Health inspection·August 28, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) received a federally required PASSR (Preadmission Screening and Resident Review - a federal requirement ensuring individuals with serious mental illness, intellectual disabilities, or related conditions are not inappropriately placed in Medicaid-certified nursing facilities and receive appropriate services) evaluation.This failure excluded Resident 3 from a complete mental health evaluation for appropriate facility placement, and non-receipt of available mental-health resources from the California Department of Developmental Services (DDS).A review of Resident 3's, admission Record (AR), indicated Resident 3 was originally admitted to the facility on [DATE], with medical diagnoses which included metabolic encephalopathy (the brain does not function properly due to underlying metabolic disturbances) cognitive communication deficit (difficulty with communication skills that results from impaired thinking abilities, such as memory, attention, and executive functions like planning and organization), and schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations [false perceptions of sensory experiences] or delusions[false beliefs]).A review of Resident 3's Minimum Data Set (MDS-An assessment tool) dated 7/22/25 indicated Resident 3's Brief Interview of Mental Status (BIMS-a tool used in nursing homes and long-term care facilities to assess and monitor cognitive function [the mental processes human brains use to acquire, store, process, and utilize information], with scores ranging from 0 to 15, where higher scores indicate better cognitive function) score of 12, indicating moderate cognitive impairment.A review of Resident 3's MDS-I (active diagnoses), dated 7/17/25 indicated Resident 3's current medical diagnoses included schizophrenia (a mental disorder characterized variously by hallucinations, delusions, disorganized thinking or behavior).A review of Resident 3's, Order Summary Report, dated 8/28/25, indicated Resident 3 currently received Zyprexa 5 milligrams (A medication to treat mental health conditions such as schizophrenia and bipolar disorder) one time a day for schizophrenia manifested by hallucinations.A review of Resident 3's California Department of Health Care Services (DCHS) PASSR Level 1 Screening, dated 7/28/25, indicated Resident 3 was diagnosed with a serious mental illness and was receiving psychotropic (drugs that affect a person's mental state) medications. This document indicated a PASSR Level 2 (its purpose is to confirm a diagnosis, determine if a nursing facility stay is medically necessary, and identify if the individual requires specialized services beyond what the facility normally provides. The evaluation helps ensure people are not inappropriately placed in nursing homes and receive services in the most integrated setting possible) screening was required.A review of DHCS mail correspondence to the facility, dated 8/02/25, indicated a PASSR level 2 was not completed for Resident 4 due to Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level 1 screening.During an interview on 8/28/25 at 1:45 p.m. with the MDS Nurse (MDSN), she stated PASSR's were filled out by acute care hospitals as a requirement before admissions to long-term care facilities. The MDSN stated it was his responsibility to ensure PASSR's were completed correctly but he had only been in this professional role for about a month. When asked if and when a PASSR would need to be corrected by the facility, the MDSN was unsure at first. After consulting with management, the MDSN stated PASSR's would be redone during annual MDS completion, if there was a change in the resident's condition, or when it was required by Medicaid (a public health insurance program which provides needed health care services for low-income individuals). When asked what would be done if a new resident presented with symptoms of a mental illness that was not reflected in the PASSR, the MDSN stated the resident would be referred for a psychiatric consult, but the MDSN was Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555844 If continuation sheet Page 2 of 3 Printed: 05/15/2026 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 555844 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2025 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete unsure if that would prompt a new PASSR process to start.During an interview on 8/28/25 at 2:30 p.m. with the Director of Nursing (DON), the DON stated there had recently been changes made in the administration and management of the facility; stating the DON, the MDS nurse (MDSN), and admissions staff were working on ensuring potential new residents were accurately screened for mental health and developmental delays. The DON stated for various reasons, Level 1 PASSR's were often not correctly completed by acute care hospitals, and this put facility residents at risk for physical or mental harm. The DON also stated residents who were not appropriately screened for mental or developmental issues might not receive appropriate oversight from the Department of Developmental Services (DDS).During a review of facility policy and procedure (P & P) titled, Pre-admission Screening Resident Review (PASRR), dated 4/25/24, indicated POLICY: The acute care hospital must complete a PASRR Level 1 and coordinate the completion of the Level 2 evaluation (if applicable) prior to admission to the skilled nursing facility. The facility staff will complete a new PASRR upon readmission from the acute care hospital if there has been a significant change in the resident's condition.PURPOSE: to ensure that all residents are screened for mental illness and intellectual disability (ID) or a related condition (RC). Event ID: Facility ID: 555844 If continuation sheet Page 3 of 3