Novato Healthcare Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to prevent one of six sampled residents (Resident 2) from being assaulted when Resident 1 hit Resident 2 on the back of her head.This failure resulted in Resident 2 feeling distressed and had the potential to result in Resident 2 experiencing feelings of fear and anxiety.A

review of Resident 1's admission Record (AR), indicated the facility admitted Resident 1 on 6/19/25 with medical diagnoses which included end stage renal disease (a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products and excess fluid from the blood) and vascular dementia (a type of cognitive decline caused by damage to the blood vessels

in the brain).A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/14/25, indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact.A review of Resident 2's AR indicated the facility admitted Resident 2 on 6/11/24 with medical diagnoses which included peripheral vascular disease (a condition that affects the blood vessels outside of

the heart and brain and involves the arteries in the legs, arms, and feet), dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, and reasoning, severe enough to interfere with daily life), anxiety disorder (disorders characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression (characterized by persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life).A review of Resident 2's MDS, dated [DATE REDACTED] indicated Resident 2's cognitive skills for daily decision making were moderately impaired (inattention/disorganized thinking).A review of Resident 2's Progress Notes, dated 7/24/25, indicated Resident 2 reported to staff an altercation with Resident 1 the night prior, in which Resident [Resident 2] spilled hot chocolate on roommate [Resident 1] and her roommate [Resident 1] in turn smacked the back of her [Resident 2's] head.During an interview on 8/27/25 at 11:30 a.m., with Resident 2,

in the facility dining room, Resident 2 stated she was distressed when Resident 1 hit her.During an

interview on 8/27/25 at 12:00 p.m. with Resident 1 in her bedroom, Resident 1 confirmed she hit Resident 2 and stated Resident 2 deserved it for calling her names.During an interview on 8/28/25 at 3:00 p.m. with the Director of Nursing (DON), the DON stated that there had been recent changes in nursing leadership and facility management. The DON stated improving resident assessment and preparatory care-planning was important to avoid altercations between residents such as this one.During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Management, last revised on 5/30/24, the P&P indicated, Prevention: The facility identifies, corrects and intervenes in situations in which abuse, neglect, exploitation, misappropriation of resident property and/or mistreatment is more likely to occur.

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

unsure if that would prompt a new PASSR process to start.During an interview on 8/28/25 at 2:30 p.m. with

the Director of Nursing (DON), the DON stated there had recently been changes made in the administration and management of the facility; stating the DON, the MDS nurse (MDSN), and admissions staff were working on ensuring potential new residents were accurately screened for mental health and developmental delays. The DON stated for various reasons, Level 1 PASSR's were often not correctly completed by acute care hospitals, and this put facility residents at risk for physical or mental harm. The DON also stated residents who were not appropriately screened for mental or developmental issues might not receive appropriate oversight from the Department of Developmental Services (DDS).During a review of facility policy and procedure (P & P) titled, Pre-admission Screening Resident Review (PASRR), dated 4/25/24, indicated POLICY: The acute care hospital must complete a PASRR Level 1 and coordinate the completion of the Level 2 evaluation (if applicable) prior to admission to the skilled nursing facility. The facility staff will complete a new PASRR upon readmission from the acute care hospital if there has been a significant change in the resident's condition.PURPOSE: to ensure that all residents are screened for mental illness and intellectual disability (ID) or a related condition (RC).

Event ID:

Facility ID:

If continuation sheet