Deficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 17, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to follow its Abuse policy and procedures to investigate and report a suspected incident of resident abuse involving Resident 14.
Complaint Details
The complaint investigation was triggered by Resident 14's allegation of abuse during a visit with three staff members, which led Resident 14 to call 911. The investigation found the facility did not investigate or report the incident as required. Resident 14 was found to have intact cognition and capacity to make decisions. The complaint was substantiated by the failure to follow policy.
Findings
The facility failed to properly investigate and report an alleged abuse incident involving Resident 14, who screamed during a visit with staff and called 911. Interviews and record reviews revealed conflicting accounts from staff and the administrator, and no investigation or reporting was conducted despite policy requirements.
Deficiencies (1)
Failure to follow Abuse policy and procedures to investigate and report suspected resident abuse involving Resident 14.
Report Facts
Resident sample size: 3
Resident 14 BIMS score: 15
Date of incident interview: Interviews conducted on 9/15/25, 9/16/25, and 9/17/25.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident 14 | Resident | Alleged victim of abuse and key interviewee. |
| SSA | Social Services Assistant | Staff member involved in the incident and interview. |
| AD | Activities Director | Staff member involved in the incident and interview. |
| IP | Licensed Vocational Nurse/Infection Preventionist | Staff member involved in the incident and interview. |
| RN1 | Registered Nurse/Unit Manager | Witnessed staff leaving Resident 14's room after screaming but did not inquire further. |
| Admin | Administrator | Heard Resident 14 scream, interacted with police, but did not investigate or report the incident. |
| MD1 | Medical Doctor | Confirmed Resident 14's capacity to make decisions and no medical distress. |
Inspection Report
Routine
Deficiencies: 13
Date: Nov 17, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to medication use, abuse investigation, PASRR screening, smoking safety, dietary services, infection control, equipment maintenance, and resident safety.
Findings
The facility was found deficient in multiple areas including improper use of psychotropic medications, failure to investigate abuse allegations, incomplete PASRR screening, inadequate supervision during smoking, insufficient dietary staff training and sanitation, improper food preparation and storage, poor infection control practices, inadequate maintenance of kitchen equipment and environment, and unsafe kitchen air temperatures.
Deficiencies (13)
Failure to prevent use of unnecessary psychotropic medications and failure to attempt gradual dose reduction for Resident 68.
Failure to respond appropriately to alleged abuse and failure to investigate and report suspected abuse for Resident 14.
Failure to complete Preadmission Screening and Resident Review (PASRR) for Resident 36.
Failure to provide adequate supervision to prevent accident hazards related to smoking for multiple residents.
Failure to employ sufficient staff with appropriate competencies and skills in dietary services, resulting in unsanitary kitchen conditions and inadequate food safety practices.
Failure to provide sufficient support personnel to safely and effectively carry out food and nutrition service functions, including proper food preparation and sanitation.
Failure to ensure food is palatable, attractive, and served at safe and appetizing temperatures, with resident complaints about bland and cold food.
Failure to ensure pureed diets were prepared according to facility diet manual requirements, resulting in inconsistent texture and potential choking risk.
Failure to procure food from approved sources and to store, prepare, distribute and serve food in accordance with professional standards, including unsanitary kitchen conditions, improper food storage, and unattended contaminated rags.
Failure to have a policy regarding use and storage of foods brought to residents by family and visitors, resulting in improperly stored and labeled resident food and financial loss.
Failure to provide and implement an effective infection prevention and control program, including use of non-EPA approved disinfectants and improper wound care practices.
Failure to keep all essential kitchen equipment working safely, including poor maintenance of kitchen physical plant, refrigerators, freezers, ice machine, and lack of preventive maintenance system.
Failure to ensure a safe, easy to use, clean and comfortable nursing home area, with kitchen air temperatures exceeding acceptable range causing discomfort and potential safety risks.
Report Facts
Medication doses: 3
Inspection dates: Nov 17, 2025
Temperature: 88.5
Temperature: 90.5
Refrigerator temperature: 46.4
Refrigerator temperature: 44.5
Refrigerator temperature: 46.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Did not wash hands properly and did not use sterile gloves during wound care for Resident 83 |
| HK 1 | Housekeeper | Used non-EPA approved cleaning solution to mop floors |
| CDM | Certified Dietary Manager | Responsible for dietary staff training and kitchen sanitation; acknowledged kitchen sanitation issues |
| RD | Registered Dietitian | Conducted monthly kitchen inspections and identified sanitation and food safety issues |
| DM | Director of Maintenance | Responsible for maintenance of kitchen equipment and physical plant; acknowledged maintenance deficiencies |
| IP | Infection Preventionist | Provided infection control education and identified improper cleaning and wound care practices |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 1, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident dignity, activities of daily living assistance, accident hazard prevention, pharmaceutical services, medication administration, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to protect resident dignity and privacy during transfers, inadequate assistance with activities of daily living for some residents, environmental hazards increasing fall risk, medication errors including unavailable medications and improper inhaler administration, unsanitary food storage and preparation conditions, and lapses in infection prevention practices such as improper hand hygiene and uncovered clean resident clothing.
Deficiencies (7)
Failed to protect the dignity and privacy of one resident when the resident's back was exposed in the hallway during transfer.
Failed to assist three residents with activities of daily living including nail care and showering as scheduled.
Failed to maintain environment free of accident hazards when bedsheet was placed on bathroom floor posing fall risk.
Failed to provide pharmaceutical services meeting resident needs when buspirone was unavailable and medication administration errors occurred.
Failed to ensure medication error rates were below 5 percent; observed 15 percent error rate including improper inhaler administration.
Failed to store, distribute, and serve food under sanitary conditions including expired and undated food items, dirty freezers, and unclean utensils.
Failed to implement infection prevention and control program; observed uncovered clean resident clothing and housekeeping staff not performing hand hygiene properly.
Report Facts
Residents sampled: 28
Medication error rate: 15
Medication doses missed: 6
Residents affected: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nursing Assistant | Named in finding related to failure to protect resident dignity and privacy during transfer |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding dignity, privacy, and fall hazard findings |
| CNA 8 | Certified Nursing Assistant | Named in finding related to failure to assist resident with nail care |
| Unit Manager 2 | Unit Manager | Interviewed regarding responsibility for nail care |
| Registered Nurse 2 | Registered Nurse | Interviewed regarding nail care for Resident 35 |
| Director of Staff Development | Director of Staff Development (DSD) | Interviewed regarding shower documentation and ADL reports |
| CNA 7 | Certified Nursing Assistant | Interviewed regarding failure to provide shower to Resident 5 |
| CNA 1 | Certified Nursing Assistant | Observed and interviewed regarding bedsheet hazard in bathroom |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse (LVN) | Interviewed regarding medication administration and buspirone unavailability |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse (LVN) | Observed and interviewed regarding inhaler medication errors |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food storage and sanitation deficiencies |
| Registered Dietician | Registered Dietician (RD) | Interviewed regarding food safety and sanitation |
| Housekeeping Staff 1 | Housekeeping Staff (HSK) | Observed and interviewed regarding hand hygiene lapses |
| Laundry Staff | Laundry Staff (LS) | Interviewed regarding uncovered clean resident clothing |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection control practices and hand hygiene |
| Maintenance Supervisor | Maintenance Supervisor (MS) | Interviewed regarding importance of hand hygiene |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 115
Deficiencies: 1
Date: Feb 28, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to inform a resident and their representative about Medicaid coverage and bed availability, which allegedly led to the resident's premature discharge and subsequent hospitalization.
Complaint Details
The complaint investigation found that Resident 1 was not informed about Medicaid bed availability and potential charges, leading to premature discharge despite the resident's and representative's wishes to remain. The resident was hospitalized two days after discharge due to serious health issues.
Findings
The facility failed to provide accurate information to Resident 1 and their representative about Medicaid coverage and bed availability, resulting in Resident 1's premature discharge despite a request to remain for custodial care. Resident 1 was hospitalized two days after discharge due to health complications.
Deficiencies (1)
Failure to give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Report Facts
Beds occupied: 103
Beds available: 5
Total licensed beds: 115
Hemoglobin level: 6.4
Blood pressure: 84/55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Case Manager | Interviewed regarding Resident 1's discharge and insurance coverage | |
| Resident 1's Representative (RR 1) | Interviewed regarding discharge and care decisions |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Dec 16, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Fremont Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to honor a resident's religious preference for a male CNA resulting in lack of showering, inoperable bathroom sink affecting resident hygiene, delayed transmission of resident assessments, inadequate foot care for a diabetic resident, environmental hazards such as warped flooring and unsafe smoking practices, failure to post nurse staffing information, and food safety violations including improper food storage and unsanitary equipment.
Deficiencies (8)
Failed to support Resident 120's preference for a male CNA for personal hygiene, resulting in no shower for three weeks.
Failed to provide a functional bathroom sink for Resident 8, limiting her ability to perform personal hygiene.
Failed to transmit completed annual and quarterly resident assessments within required timeframes for multiple residents.
Failed to provide appropriate foot care for Resident 13, resulting in intense itching and risk of infection.
Failed to keep environment free from accident hazards including warped flooring creating tripping hazard and unsafe storage of smoking materials by Resident 119.
Failed to post daily nurse staffing information in a prominent place accessible to residents and visitors.
Failed to store food in accordance with professional standards including unlabeled opened food, raw food stored improperly, rusty refrigerator walls, unsanitary ice machine, and peeling plate covers.
Failed to complete a smoking care plan for Resident 119 despite assessment indicating need.
Report Facts
Residents with overdue MDS transmissions: 23
Residents sampled: 12
Residents affected by warped flooring: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 2 | CNA | Reported Resident 120's preference for male CNA and frustration due to lack of male CNA availability. |
| Unit Manager | UM | Reviewed care plans and was unaware of Resident 120's preference for male CNA; also reviewed Resident 13's records. |
| Maintenance Director | MD | Reported on warped flooring, sink repairs, and ice machine sanitation issues. |
| Administrator | ADM | Provided information on sink repair timing and staffing coordinator vacancy. |
| Licensed Vocational Nurse 2 | LVN | Assisted with MDS assessments and reported backlog. |
| Director of Nursing | DON | Reported on MDS transmission responsibility and lack of smoking care plan for Resident 119. |
| Licensed Vocational Nurse 1 | LVN | Observed and reported on Resident 13's foot rashes and treatment. |
| Treatment Nurse | TN | Acknowledged lack of knowledge about Resident 13's foot rashes and intention to request physician order. |
| Director of Food and Nutrition Services | DFNS | Observed food storage and sanitation issues in kitchen. |
| Dietary Aide | DA | Reported on refrigerator leaks and food deliveries. |
| Director of Staff Development | DSD | Reported staffing information was kept in binder, not posted. |
| Occupational Therapist | OT | Reported on tripping hazard due to warped flooring. |
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