Novato Healthcare Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

into the computer for Resident 1 on 8/18/25. The DON acknowledged Resident 1 received 27 units of insulin lispro on 8/19/25. When asked if this was a medication error, the DON stated, Most possibly. When asked if the facility did a medication error report, she stated, Yes.During an interview on 9/11/25 at 12:59 p.m., Resident 1 stated nobody told her she was given a double dose of insulin in error on 8/19/25.

Resident 1 stated the facility should have informed her because she did not know what happened. Resident 1 further stated she wanted to be notified of her condition.During an interview on 9/11/25 at 1:13 p.m., the DON stated Resident 1 was informed of the medication error which occurred on 8/19/25 by LN E.During an

interview on 9/11/25 at 2:54 p.m., LN E stated had not notified Resident 1 of the medication error that occurred on 8/19/25.A review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, dated 4/1/15, indicated, Purpose.To ensure residents, family, legal representative, and physicians are informed of changes in the resident's condition in a timely manner.The Facility will promptly inform the resident, consult with the resident's attending 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.A significant change in the resident's physical, mental, psychological status.A

review of the facility's P&P titled, Resident Rights-Quality of Life, dated March 2017, indicated, To ensure that each resident receives the necessary care and services to attain on maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Event ID:

Facility ID:

If continuation sheet

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

09/08/2025

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 0760 Level of Harm - Actual harm Residents Affected - Few

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

indicated, . [Resident 1].Medication Involved in Error: Lispro [insulin].Dates Medication Was Administered in Error.8/19/25.Type of Error: Double dose given .Cause of Error: Transcription error.Describe Any Adverse Reaction: Hypoglycemia.Describe event .Two orders were placed for Lispro 12 units. The [LN] who placed duplicate order failed to D.C. [discontinue] the prior order.A review of a facility policy and procedure titled Medication Administration dated 8/19/25, indicated, The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner.

Event ID:

Facility ID:

If continuation sheet

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

09/08/2025

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 0790

Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to assist one resident (Resident 2) of two sampled residents, to obtain dental care to be conducted in a timely manner, after the facility received a letter from a local oral surgery clinic which indicated Resident 2 had to be referred to a hospital to receive the procedure

he needed.This failure decreased the facility's potential to ensure residents received the necessary care and increased Resident 1's potential to experience oral pain and discomfort which could negatively affect his health and well-being. Findings:A review of Resident 2's admission record indicated admission to the facility on [DATE REDACTED] with diagnosis which included heart failure (a chronic condition in which the heart is unable to pump blood as well as it should) and chronic kidney disease (a condition where the kidneys are unable to filter waste from the blood).A review of Resident 2's care plan initiated on 1/27/24 indicted, The resident has oral/dental problems r/t [related to] poor oral hygiene, has likely cavities. The care plan indicated licensed nurses or a social worker were expected to Coordinate arrangements for dental care, transportation as needed/as ordered.A review of Resident 2's referral, dated 5/29/25, to a local oral surgery clinic indicated, Please re-evaluate for full mouth extractions [the removal of all of Resident 2's teeth].A

review of a letter dated 8/8/25 from the local oral surgery clinic indicated, [Resident 2] was seen in our office for a consultation on June 23, 2025. [Resident 2] was referred to our office for full mouth extractions.

After review of [Resident 2's] medical history, it has been decided that he be referred to a hospital with an oral surgery department.A review of Resident 2's progress note dated 9/4/25 at 3:58 p.m., written by a social worker indicated, SS [Social Services] called Denti-Cal [California's Medi-Cal dental program which offers dental benefits to eligible low-income individuals] office in regard to [Resident 2's] teeth extractions.

As [Resident 2] was denied by Denti-Cal prior and also [local oral surgery clinic] and [hospital name] declined the services as well.Informed Ombudsman [a neutral, independent intermediary who investigates complaints to ensure fairness, accountability, and resolution of issues for the public] and [Resident 2's Responsible Party (RP, a person assigned to make healthcare decisions for Resident 2)].During an

interview on 9/24/25 at 4:05 p.m., the Social Services Director (SSD) stated Resident 2 did not have dental pain, but his RP was adamant to have his dental extractions done. The SSD stated Licensed Nurse C (LN C) called the hospital to request if Resident 2's procedure could be done because it was now a nurse's responsibility to find a location to conduct Resident 2's procedure. The SSD stated she would look for a progress note written by LN C regarding when LN C contacted the hospital and the hospital's response.

During an interview on 9/25/25 at 4:30 p.m., the Administrator (ADM) stated he would look for a referral to

the hospital which was declined.During a telephone interview on 9/26/25 at 9:50 a.m. with the ADM, SSD, and the facility's social worker, the ADM stated he was unable to find any documentation that a formal referral was sent to the hospital. The ADM stated the SSD or the facility's social worker were responsible for arranging the appointment for Resident 2's dental care needs. A review of the facility's policy and procedure titled, Oral Healthcare and Dental Services, dated 7/14/17, indicated, .Assisting Residents with Dental Appointments.The Social Service Staff/Designee is responsible for assisting with arranging necessary dental appointments.All requests for routine and emergency dental service should be directed to the Social Service Staff/Designee to ensure that appointments are made in a timely manner. Social Service will document extenuating circumstances that led to delayed referrals.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet