Health inspection·December 31, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1's room on 12/30/25 at 1:15 p.m., Resident 1 recalled the incident and stated Resident 2 was moving his nightstand and stealing his water. Resident 1 stated he hit Resident 2 with his pillow to make him stop.During an observation in Resident 2's room on 12/30/25 at 2:33 p.m., Resident 2 was lying on his side in bed. Resident 2 made eye contact but would not speak.During an interview in the Administrator's office on 12/30/25, at 3:47 p.m., the Administrator (ADM) stated he substantiated the allegation of resident-to-resident abuse between Resident 1 and Resident 2.During a phone interview on 12/31/25, at 3:10 p.m., Certified Nursing Assistant 1 (CNA 1) stated when he started his shift on 12/14/25, he heard a resident saying Stop followed by soft thuds. Upon locating the room, CNA 1 witnessed Resident 1 strike Resident 2 in the upper body with a pillow multiple times. Resident 2 had his arms up as though to protect himself. CNA 1 stated he was able to remove Resident 1 from Resident 2's bedside with the help of LN 1.2. A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (final stage of kidney failure in which the kidneys have lost 85-90% of their function and can no longer filter out waste or balance fluid effectively enough without medical intervention).A review of Resident 3's MDS, dated [DATE], indicated a BIMS score of 13 of 15 which indicated no cognitive impairment. An MDS dated [DATE] indicated Resident 3 had demonstrated delusional (firmly held beliefs contrary to reality) behaviors and had verbally threatened, screamed at, or cursed at others.A review of Resident 3's Care Plans indicated the following goals and interventions:A care plan dated 7/7/25 indicated Resident 3 was confabulating stories about the staff. The goal was to reduce confabulation statements. To reach this goal, staff were to provide support with active listening.A care plan dated 7/23/25 indicated Resident 3 had an altercation with another resident. The goal was for Resident 3 to have no change in routine. To achieve this goal, the Social Services team would follow up as needed.A care plan dated 8/12/25 indicated Resident 3 was placed on 1:1 (when a staff member is exclusively assigned to a patient) monitoring due to a negative interaction with another resident. The goal was for Resident 3 to have minimal opportunity for verbal arguments or physical contact with other residents, specifically during smoking times. To achieve this goal, a 1:1 staff member was assigned during the morning and evening shifts and off set Resident 3's smoking schedule. A psychological consultation was advised.A review of Resident 4's admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following a cerebral infarction affecting the left side, Muscle Weakness, and Parkinson's Disease (a brain disorder characterized by involuntary movements).A review of Resident 4's MDS, dated [DATE], indicated a BIMS score of 14 of 15 which indicated no cognitive (process of acquiring and understanding) impairment. This MDS also indicated Resident 4 was completely dependent on staff or required maximum assistance for staff to complete all activities of daily living which included hygiene and eating due to her medical condition.A review of Resident 3's Progress Notes dated 12/16/25at 11:24 p.m., indicated LN 1 witnessed Resident 3 and Resident 4 engaged in a verbal dispute. LN 1 stated Resident 4 reported to her that Resident 4 became upset after Resident 3 turned off a bedside fan. Resident 4 tossed a full bottle of a nutritional supplement at Resident 3, which landed on Resident 3's face. Resident 3 picked up the bottle and tossed it back towards Resident 4, and the bottle landed on Resident 4's face.A review of Resident 3's IDT Note dated 12/17/25 at 12:43 p.m., indicated, During a follow up investigation [Resident 3] revised her statement. This time she stated that [Resident 4] started the incident by calling her a ‘bitch', saying ‘you're a whore' and ‘your kids don't like you'. [Resident 3] then says [sic] she saw the PM [evening] supervisor at the nursing desk and told him what was going on however, the PM supervisor head the incident while doing rounds and intervened. [Resident 3] also stated that ‘I was on my (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555844 If continuation sheet Page 2 of 5 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 12/31/2025 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete bedside when she threw it.' When asked about the curtain she stated it was open. However, staff normally keeps the curtain pulled to the foot of bed to provide for privacy. [Resident 3] also stated that the ‘Lady [Resident 4] screams for no reason and always calls me a bitch and a whore.' This behavior has not been observed or heard by staff even though [the door to the room] is facing nursing desk and is the first room from nursing station. [Resident 3] has a behavior problem of fabricating stories that she is being disrespected by peers and staff. [Resident 4]'s version remains consistent, saying [Resident 3] came into her section.'turned off my fan and then began going through my stuff.'