject: Freezer Storage: Procedure: . 5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn . 2. During an interview on 3/22/23 at 9 a.m., Dietary Aide D stated the procedure for cleaning the dirty kitchen countertops was as follows: First clean the dirty countertops with soapy water located in the green bucket, wipe with the clean water located in the blue bucket, and then sanitize the countertops with the sanitizer located in the red bucket. Dietary Aide D stated the sanitizer wet time (the time that a disinfectant/sanitizer needs to stay wet on a surface to ensure efficacy) for the quat sanitizer wet time was 10 minutes. During an interview on 3/23/23 at 8 a.m., the Dietary Supervisor stated the kitchen countertop needed to be sanitized after preparing meat such as the hamburger and ground turkey to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 3/23/23 at 9:20 a.m., when the Dietary Supervisor was asked what the contact/wet time was for the sanitizer used to sanitize the kitchen countertops, he stated he would have to look up the wet time. When the Dietary Supervisor returned, he stated the sanitizer wet time was 10 minutes. During a concurrent observation, interview and review of Purell's sanitizer directions on 3/23/23 at 9:15 a.m. Dietary Aide C stated she used the Purell spray to sanitize the meal tray carts, which appeared to be made of stainless steel. Dietary Aide C stated she sprayed the sanitizer throughout each cart and then wiped the sanitizer, so the solution was evenly spread throughout the carts, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 26 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many then she let the sanitizer air dry. When Dietary Aide C was asked what the contact/wet time was for the sanitizer, Dietary Aide C stated she thought 10 seconds. The Purell sanitizer instructions on the back of the Purell (Foodservice surface sanitizer) indicated: Sanitization Directions to Sanitize Hard, Nonporous (a surface, such stainless steel, metal, glass, hard plastic, and varnished wood whereby any kind of liquid and air cannot penetrate the material, and they just remain on the surface) Food-Contact Surfaces: Visible soil must be removed prior to sanitizing. Wash surface and follow with potable water rinse. Spray, pour, or apply this product with a cloth, mop, or sprayer device until surface is thoroughly wet. For spray application, spray 6-8 inches from the surface. Treated surface must remain wet for 60 seconds. Wipe or allow to air dry. No rinse required. To Spot Sanitize Soft Surfaces: Visible soil must be removed prior to sanitizing. Spray this product 6-8 inches from soft surface until wet. Do not saturate. Let stand for 30 seconds. Allow to air dry. During a concurrent interview and review of the Shurguard Ultimate (Food Contact Sanitizer/Disinfectant) on 3/24/23 at 12:08 a.m., the surveyor met with the DON (Director of Nursing), Maintenance Manager, and the Rehabilitation Manager to go over the sanitizer solution dietary staff was supposed to use in the kitchen to clean the kitchen countertops. The Maintenance Manager stated the dietary staff were supposed to use the Purell spray bottle solution for the countertops per oversight with the Infection Preventionist. The Shurguard was supposed to be used for the three-sink compartment (manual procedure for cleaning and sanitizing the dishes). The Rehabilitation Manager stated she trained the dietary staff to use the Purell sanitizer to sanitize the kitchen countertops. The Rehabilitation Manager was asked if she was a qualified Certified Dietary Manager whose duties included training the dietary staff on sanitation procedures. The Rehabilitation Manager stated she was not qualified to act as the Dietary Manager. The Shurguard Ultimate directions were for both sanitizer (a quat solution, reduces the number of germs on a surface, safe for food to come in contact with, and does not need to be rinsed) and a disinfectant (kills most germs, the solution is a stronger concentration, not safe for food to come in contact with, so the surfaces that come in contact with food needed to be rinsed with potable water after using the sanitizer as a disinfectant) use on countertops. The wet time for using the Shurguard Ultimate solution as a sanitizer was 1 minute and use as a disinfectant was 10 minutes. The facility P/P titled, Shelves, Counters and Other Surfaces Including Hand Washing Sinks, dated 2018, indicated: Cleaning Procedure: . 3. Spray or wipe with Quaternary bucket solution containing sanitizer. Read sanitizer directions to learn how long surface is to remain wet. Use enough sanitizer to meet this time. Do not rinse. 3. During an observation on 3/22/23 at 10:25 a.m., [NAME] B used the soapy water in the green bucket to wipe the countertops off after finishing making the meatloaf with the added ground turkey. [NAME] B then used the clean water from the blue bucket to wipe the soapy countertops but stopped there and did not sanitize the countertops. During an interview on 3/22/23 at 10:35 a.m., the Dietary Supervisor was asked if [NAME] B should have sanitized the countertops after he finished preparing the meatloaf, whereby meat particles landed on the countertops. The Dietary Supervisor stated [NAME] B should have sanitized the countertops, but he forgot to. The Dietary Supervisor then cued [NAME] B to sanitize the countertops after preparing the meatloaf. [NAME] B stated he would normally sanitize the countertops, but he got busy with food preparation closer to tray line, his head went in multiple directions and he forgot to sanitize the countertops. The facility job description titled, Cook, revised 10/17, indicated: . Follow established Infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 27 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Control and Universal Precautions policies and procedures when performing daily tasks . Level of Harm - Minimal harm or potential for actual harm 4. During and observation on 3/22/23 at 11:30 a.m., [NAME] B was observed not wearing an apron