Northbrook Healthcare Center
64 Northbrook Way, Willits, CA 95490 · Mendocino County · 70 certified beds · avg 38 residents/day · certified since Apr 1, 1973
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 5, 2025 · F-0604 · triggered by a complaint
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 27, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (25)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 30, 2026 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 30, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 30, 2026 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Jan 30, 2026 | E · Potential for harm, repeated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 30, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 29, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 10, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 5, 2025 | ▲ G · Actual harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Mar 27, 2023 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 27, 2023 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Mar 27, 2023 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Mar 27, 2023 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Mar 27, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 27, 2023 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Mar 27, 2023 | F · Potential for harm, facility-wide | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Mar 27, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 27, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Mar 27, 2023 | E · Potential for harm, repeated | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Mar 27, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 14 | 0 | F |
| 2025 | 4 | 1 | G ▲ |
| 2026 | 7 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $9,295.
| Date | Type | Amount / length |
|---|---|---|
| Mar 5, 2025 | Fine | $9,295 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.01 | 4.31 | 3.95 | bottom 42% in California; top 39% in the U.S. |
| Registered Nurse hours | 0.37 | 0.61 | 0.69 | bottom 25% in California; bottom 17% in the U.S. |
| Weekend total nurse staffing | 3.58 | 3.90 | 3.50 | bottom 37% in California; top 38% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.29 | 0.51 | 0.48 | bottom 32% in California; bottom 30% in the U.S. |
| Total nursing staff turnover (%) | 42.4 | 36.7 | 45.8 | bottom 32% in California; top 43% in the U.S. |
| RN turnover (%) | 0.0 | 38.1 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.04, RN 0.37, weekend 3.61. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 01/30/2006 |
| Caretrust GP LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/15/2001 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/15/2001 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 11/15/2001 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/15/2001 |
| Gamble, Shawndee | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/15/2001 |
| Gamble, Shawndee | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/15/2001 |
| Gamble, Shawndee | Individual | ADP of the SNF | NOT APPLICABLE | 11/15/2001 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/11/2025 |
| Rao, Seema | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2024 |
| Rao, Seema | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2024 |
| Rao, Seema | Individual | ADP of the SNF | NOT APPLICABLE | 04/01/2024 |
| Twomagnets LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/2002 |
| Twomagnets LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2002 |
| Willits Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/15/2001 |
| Willits, Adam | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your policy on physical restraints, and what alternatives do you try first?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "How do you track each resident's food allergies and preferences, and what happens if they don't like what's served?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
No other Medicare-certified nursing homes within 20 miles in the current records.
Facility data as of CMS processing date 2026-08-01. CCN 056215.