Health inspection·April 10, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 3 errors out of 43 opportunities, which resulted in a medication error rate of 6.98 % for 2 (Resident #2 and Resident #4) of 5 residents observed during medication administration. Residents Affected - Few Findings included: A facility policy titled, Administration Procedures For All Medications, dated 05/2022, indicated, C. Review 5 Rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR [medication administration record/treatment administration record] for order. b. Note any allergies or contraindications the resident may have prior to drug administration. c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. d. Check for vital signs, other tests to be done during/prior to medication administration. e. Prepare resident for medication administration. 2) Prior to removing the medication from the container a. Check the label against the order on the MAR. b. Note any supplemental labeling that applies (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication, etc. [et cetera, and other similar things]). 1. An admission Record indicated the facility admitted Resident #2 on 10/10/2008. According to the admission Record, the resident had a medical history that included diagnoses of heart failure, atherosclerotic heart disease, and constipation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #2's Order Summary Report, reflecting active orders as of 04/09/2025, contained an order dated 10/30/2015 for aspirin 81 milligram (mg), give two tablets by mouth one time a day for coronary atherosclerosis. The Order Summary report also contained an order dated 05/04/2023 for sennosides-docusate sodium 8.6-50 mg, give two tablets by mouth one time a day for bowel care, with instructions to hold for loose stools. Resident #2's 04/2025 MAR revealed the resident's aspirin and sennosides-docusate sodium were scheduled for administration at 8:00 AM each day. An observation of medication administration on 04/09/2025 at 7:05 AM, revealed Registered Nurse (RN) #3 administered one aspirin 81 mg tablet and one sennosides-docusate sodium 8.6-50 mg tablet to Resident #2, instead of two of each tablet as ordered. (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 5 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 04/10/2025 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)