over his sweatshirt when cooking and/or for washing dirty utensils/equipment. [NAME] B was observed wearing a sweatshirt while cooking and going back and forth between cooking/the food prep area and the dirty dishwasher area where he was washing his cooking utensils/equipment and then going back to preparing the food/placing the food on the steamtable and plating the food for the residents' lunch. Both dietary aides and the 2nd cook had a cloth apron on while preparing the food/getting trays read for the tray line. Residents Affected - Many During an observation and interview on 3/22/23 at 12:45 p.m., Dietary Aide C stated she used a cloth apron when working with food, when on the tray line and preparing the residents' meal tray. Dietary C stated she used a disposable plastic apron when washing dishes. Dietary Aide C pointed to her cloth apron placed on the hook near the coffee machine and kitchen door leading to the hallway. [NAME] B was observed washing his cooking utensils/dishes without a disposable apron over his clothes. During an interview on 3/23/23 at 8 a.m., the Dietary Supervisor stated the dietary staff used a disposable apron to wash dishes and a cloth apron while preparing foods such the hamburger and ground turkey and when cooking to prevent cross contamination. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD has never overseen him. The facility P/P titled, Dress Code For Women and Men, dated 2018, indicated: Purpose: Appropriate dress in the Food and Nutrition Department. Personal hygiene and appropriate dress are very important part of the total appearance of Food and Nutrition Services Department. All clothing should be in good repair. Appearance is very important in maintaining a high standard of food service. The following recommendations are made: . Men: . 5. Clean apron, plastic or cloth . The facility job description titled, Registered Dietician (RD), revision 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the RD would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . Food Preparation: . 18. All food production surfaces are cleaned and sanitized after use. The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not a Certified Dietary Manger/had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 28 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to sanitation inspections . and enforcement/education of State, County and Federal regulations . Event ID: Facility ID: 056215 If continuation sheet Page 29 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 12) who signed arbitration agreements understood the agreement when Resident 12 was cognitively impaired when he signed the agreement. This failure resulted in Resident 12 agreeing to something he did not understand. Residents Affected - Few Findings: During an interview and record review on 3/22/23, at 10:05 a.m., the Business Office Manager (BOM) stated she was responsible for offering and explaining the facility's arbitration agreement to residents. The BOM stated residents were offered arbitration agreements during the admission process. The BOM stated Resident 12 had signed an arbitration agreement upon admission and provided the agreement. A review of the agreement indicated it was signed by Resident 12 himself on 10/27/22, which was confirmed by the BOM. During an observation and interview on 3/22/23, at 10:18 a.m., Resident 12 was in his room and was asked if he knew what an arbitration agreement was and if he remembered signing one at the facility. Resident 12 stated no to both questions. During an interview and record review on 3/22/23, at 10:25 a.m., the Director of Nursing (DON) reviewed Resident 12's clinical record. The DON stated Resident 12 was admitted to the facility on [DATE] from the General Acute Care Hospital for care following a stroke. The DON stated Resident 12 was his own Responsible Party. The DON stated on 10/31/22 a Minimum Data Set (MDS) assessment was completed which indicated Resident 12 had a Brief Interview for Mental Status (BIMs) (the MDS tool that measures resident cognition) score of 7 (BIMs scores range from 0-15 and are interpreted as follows: 0-7 = indicate severe cognitive impairment; 8-12 indicate moderate cognitive impairment and 13-15 = indicate intact cognition). A second and subsequent MDS assessment was completed on 1/31/23 which indicated Resident 12 had a BIMs score of 6. A further review of Resident 12's clinical record indicated Resident 12's Discharge Summary from the General Acute Care Hospital dated 10/24/22. The Discharge Summary indicated Resident 12 had diagnoses including Stroke due to intracerebral hemorrhage (bleeding in the brain) and Wernicke-Korsakoff syndrome (an amnestic disorder). Resident 12's Discharge Summary further indicated Resident 12 suffered from dementia and was profoundly impaired. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 30 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program addressed the full range of care and services provided by the facility when a dietary department representative participated in only three of the previous 12 QAPI meetings. This failure had the potential for the facility to neglect dietary quality deficits. Residents Affected - Some Findings: During an interview and record review on 3/24/23, at 1:26 p.m., the Administrator stated the facility's Quality Assurance and Performance Improvement (QAPI) committee met monthly to review and address quality issues in the facility. The Administrator stated all department heads attended the QAPI committee meetings. The Administrator provided the attendance sheets of the past 12 QAPI committee meetings, held on 2/28/23, 1/25/23, 12/22/22, 11/30/22, 10/27/22, 9/28/22, 8/30/22, 7/28/22, 6/22/22, 5/26/22, 4/28/22 and 3/23/22. A review of the attendance sheets of the above 12 meetings indicated a representative from the dietary department only attended three of the meetings: on 2/28/23, 1/25/23 and 5/26/22, which was confirmed by the Administrator. A review of facility policy and procedure titled: 2023 Quality Assurance and