Health inspection·December 29, 2025

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 interview and record review, the facility failed to provide medications as ordered by the prescriber, when two residents (Resident 1 and Resident 2) of three sampled residents received their medications late on two days.This failure decreased the facility's potential to prevent serious health consequences including worsening symptoms, disease progression, and increased risk of complications.Findings:A review of Resident 1's admission record, dated 12/19/25, indicated Resident 1 was admitted with diagnoses that included trigeminal neuralgia (a chronic pain condition causing sudden, severe, electric shock-like pain in the face, affecting the trigeminal nerve) and syndrome of inappropriate secretion of antidiuretic hormone (a condition that causes excessive water retention in the kidneys).During a concurrent interview and record review on 12/20/25 at 3:10 p.m. with the Director of Nursing (DON), Resident 1's Medication Admin Audit Reports dated 12/20/25-12/21/25 were reviewed. The report indicated Resident 1 had the following medications scheduled for 12/20/25 and 12/21/25 at 4 p.m.:- Gabapentin Oral Capsule (used to relieve chronic nerve pain) 100 MG (milligrams, a unit of weight) Give 2 capsules by mouth three times a day for trigeminal neuralgia;- Keppra(R) Oral Tablet (an anticonvulsant used as an add-on therapy for chronic nerve pain) 500 MG Give 1 tablet by mouth two times a day for trigeminal neuralgia;- Flomax(R) Oral Capsule (used to promote urine flow) 0.4 MG Give 1 capsule by mouth two times a day for urinary retention;DULoxetine HCL Oral Capsule Delayed Release Sprinkle (an antidepressant used to relieve symptoms of various chronic pain conditions) 30 MG Give 1 capsule by mouth two times a day for trigeminal neuralgia; and,- IamoTRIgine Oral Tablet (used to treat trigeminal neuralgia) 100 MG Give 1 tablet by mouth two times a day for trigeminal neuralgia.Further review of the report indicated the five medications had an Administration Time of 5:09 p.m. on 12/20/25, and 5:33 p.m. on 12/21/25. The DON stated medications were supposed to be administered within an hour of schedule, and confirmed Resident 1's 4 p.m. gabapentin, Keppra(R), Flomax(R), duloxetine, and Iamotrigine were given late on 12/20/25 and 12/21/25.A review of Resident 2's admission record, dated 12/25/25, indicated Resident 2 was admitted with diagnoses that included bilateral osteoarthritis of the hip (degenerative joint disease of both hip joints characterized by deep ache or sharp pain), benign prostatic hyperplasia (or BPH, an enlarged prostrate that causes difficulty peeing) and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls).During a concurrent interview and record review on 12/20/25 at 3:26 p.m. with the DON, Resident 2's Medication Admin Audit Reports dated 12/28/25-12/29/25 were reviewed. The report indicated Resident 2 had the following medications scheduled for 12/28/25 and 12/29/25 at 8 p.m.:- Diclofenac Sodium External Gel 1% (used to relieve pain) Apply to affected areas topically (to the skin) four times a day for pain. Apply 2 grams of gel to affected area 4 times daily;- Atorvastatin Calcium Oral Tablet (used to lower bad cholesterol and fats) 40 MG Give 1 tablet by mouth at bedtime; and,- Tamsulosin HCl Oral Capsule (used to improve urine flow) 0.4 MG Give 1 capsule by mouth at bedtime for BPH.Further review of the report indicated the Page 1 of 2 056215 056215 12/29/2025 Northbrook Healthcare Center 64 Northbrook Way Willits, CA 95490

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some three medications had an Administration Time of 10:18 p.m. on 12/28/25, and 9:27 p.m. on 12/29/25. The DON confirmed the 8 p.m. medications were given late. The DON stated the atorvastatin and tamsulosin might have been given late as both were labeled at bedtime but added both should have been given within an hour of 8 p.m., as it was it was scheduled as such. The DON stated medications must be administered as ordered, as risks for not following the scheduled for these medications could affect the adequacy of Resident 1 and 2's pain control, and could worsen their urinary symptoms.A review of the facility's policy titled, MEDICATION ADMINISTRATION - GENERAL GUIDELINES, dated May 2022, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices. FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. Medications are administered within 60 minutes of schedule time. 056215 Page 2 of 2