.[Resident 3] Hit me in the head with a bottle.' Due to these considerations, it is possible.[Resident 3] was the aggressor with [Resident 4] reacting. [Resident 4] was later noted with discoloration below lower lip 1.5x [by] 0.5 cm [centimeters, a unit of measurement] which may have happened during altercation.During a concurrent observation and interview in Resident 4's room on 12/30/25 at 2:10 p.m., Resident 4 stated Resident 3 was always ugly towards her. Resident 4 stated Resident 3 would become angry with her for turning on her own TV and would cuss [curse] me out. She stated on 12/16/25, Resident 3 turned off her TV and took her remote, so Resident 4 began to yell at her to return the remote. Resident 4 denied throwing anything at Resident 3 and stated, I have one good hand, and that is weak. Resident 4's left arm and hand was observed to be contracted. Resident 4 further stated, But she took my bottle of [nutritional supplement] and threw it at me. It hit my face. Resident 4 also stated Resident 3 would attempt to scare Resident 4 every day by standing at her bedside and raising her arm as though to hit her. Resident 4 stated it made her mad. Resident 4 was noted to have increased respirations while she recounted this event.During an interview in Resident 3's room on 12/30/25, at 2:21 p.m., Resident 3 stated that as she was entering her shared room with Resident 4 on 12/17/25, Resident 4 threw a full bottle which landed on her cheekbone. Resident 3 further stated, It started because [Resident 4's] TV was so loud. I tried to take her remote, that's when she got the bottle of [nutritional supplement] to hit me. Resident 3 admitted throwing the bottle back at Resident 4, which landed on her face.During an interview in the ADM's office on 12/30/25 at 3:47 p.m., the ADM stated he substantiated the allegation of resident-to-resident abuse between Resident 3 and Resident 4.During an interview in the ADM's office on 12/30/25 at 3:53 p.m., the Social Worker (SW) stated Resident 3 had a history of hitting other residents. The SW noted there were different stories from each resident, but Resident 4 had a bruise to her lower lip which she stated likely came from the nutritional supplement bottle.During a review of the facility's policy titled Abuse Prevention and Management, revised on 5/30/24, indicated, Abuse is defined as the willful, deliberate infliction of injury.During a review of the facility's policy titled Resident Rights-Quality of Life, revised on March 2017, indicated the purpose of the policy was, To ensure each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being. Event ID: Facility ID: 555844 If continuation sheet Page 3 of 5 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 12/31/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision for one resident (Resident 1) out of a sampled 6 residents when staff were unaware that Resident 1 eloped from the facility.This failure decreased the facility's potential to prevent serious injury, harm, or death to Resident 1.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Aphasia (damage to the brain's language center affecting the ability to communicate) following Cerebral Infarction (stroke), Muscle Weakness, Unsteadiness on feet, and a history of falling.A review of Resident 1's Elopement Evaluation, dated 11/23/25, indicated Resident 1 had a history of elopement and wandering which flagged Resident 1 at risk for exiting the facility unnoticed.A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 11/28/25, indicated Resident 1 completed the activity of walking 50 feet with two turns with supervision or guard assistance. Due to safety concerns, Resident 1 was not assessed to walk 150 feet, walk 10 feet on uneven surfaces, or go up or down on a curb. This MDS also indicated Resident 1 used a walker or wheelchair for mobility. A review of Resident 1's Care Plan, dated 11/23/25, indicated Resident 1 was at risk for wandering/elopement. Resident 1's goal was to maintain safety and staff were expected to implement the following activities to meet this goal:Engage Resident 1 in purposeful activity;Place a wandering device on Resident 1and check the presence of the device every shift;Monitor