Novato Healthcare Center

In the surveyor’s words

From the most serious findings on record at Novato Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 4, 2026

  Based on interviews and record reviews, the facility failed to protect one of three resident's sampled for abuse (Resident 1), right to remain free from physical abuse when Certified Nursing Assistant 1 (CNA 1), ignored Resident 1's verbalizations of pain during transfer, requests for CNA 1 to stop cleaning Resident 1, and Resident 1's tears while CNA 1 continued to provide incontinence care. This failure caused Resident 1 to experience pain, feel scared, vulnerable, and treated like an object. […]

• Actual harm, isolatedF760Sep 8, 2025

  Based on interviews and record reviews, the facility failed to ensure one resident (Resident 1) of two sampled residents was free of a significant medication error when a double dose of insulin lispro (a fast-acting, man-made insulin (a hormone that regulates blood sugar allowing it to be used by our body as energy) used to treat diabetes) was administered by licensed nurses on the morning of 8/19/25.This failure resulted in Resident 1 having a hypoglycemic (when blood sugar level reaches a low level) episode in which she became unresponsive. […]

• Actual harm, isolatedF600Apr 25, 2025

  Based on observations, interviews, and record reviews, the facility failed to protect one resident (Resident 1) from physical abuse by Resident 2, when Resident 2 struck Resident 1 on the head with a coffee cup which shattered into small pieces. This failure resulted in Resident 1 being sent to the hospital Emergency Department (ED) for evaluation and treatment of a head injury. Findings: A review of Resident 1's Admission Record, indicated he was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Sep 5, 2023

  Based on interviews and record reviews, the facility failed to identify risks, evaluate, and analyze risks and implement interventions to reduce risk when the facility did not provide physical supervision to prevent avoidable accident for one out of three sampled residents (Resident 1), while he was eating his sandwich alone in his room. This failure resulted to Resident 1 choking on his sandwich. Due to this choking incident, Resident 1 was sent to the hospital twice. Resident 1 was then diagnosed with multiple rib fracture which resulted to Resident 1 experiencing shortness of breath (SOB, the frightening sensation of being unable to breathe normally or feeling suffocated), desatting (a term used to mean that saturations (oxygen levels) are dropping) and complaining of 10 out of 10 pain… […]

• Actual harm, isolatedF626Mar 18, 2022

  Based on observation, interview and record review, the facility failed to follow its own policies & procedures when one of three sampled residents (Resident 1) was not allowed to return to the facility, after being taken into police custody for a few hours, without any prior notices of pending discharge. As a result, Resident 1 was hospitalized twice, and left homeless without health care services, medications, shelter or food, placing his life at serious risk for harm and death. Findings: Record review revealed Resident 1 was admitted to the facility on [DATE], with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]