Deficiencies (last 4 years)
Deficiencies (over 4 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
Occupancy
Latest occupancy rate
63% occupied
Based on a September 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to assess compliance with Federal, State, and local laws and professional standards following an unusual occurrence involving a resident fall with injury.
Findings
The facility failed to report an incident involving a resident's fall with a skin laceration and hospitalization to the California Department of Public Health as required by state regulation, posing potential risk for negative outcomes.
Deficiencies (1)
F 0836: The facility did not report a resident's fall with a 2 cm skin laceration and hospitalization to the California Department of Public Health as required by state regulation 22 CCR § 72541.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to report resident fall incident |
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
Routine inspection to assess compliance with nursing care competencies, RN staffing, medication management, food safety, hospice care coordination, and equipment maintenance.
Findings
The facility failed to conduct annual competency assessments for licensed nurses, lacked RN coverage on multiple weekends, improperly administered antipsychotic medications without adequate clinical indication, stored medications and food improperly, failed to coordinate hospice care planning, and did not maintain ice machine sanitation.
Deficiencies (8)
F 0726: Facility failed to ensure annual competency assessments were completed for licensed nurses employed more than one year, risking compromised skilled nursing care for 62 residents.
F 0727: Facility failed to have a registered nurse on duty for at least eight consecutive hours on nine weekends during June, July, and August 2023, risking limited nursing assessment and compromised resident safety.
F 0758: Facility administered antipsychotic medications to three residents with Alzheimer's dementia without adequate clinical indication, risking unnecessary drug exposure and adverse effects.
F 0761: Facility failed to label and store drugs and biologicals properly, including medication refrigerator temperatures out of range, expired medications, undated opened products, and non-pharmaceutical items in medication carts.
F 0812: Facility failed to ensure food items in the refrigerator were labeled with use-by dates and maintained sanitary storage conditions, including cluttered walk-in freezer.
F 0813: Facility failed to follow food safety requirements for foods brought by family/visitors, including unlabeled food and not allowing reheating of cold leftovers, risking foodborne illness.
F 0849: Facility failed to coordinate hospice care planning with hospice representatives for one resident, risking lack of person-centered care.
F 0908: Facility failed to maintain the kitchen ice machine in safe and proper working condition, including lack of sanitation per manufacturer instructions, risking foodborne illness.
Report Facts
Residents affected: 62
Weekends without RN coverage: 9
Antipsychotic medication recipients: 3
Expired insulin pens: 2
Expired insulin bottles: 1
Medication refrigerator temperature: 32
Medication refrigerator recommended temperature range: 36
Medication refrigerator recommended temperature range: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Responsible for licensed nurses annual competency evaluation; acknowledged no annual competency assessments were completed |
| Administrator | Administrator | Unaware that licensed nurses competency assessments were not completed |
| Assistant Director of Nursing | Assistant Director of Nursing | Assigned contact with hospice provider; stated hospice did not participate in care planning |
| Social Service Designee | Social Service Designee | Reported hospice provider did not attend care plan conferences due to staffing shortages |
| Dietary Supervisor | Dietary Supervisor | Reported food labeling and freezer clutter issues |
| Licensed Vocational Nurse 14 | Licensed Vocational Nurse | Verified expired medications and non-pharmaceutical items in medication cart |
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
Census: 73
Deficiencies: 5
Date: Sep 26, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for We Care Skilled Nursing - Fremont.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had Advance Directives on file, failure to safeguard resident property, failure to provide baseline care plan summaries to residents, failure to monitor unnecessary drug use, and failure to maintain sanitary food storage conditions.
Deficiencies (5)
F 0578: The facility failed to ensure four residents had Advance Directives on file, risking that their treatment preferences may not be honored if incapacitated.
F 0585: The facility failed to follow its theft and loss program policy when Resident 25's clothing was bleached and discarded without replacement, potentially causing emotional distress.
F 0655: The facility failed to provide Resident 116 and representatives with a summary of the baseline care plan within 48 hours of admission, risking miscommunication of care.
F 0757: The facility failed to monitor Resident 17's use of Ativan for tremors/seizures, risking unnecessary medication and adverse side effects.
F 0812: The facility failed to maintain sanitary food storage by storing brown bananas with unexpired food, risking foodborne illness.
Report Facts
Residents sampled: 24
Residents sampled: 73
Medication dose: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to monitor seizure episodes and care plan instructions |
| Social Services Director | Social Services Director | Interviewed regarding Advance Directive follow-up and theft/loss program |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding laundry damage to Resident 25's clothing |
| 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: 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
Routine
Deficiencies: 6
Date: Aug 9, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, discharge procedures, diagnostic testing, food safety, and emergency preparedness at We Care Skilled Nursing - Fremont.
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)
F 0580: The facility failed to notify the physician of Resident 19's refusal to be weighed on two occasions, delaying potential life-saving treatment.
F 0661: The facility failed to ensure a physician discharge summary was present in the clinical record for Resident 100, risking lack of treatment coordination after discharge.
F 0756: The facility failed to promptly act on the pharmacist's medication regimen review recommendations for Resident 19, potentially delaying treatment and increasing risk of side effects.
F 0777: The facility failed to provide four ordered laboratory tests for Resident 19, risking delayed identification of worsening medical conditions.
F 0812: The facility stored multiple outdated food items in refrigerators, risking food-borne illness.
F 0838: The facility failed to maintain adequate emergency food supplies as specified in the emergency menu, risking insufficient food 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 (LVN) 1 | Interviewed regarding Resident 19's refusal to be weighed and medication regimen review follow-up | |
| Licensed Vocational Nurse (LVN) 3 | Interviewed regarding Resident 19's condition and swelling legs | |
| Director of Nursing (DON) | Confirmed no weights were done for Resident 19 and discussed medication regimen review process | |
| Assistant Medical Record (AMR) | Interviewed about missing discharge summary for Resident 100 | |
| Medical Record Director (MRD) | Interviewed about discharge summary fax process | |
| Consultant Pharmacist (CP) | Interviewed about medication regimen review timelines | |
| Dietary Aide 1 (DA 1) | Interviewed about leftover food storage practices | |
| Dietary Supervisor (DS) | Interviewed about missing emergency food supply items |
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 |
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