Novato Healthcare Center

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

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

bedside when she threw it.' When asked about the curtain she stated it was open. However, staff normally keeps the curtain pulled to the foot of bed to provide for privacy. [Resident 3] also stated that the ‘Lady [Resident 4] screams for no reason and always calls me a bitch and a whore.' This behavior has not been observed or heard by staff even though [the door to the room] is facing nursing desk and is the first room from nursing station. [Resident 3] has a behavior problem of fabricating stories that she is being disrespected by peers and staff. [Resident 4]'s version remains consistent, saying [Resident 3] came into her section.'turned off my fan and then began going through my stuff.'.[Resident 3] Hit me in the head with

a bottle.' Due to these considerations, it is possible.[Resident 3] was the aggressor with [Resident 4] reacting. [Resident 4] was later noted with discoloration below lower lip 1.5x [by] 0.5 cm [centimeters, a unit of measurement] which may have happened during altercation.During a concurrent observation and

interview in Resident 4's room on 12/30/25 at 2:10 p.m., Resident 4 stated Resident 3 was always ugly towards her. Resident 4 stated Resident 3 would become angry with her for turning on her own TV and would cuss [curse] me out. She stated on 12/16/25, Resident 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.

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

12/31/2025

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

he was made aware Resident 1 was outside at the front of the facility. CNA 1 went to the front of the facility and attempted to persuade Resident 1 to come back inside but Resident 1 refused. CNA 1 then went back into the facility to inform Resident 1's nurse of his refusal to come back inside. CNA 1 stated he then resumed his work and was informed upon completion that Resident 1 was missing.During a phone

interview on 12/31/25at 11:02 a.m., LN 1 stated she was informed Resident 1 was in front of the facility, sitting in a lounge chair by CNA 1. CNA 1 told her he could not persuade Resident 1 to come back inside.

LN 1 stated she immediately went toward the front of the building and did not see Resident 1 sitting in a lounge chair. LN 1 then looked in Resident 1's room and the Dining Room and asked LN 3 for 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.

Event ID:

Facility ID:

If continuation sheet