Health inspection·December 3, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality and follow its own policies when Certified Nursing Assistant 1 (CNA 1) did not immediately report an incident of falls for one of three sampled residents (Resident 1). As a result, nursing staff did not promptly complete a change of condition assessment.This incident led to a two-day delay in diagnosing Resident 1's left arm fracture possibly caused by the fall, which resulted in an unwarranted postponement of appropriate treatment and pain management for Resident 1.During a review of Resident 1's admission Record (a facility demographic), dated 12/03/25, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Dementia (a condition that affects memory, thinking and behavior).During a review of Resident 1's Minimum Data Set Section C (MDS-an assessment tool), dated 11/14/25, it indicated Resident 1 had a moderately impaired ability to make decisions, had both short-term and long-term memory problems, and was rarely understood.During a review of a facility document titled, Situation, Background, Assessment, Recommendation [SBAR- a simple, structured communication tool used in healthcare to standardize information exchange for patient safety] Communication, dated 11/20/25, it indicated the following, The change in condition, symptoms, or signs observed and evaluated is/are: Edema [swelling] (new or worsening).Left upper arm discoloration and Left forearm swelling with skin tear on Elbow. According to this document, Resident 1 displayed obvious pain, and an immediate X-ray was ordered.During a review of a facility document titled, Novato Healthcare Center Progress Notes, dated 11/21/25, it indicated Resident 1 suffered a broken left humerus (long bone in the upper arm that connects the shoulder to the elbow) with slight displacement and angulation (misalignment and tilting).During a review of the facility document titled, Novato Healthcare Center Interview, dated 11/24/25, it indicated CNA 1 was interviewed by the Assistant Director of Nursing (ADON). During this interview CNA 1 stated she and another staff member assisted Resident 1 in the shower room to change his incontinent brief on 11/18/25, between the hours of 8 p.m. and 9 p.m. During this time, according to this document, Resident 1 was standing but started to fall and grabbed the metal bar attached to the wall, suddenly lowering himself to the floor, then began yelling, kicking and swinging his arms for three to five minutes. According to this document, the two assisting CNA's noted Resident 1 had sustained a skin tear and scratched his left arm after the incident and told Licensed Nurse 1 (LN 1) of these injuries.During a phone interview on 12/3/25 at 12:28 p.m., LN 1 stated that although he was informed that Resident 1 had sustained a skin tear and scratch to his left arm, CNA 1 told LN 1 she was not aware of how Resident 1 got these injuries. LN 1 stated he believed the wounds to be superficial in nature, not requiring any in-dept assessment or treatment other than first aid. LN 1 stated he meant to complete a change of condition assessment, but was busy the night of the incident, and he, forgot. During an interview on 12/03/25 at 3:45 p.m., the Director of Nursing (DON) stated CNA 1 should have communicated all information to LN 1 regarding Resident 1's fall on Residents Affected - Few (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: 555844 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 555844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Novato Healthcare Center 1565 Hill Road Novato, CA 94947 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)