Novato Healthcare Center: Screening Failures Put Residents at Risk - CA
The acknowledgment came during an inspection on August 28, 2025, triggered by a complaint. The Director of Nursing said the failures were happening for "various reasons," and that the screenings, known as Pre-Admission Screening and Resident Review evaluations, or PASSR, were often not being correctly completed by the acute care hospitals sending residents to the facility.
The process exists for a specific purpose: to make sure that anyone moving into a skilled nursing facility has been evaluated for mental illness, intellectual disability, or a related condition before they arrive. A resident who clears an initial screening moves through without further review. A resident who raises flags during that first evaluation is supposed to receive a more thorough second-level assessment before admission is allowed to proceed.
What inspectors found was that the system had been breaking down at the front end, and staff at Novato Healthcare Center were uncertain about what to do when it did.
The Director of Nursing described a facility in the middle of administrative and management changes, with the nursing director, the MDS nurse, and admissions staff all working to get the screening process back on track. The concern wasn't hypothetical. The Director of Nursing told inspectors that residents who slipped through without proper screening might not receive appropriate oversight from the California Department of Developmental Services, the state agency responsible for supporting people with developmental disabilities.
That oversight gap is the consequence that makes the paperwork failure something more than a paperwork failure. A resident with an unidentified intellectual disability or serious mental illness, placed in a skilled nursing environment without the supports or supervision their condition requires, is a resident whose needs may go unmet entirely.
The facility's own written policy, last updated in April 2024, states clearly that the acute care hospital must complete the initial screening and coordinate any required second-level evaluation before a resident is admitted. It also requires staff to complete a new screening when a resident returns from a hospital stay if their condition has changed significantly. Inspectors found staff who were unsure whether a given situation would require that process to restart.
The deficiency was cited at a level of minimal harm or potential for actual harm, meaning inspectors determined that residents had not yet suffered documented injury as a direct result of the screening gaps, but that the conditions created real risk.
The Director of Nursing did not dispute the problem. She named it plainly: incomplete screenings put residents at risk.
What remains unresolved is how many residents passed through admissions during the period when the process was failing, and whether any of them are now living at Novato Healthcare Center without the mental health or developmental disability supports their conditions require. The inspection report does not say. The facility's acknowledgment that changes in administration contributed to the breakdown does not say how long those changes had been underway, or how far back the screening failures go.
A resident with an undiagnosed or unaccommodated developmental disability does not necessarily look like a compliance gap from the outside. They may look like someone who is difficult, or confused, or not adjusting well to the facility. The screening process exists precisely because those distinctions matter, and because getting them wrong has consequences that don't show up in a chart until something goes wrong.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Novato Healthcare Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 10, 2026 · Our methodology
NOVATO HEALTHCARE CENTER in NOVATO, CA was cited for violations during a health inspection on August 28, 2025.
The acknowledgment came during an inspection on August 28, 2025, triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.