Performance Improvement (QAPI) Plan indicated: The scope of the QAPI program encompasses all segments of care and services provided by our facility that impact clinical care, quality of life, resident choice, and care transitions with participation from all departments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 31 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a glucometer was not disinfected in accordance with facility policy and procedure (P&P) and manufacturer's specifications after resident use. This failure had the potential to result in the development of infection and transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C). Residents Affected - Some Findings: During an observation on 3/20/23, at 12 p.m., with Licensed Nurse 2 (LN 2), LN 2 was observed testing Resident 4's blood sugar using an Assure Platinum glucometer. He inserted the test strip into the glucometer, poked the resident's finger with a lancet, placed a drop of Resident 4's blood on the test strip, and allowed the glucometer to measure the blood sugar level. Once the reading was complete, LN 2 disposed of the test strip and returned to the medication cart with the glucometer. LN 2 then used an alcohol prep pad to wipe down the glucometer. During an interview on 3/20/23, at 12:08 p.m., with LN 1, LN 1 stated the proper way to disinfect the glucometer after use was to wipe it down with a Super Sani-Cloth germicidal wipe, then use a second wipe to wrap around the meter for two minutes. During an interview on 3/20/23, at 12:11 p.m., with LN 2, LN 2 stated the process he followed for disinfecting the glucometer was to, Wipe it down with alcohol wipes, let it dry off then take it to the next [resident]. LN 2 stated he was trained to use the Super Sani-Cloth wipes and when asked if the alcohol prep pads were just as effective he stated, No. During an interview on 3/21/23, at 10:35 a.m., with the Director of Nursing (DON), DON stated the guideline for cleaning and disinfecting the glucometer after use was to wipe it with alcohol and then disinfect with a Super Sani-Cloth wipe, leaving the surface wet for a minimum of two minutes. During a review of the facility's P&P titled, Maintenance: Cleaning and Disinfecting Guidelines, undated, indicated, Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. During a review of the facility's P&P titled, Obtaining a Fingerstick Glucose Level, revised 10/2011, indicated, Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 32 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to designate a qualified staff member to function in the role of Infection Preventionist (IP) (individual responsible for the facility's activities aimed at reducing the spread of disease by collecting and analyzing data on healthcare-associated infections, identifying outbreaks, and using appropriate prevention strategies to prevent and control further spread), per the facility's assessment plan. This failure created potential for inability to implement programs and activities to prevent and control infections in a population of vulnerable residents, which placed 33 of 33 Residents at risk for infections. Findings: During an interview on 03/22/23 at 12 p.m., the Director of Nursing (DON) and Licensed Nurse A (LN A) were asked about the IP at the facility. The DON stated the IP had quit working at the facility approximately five to six weeks earlier. During and interview on 03/22/23 at 4:01 p.m., the DON stated the facility did not have a full-time IP Nurse, as the prior IP nurse left her position at the facility in early February, 2023. The DON stated the facility's goal was for LN A (who worked as an IP at another facility) to transition into the IP position in April, 2023. The DON stated two nurses were currently out on medical leave and LN A needed to work the floor (as a charge nurse) until their return. The DON stated the facility was able to, piece (IP duties) together. She stated LN A, Consultant E did some of the work and she (the DON) and other nurses, helped. Review of facility document titled, (Facility Name), subtitled, Facility Assessment, subtitled, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, further subtitled, Staffing Plan, (dated 1/25/2023) indicated, Nursing Service Staffing Plan . Infection Preventionist: 40 hrs. qwk (hours per week) . Review of the facility's IP job description titled, Infection Preventionist (CA), subtitled, Purpose of Your Job Position (reviewed 01/27/23), The primary purpose of your job position is to plan, organize, develop, coordinate, direct, and implement the facility's Infection Prevention and Control Program (IPCP) and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs . to ensure that an effective infection control program is maintained at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 33 of 34 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056215 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the call light system was accessible to residents while lying on the floor in the restrooms for residents in 19 of 21 rooms. This failure created the potential for residents, who fell while using the restroom, from activating the call light system and summoning help. Residents Affected - Many Findings: During an observation and interview on 3/22/23, at 8:50 a.m., with the Director of Maintenance (DM), the restrooms used by residents in 19 of 21 rooms (Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 19, 20, 21, 2, 23, 24 and 25) were inspected. All the restrooms had the call light button located next to the toilet at elbow level from a resident sitting on the toilet. There was no string or cord from the call light button reaching the floor. The DM measured the height of the call light button in all restrooms and stated it was 36 inches from the floor. During a simulation of a fall from the toilet in the restroom used by residents in rooms [ROOM NUMBERS], it was not possible to reach the call light while lying on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056215 If continuation sheet Page 34 of 34