Novato Healthcare Center
Inspection Findings
F-Tag F0550
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-11-13.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0558
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2025-11-13.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0578
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-11-13.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
disciplines who discuss resident care needs and concerns and usually consists of Director of Nursing, Administrator, Social Services) was notified regarding issues with Resident 172's hygiene and feeding.
During a concurrent interview and record review on 9/18/25, at 3:04 p.m., LN 8 stated Resident 172 was able to voice her needs and requests and had no behaviors of rejection of care, except occasional refusals to get out of bed. LN 8 stated Resident 172's functional abilities declined in the summer and the resident required one-on-one assistance with feeding due to risks for aspiration (the entry of foreign material into the windpipe or lungs). LN 8 stated the resident was eating her breakfast unassisted on 8/10/25 when she administered her medications around 9:30 a.m., and was still working on her breakfast at 11:30 a.m., when
the resident's daughter came. LN 8 stated that Resident 172's daughter was very upset that the resident was not assisted with feeding, had food all over her, and was soiled. LN 8 agreed that eating food that was sitting in resident's room for several hours was unsafe and could cause food poisoning.
During an interview with CNA 6 on 9/19/25, at 11:15 a.m., CNA 6 stated Resident 172 had difficulties with communication but was able to verbalize her needs. CNA 6 stated the resident's condition worsened later in
the summer and the resident became more dependent on staff with turning, hygiene and cleaning. CNA 6 stated that Resident 172 was at risk for aspiration and required one-on-one assistance with feeding and to have her head of bed elevated 30 minutes after the feeding. CNA 6 stated that resident's family visited the resident on weekends and voiced her concerns with mother's personal care. CNA 6 explained, One time daughter complained that she found her mother not assisted with feeding. mother was very messy, soaking wet and soiled.
During an interview with Regional MDS Director (RMDS) on 9/19/2025 at 11:23 a.m., confirmed that he was in the facility on 8/10/25 and discussed Resident 172's daughter's concerns with her mother's care.
RMDS stated he met the resident's daughter in her mother's room, emotional and upset. RMDS stated the daughter was very concerned with her mother's wellbeing, and stated that her mother was not cared for and not cleaned that day.Was soiled and wet.Upset that resident was not supposed to eat by herself and was not assisted with feeding and attempted to eat by herself.
During a concurrent interview and record review with DON on 9/18/25, at 12:15 p.m., the DON reviewed Resident 172's nursing progress note dated 8/10/25. The DON stated, We are responsible that residents receive quality care. The DON added the expectation for staff was to provide personal care, clean, and change the resident every two hours or more often as needed, especially for residents that are dependent
on staff assistance.
A review of the facility's 'Dining Program' policy dated 1/30/25 indicated the purpose of the policy was To ensure that the facility serves meals.provides residents with adequate supervision and/or assistance with meals.Process: Nursing staff will provide assistance as needed to those residents who have difficulty or are unable to feed themselves.Residents will be monitored by nursing staff.to ensure assistance if needed.
A review of the facility's policy titled, Incontinence Care, dated 9/2014, indicated, Residents who are incontinent of urine, feces, or both, will be kept clean, dry and comfortable.Incontinence care is provided when the resident is wet or soiled.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
11/13/2025
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-Tag F0679
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2025-11-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide activities to meet all resident's needs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0686
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-11-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0692
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-11-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0697
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0697 during a standard health inspection conducted on 2025-11-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0726
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0726 during a standard health inspection conducted on 2025-11-13.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0757
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-11-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0759
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-11-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0760
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-11-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0761
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-11-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0802
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0802 during a standard health inspection conducted on 2025-11-13.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0804
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0804 during a standard health inspection conducted on 2025-11-13.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0812
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-11-13.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0880
F 0880
bag to protect it and keep it clean.
Level of Harm - Minimal harm or potential for actual harm
During an interview on 9/19/25 at 8:26 a.m. with the Infection Preventionist (IP), reviewed that CPAP mask was observed in a resident's room laying uncovered on a nightstand. The IP stated the CPAP mask should be in a bag to protect from germs and keep it clean.
Residents Affected - Some
- 9. A review of Resident 10's admission Record indicated Resident 10 was admitted to the facility in July
2025 with multiple diagnoses including fracture of left femur (bone of the upper leg), chronic respiratory failure (lungs are unable to exchange oxygen and carbon dioxide effectively), chronic obstructive pulmonary disease (lung disease that blocks air flow making it difficult to breathe) and dementia (impairment of brain functions causing memory loss and impaired judgement).
A review of Resident 10's MDS, dated [DATE REDACTED], indicated Resident 10 had a BIMS score of 8 out of 15 that indicated Resident 10 had moderate cognitive impairment.
A review of Resident 10's orders indicated an order dated 7/21/25, .Administer oxygen at 2 L [liters] per minute via nasal cannula to maintain O2 [oxygen] saturation between 88-92% [level of oxygen in the blood] .
During an observation on 9/16/25 at 10:20 a.m., of Resident 10's room, observed oxygen concentrator (machine to supply oxygen) with humidifier. Observed oxygen tubing was not labeled with the date changed.
During a concurrent observation and interview on 9/17/25 at 9:29 a.m. with Resident 10, observed Resident 10 with oxygen via nasal cannula. Observed oxygen tubing was not labeled with date changed.
Resident 10 stated he does not know when the tubing was changed that he does not pay attention.
During a concurrent observation and interview on 9/17/25 at 9:35 a.m. with LN 15, LN 15 confirmed that Resident 10's oxygen tubing was not labeled with date changed. LN 15 stated the tubing should be labeled with date changed. LN 15 stated that the tubing should be changed every night shift.
During an interview on 9/18/25 at 2:07 p.m. with the Director of Nursing (DON), reviewed that Resident 10's oxygen tubing was not labeled with the date changed The DON stated the oxygen tubing should be labeled with the date changed.
A review of the facility's Policy & Procedure (P&P) titled Oxygen Therapy, revised 11/17, indicated .To ensure the safe storage and administration of oxygen in the facility .Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed .
A review of the facility's P&P titled Infection Control - Policies & Procedures, revised 1/1/12, indicated .To provide infection control policies and procedures required for safe and sanitary environment .Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard precautions .
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0908
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0908 during a standard health inspection conducted on 2025-11-13.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Keep all essential equipment working safely.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
F-Tag F0919
Federal health inspectors cited NOVATO HEALTHCARE CENTER in NOVATO, CA for a deficiency under regulatory tag F-F0919 during a standard health inspection conducted on 2025-11-13.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure that a working call system is available in each resident's bathroom and bathing area.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 19 deficiencies cited during this inspection of NOVATO HEALTHCARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-29.
NOVATO HEALTHCARE CENTER in NOVATO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in NOVATO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NOVATO HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.