Novato Healthcare Center
NOVATO HEALTHCARE CENTER in NOVATO, CA — inspection on September 8, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/08/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Novato Healthcare Center
1565 Hill Road Novato, CA 94947
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/08/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Novato Healthcare Center
1565 Hill Road Novato, CA 94947
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: