Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a failure by the facility to comply with reporting requirements after a resident's fall resulting in a skin laceration and hospitalization.
Findings
The facility failed to report an unusual occurrence involving Resident 1's fall and head laceration to the California Department of Public Health as required by state regulations, despite the resident being hospitalized and returned to the facility the next day.
Deficiencies (1)
Failure to report an unusual occurrence (fall with skin laceration and hospitalization) to the California Department of Public Health as required by state regulation.
Report Facts
Laceration size: 2
Time paramedics arrived: 334
Time resident fell: 316
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to report incident to CDPH |
Inspection Report
Routine
Census: 62
Deficiencies: 8
Date: Sep 1, 2023
Visit Reason
The inspection was conducted to evaluate compliance with nursing competency assessments, RN staffing, medication management, food safety, hospice care coordination, and equipment maintenance at We Care Skilled Nursing - Fremont.
Findings
The facility failed to conduct annual competency assessments for licensed nurses, lacked RN coverage on multiple weekends, improperly managed psychotropic medications for residents with dementia, failed to store and label medications and food properly, did not coordinate hospice care planning with hospice providers, and did not maintain the ice machine according to manufacturer instructions.
Deficiencies (8)
Failure to ensure annual competency assessments for licensed nurses employed more than one year.
Failure to have a Registered Nurse on duty for at least eight consecutive hours for nine weekends during June, July, and August 2023.
Failure to ensure residents were free from unnecessary psychotropic drugs without adequate clinical indication.
Failure to label and safely store drugs and biologicals, including expired medications and improper temperature control of medication refrigerators.
Failure to store food under sanitary conditions, including unlabeled food items and cluttered walk-in freezer.
Failure to follow food safety requirements for foods brought by family/visitors, including unlabeled and improperly stored food and lack of reheating procedures.
Failure to coordinate care planning with hospice providers for residents receiving hospice services.
Failure to maintain ice machine in safe and proper working condition and to sanitize it per manufacturer instructions.
Report Facts
Residents affected by competency assessment deficiency: 62
Weekends without RN coverage: 9
Sampled residents with psychotropic medication issues: 3
Expired insulin pens found: 2
Expired insulin bottles found: 1
Food items unlabeled in refrigerator: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding medication refrigerator temperature and psychotropic medication use. |
| LVN 14 | Licensed Vocational Nurse | Interviewed regarding RN coverage, medication cart inspection, and food safety. |
| DON | Director of Nursing | Interviewed regarding competency assessments, RN coverage, medication storage, and hospice care coordination. |
| ADON | Assistant Director of Nursing | Interviewed regarding food safety and hospice care coordination. |
| DS | Dietary Supervisor | Interviewed regarding food storage and ice machine maintenance. |
| Admin | Administrator | Interviewed regarding ice machine maintenance and RN staffing. |
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding RN coverage and resident behavioral symptoms. |
| LVN 3 | Licensed Vocational Nurse | Interviewed regarding resident behavioral symptoms. |
| LVN 12 | Licensed Vocational Nurse | Mentioned in personnel file review for competency assessments. |
| LVN 11 | Licensed Vocational Nurse | Mentioned in personnel file review for competency assessments. |
| RN 1 | Registered Nurse | Mentioned in personnel file review for competency assessments. |
| RN 2 | Registered Nurse | Mentioned in personnel file review for competency assessments. |
| IP | Infection Preventionist | Mentioned in personnel file review for competency assessments. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 26, 2019
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident rights, care planning, medication management, food safety, and other facility policies.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had advance directives on file, inadequate safeguarding of resident property, failure to provide baseline care plan summaries to residents, lack of monitoring for unnecessary drug use, and improper food storage practices. These deficiencies had the potential to cause minimal harm or emotional distress to residents.
Deficiencies (5)
Failure to ensure residents had an Advance Directive on file for four sampled residents.
Failure to follow theft and loss program policy to safeguard a resident's property when clothing was bleached and not replaced.
Failure to provide a summary of the baseline care plan to one resident and their representatives within 48 hours of admission.
Failure to ensure one resident was free from unnecessary drugs by not monitoring Ativan administration for seizure behavior.
Failure to serve food under sanitary conditions due to storage of brown bananas with unexpired food.
Report Facts
Residents sampled: 24
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding Advance Directive follow-up and theft/loss program |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan instructions and medication monitoring |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding bleached clothing incident |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food storage and inspection practices |
| Admission Director | Admission Director | Interviewed regarding Advance Directive process at admission |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 9, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for a skilled nursing facility, including medication management, discharge procedures, diagnostic testing, food safety, and emergency preparedness.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident treatment refusals, lack of physician discharge summaries, delayed pharmacist medication regimen review follow-up, failure to provide ordered laboratory tests, improper storage of outdated food items, and inadequate emergency food supplies.
Deficiencies (6)
Failure to notify the physician of Resident 19's refusal to be weighed, potentially delaying life-saving treatment.
Failure to ensure physician discharge summary was in the clinical record for Resident 100, risking lack of treatment coordination after discharge.
Failure to promptly act upon pharmacist's medication regimen review recommendations for Resident 19, risking delayed treatment and serious side effects.
Failure to provide ordered laboratory tests for Resident 19, potentially delaying identification of worsening medical condition and treatment.
Failure to store food under sanitary conditions with multiple outdated food items found in refrigerators, risking food-borne illness.
Failure to maintain adequate emergency food supply as specified in the facility's emergency menu, risking inadequate food supplies during emergencies.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 1
Residents affected: 1
Outdated food items: 6
Missing emergency food items: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding Resident 19's refusal to be weighed and medication regimen review follow-up |
| Licensed Vocational Nurse 3 | LVN | Observed Resident 19's condition during inspection |
| Director of Nursing | DON | Confirmed no weights were done for Resident 19 and discussed medication regimen review process |
| Assistant Medical Record | AMR | Interviewed regarding missing discharge summary for Resident 100 |
| Medical Record Director | MRD | Interviewed regarding discharge summary fax process |
| Consultant Pharmacist | CP | Interviewed regarding medication regimen review timelines |
| Dietary Aide 1 | DA 1 | Interviewed about food storage and leftover food policies |
| Dietary Supervisor | DS | Interviewed about emergency food supply deficiencies |
Viewing
Loading inspection reports...
