Health inspection·March 5, 2025

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - 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 resident (Resident 1) of four sampled residents was free from physical abuse when two Certified Nursing Assistants (CNAs) intentionally held down Resident 1 against his will while performing perineal care (the cleaning and maintenance of the genital and anal areas). Residents Affected - Few This failure resulted in Resident 1 feeling belittled and upset. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with a diagnosis of pleural effusion (abnormal buildup of fluid between the lungs and the chest wall). A review of a care plan, initiated on 2/19/25, indicated Resident 1 had an activities of daily living self care performance deficit related to generalized weakness. In order to assist Resident 1 to safely perform grooming, toilet use, and personal hygiene, staff were to conduct the following interventions, [For] toilet use .[Resident 1] requires assistance to .clean self, transfer onto toilet, transfer off toilet, to use toilet .Encourage [Resident 1] to discuss feelings about self-care deficit .Encourage [Resident 1] to participate to the fullest extent possible with each interaction . A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated assessment tool), dated 2/20/25, indicated the following: -Section C: A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident's) score of 4, which indicated severe cognitive (relating to processes of thinking and reasoning) impairment. -Section F: Resident 1 notified staff it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. -Section GG: Facility staff assessed Resident 1 was able to perform toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding, etc.), lower body dressing (the ability to dress and undress below the waist), and toilet transfer (the ability to get on and off the toilet or commode) with partial/moderate assistance (when the helper does less than half of the effort to carry out the activity). -Section H: Facility staff assessed Resident 1 was always continent (had the ability to control (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056215 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 03/05/2025 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)