Resident 1's whereabouts every 15 minutes; and,Identify wandering/elopement de-escalation behaviors.A review of a Situation, Background, Assessment and Recommendation (SBAR- a standardized communication framework used by healthcare professionals to convey critical information accurately) form dated 12/12/25 at 3 p.m., indicated Licensed Nurse 1 (LN 1) was notified Resident 1 was outside the facility. LN 1 had checked the front of the building to search for [Resident 1] and did not find [Resident 1]. [LN 1] went inside and checked [Resident 1's] room and dining room. [Resident 1] was still not found. [LN 1] went outside once again to look for [Resident 1] .and found [Resident 1] walking down the street. LN 1 redirected [Resident 1] back into facility. [Resident 1] was found uninjured.A review of a progress note dated 12/12/25 at 6:15 p.m., the Social Worker (SW) indicated Resident 1 had no recollection of leaving the facility.During a concurrent observation and interview in Resident 1's room on 12/30/25 at 12:06 p.m., Resident 1 did not recall eloping from the facility. Resident 1 stated he was unsure why his room was changed but would like to return to his previous room.During an interview at the nurse's station on 12/30/25 at 12:16 p.m., LN 2 stated Resident 1 was transferred into the alarmed unit (a unit for residents who were at high risk for elopement) on 12/30/25 after breakfast. LN 2 stated he witnessed Resident 1 walk to the alarmed set of closed double doors to peer out the window.During an interview on 12/30/25 at 4 p.m., the Director of Nursing (DON) stated staff should check all residents' wandering devices for placement and functionality daily. This monitoring should be documented on the Medication Administration Record (MAR). It was placed on the MAR to remind staff the residents were wearing a wandering device and needed closer monitoring. The DON reviewed Resident 1's MAR dated November 2025 and confirmed Resident 1 did not have documentation to indicate his wandering device was being monitored.During an interview at the front desk on 12/31/25 at 10:11 a.m., the receptionist stated she witnessed Resident 1 walk out the front doors on 12/12/25. She stated the alarm sounded so she turned off the alarm, checked on Resident 1, and saw that he was walking towards a lounge placed at the left front of the building. When Resident 1's Certified Nursing Assistant (CNA 1) came out of the building, the receptionist went back into the facility to resume her work.During a phone interview on 12/31/25 at 10:45 a.m., CNA 1 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555844 If continuation sheet Page 4 of 5 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 12/31/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete he was made aware Resident 1 was outside at the front of the facility. CNA 1 went to the front of the facility and attempted to persuade Resident 1 to come back inside but Resident 1 refused. CNA 1 then went back into the facility to inform Resident 1's nurse of his refusal to come back inside. CNA 1 stated he then resumed his work and was informed upon completion that Resident 1 was missing.During a phone interview on 12/31/25at 11:02 a.m., LN 1 stated she was informed Resident 1 was in front of the facility, sitting in a lounge chair by CNA 1. CNA 1 told her he could not persuade Resident 1 to come back inside. LN 1 stated she immediately went toward the front of the building and did not see Resident 1 sitting in a lounge chair. LN 1 then looked in Resident 1's room and the Dining Room and asked LN 3 for assistance in locating Resident 1. LN 1 and LN 3 each drove their own vehicles in opposite directions to search for Resident 1. LN 1 stated Resident 1 was found at a public intersection approximately 0.8 miles from the facility. LN 1 stated she did not inform the Administrator (ADM) or DON of the elopement until Resident 1 was found. LN 1 also stated she did not make a facility announcement upon discovery of Resident 1's elopement. A review of the facility's policy titled Wandering and Elopement, dated 1/31/23, indicated, If Facility Staff observes a resident leaving the premises unaccompanied or without having followed proper procedures, he/she may.Get help from other Facility Staff in the immediate vicinity.If the resident exits the facility despite efforts to stop the resident, a staff member will accompany or follow the resident to ensure the resident's safety until assistance arrives. The Facility Staff member who finds that a resident is missing will alert Facility Staff. The Charge Nurse will make an announcement in the facility and organize a search. Event ID: Facility ID: 555844 If continuation sheet Page 5 of 5