Novato Healthcare Center
NOVATO HEALTHCARE CENTER in NOVATO, CA — inspection on December 31, 2025.
Found 2 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
[Resident 4] reacting. [Resident 4] was later noted with discoloration below lower lip 1.5x [by] 0.5
stated Resident 3 was always ugly towards her. Resident 4 stated Resident 3 would become angry
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.
555844 12/31/2025
Novato Healthcare Center 1565 Hill Road Novato, CA 94947
his work and was informed upon completion that Resident 1 was missing.During a phone interview on
stated she immediately went toward the front of the building and did not see Resident 1 sitting in a
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.