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 Page 1 of 2 555844 555844 12/03/2025 Novato Healthcare Center 1565 Hill Road Novato, CA 94947

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11/18/25, and Resident 1 most likely would have been assessed and treated immediately.A review of the facility policy and procedure (P & P) titled Fall Management Program, dated 2022, indicated, the facility will maintain an environment free of accidental hazards, provide adequate supervision, and assistive devices to prevent avoidable accidents.and robust post-fall management .fall: an event in which a person inadvertently comes to rest on the ground, floor, or lower level but not as a result of an overwhelming external force.A review of the facility P & P titled, Change of Condition Notification, dated 2022, indicated, the facility will promptly inform the resident, consult with the resident's Physician, and notify the resident's legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by but not limited to: a. an accident.A review of the facility document titled, CNA Job Description, dated 3/14/25, indicated, General Duties and Responsibilities.Report bruises, skin tears, incidents or accidents to the Charge Nurse immediately. 555844 Page 2 of 2