Fremont Healthcare Center

Inspectors wroteBased on interview and record review for two of three sampled residents (Resident 1 and Resident 2), the facility failed to follow their policies and procedures (P&P) for reporting to appropriate agencies the physical altercation on 2/24/26, between Resident 1 and Resident 2. The facility failed to confirm reported physical altercation between Resident 1 and Resident 2 was received by the licensing agency and local agency in a timely manner. This failure to report promptly resulted in:1. Potential to negatively impact the protection of residents from abuse. 2. Licensing agency unaware of the physical altercation between Resident 1 and Resident 2 until after the receipt of facility's Abuse Investigation Summary on 2/27/26. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure two (Resident 68 and 79) of five sampled residents were free from unnecessary drugs when: 1. Resident 68 with diagnosis of non-Alzheimer's dementia was administered Haloperidol (Haldol an antipsychotic medication) for hitting and grabbing, an inadequate indication for use. Facility did not address Resident 68's involuntary jerky movements as an adverse reaction for the use of Haldol. Facility did not attempt gradual dose reduction (GDR) for Resident 68 use of Haldol. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide staff supervision for five sampled residents (Resident 99, 11, 20, 24 and 91 during smoking to ensure an environment free of accident hazards. This failure had the potential to cause fire hazards, injuries, and jeopardize the health and safety of the residents. During an observation on 9/16/25 at 10:15 a.m. Resident 99 smoking a cigarette outside her room by the sliding door leading to the smoking patio. There was an oxygen tank filled with oxygen beside her bed (Bed D) in her room, and an oxygen concentrator with oxygen in her space next to Bed C. Certified Nursing Assistant (CNA) 5 confirmed that Resident was smoking. On approaching Resident 99, Resident 99 quickly put out the cigarette and dropped the cigarette butt on the ground already with two cigarette butts. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the Registered Dietitian (RD) and Certified Dietary Manager (CDM) had the necessary skill sets to carry out the functions of the food and nutrition service when:1. There was not an effective system in place to ensure the sanitation and food safety of the food services areas.2. There was not an effective system in place to ensure adequate training, competence and regular monitoring of dietary staff work practices. During an interview on 9/15/25 at 9:45 a.m., the CDM stated she had been the Director of Food and Nutrition Services since 2021. During an interview with the Registered Dietitian on 9/15/25 at 9:54 a.m., she stated she had worked at the facility for one year. [...]

Inspectors wroteBased on observation, staff interviews, and record reviews, the facility failed to ensure sufficient competent dietary services staff to consistently meet professional standards of practice for safe food preparation and service when:Staff did not clean fixed equipment (equipment that cannot be cleaned in a dishwasher, or the 3-compartment sink such as counters, carts, and refrigerators) according to manufacturer's instructions and professional standards of practice and the equipment was not sanitary. Staff did not consistently perform professional standards of practice to minimize the risk of cross-contamination. Staff did not puree foods according to recipe and diet manual specifications. Staff did not complete ambient food cooling logs consistently. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure food provided to residents was palatable (refers to the flavor and taste of food) and served at a safe and appetizing temperature when1. Four out of 97 residents sampled stated the food did not taste good.2. Three out of 97 residents sampled stated hot food was not served hot. These deficiencies had the potential to result in decreased resident satisfaction with meals, food safety issues, and decreased resident meal intakes that could lead to weight loss and malnutrition. Review of a policy titled Nutrition Care, Subject: Residents Rights, dated 2023, showed Residents have the right to: be served food per their individual preferences, within restrictions imposed by the diet; refuse any food items and receive an appropriate food substitute; refuse their therapeutic diets; [...]

Inspectors wroteBased on observation, staff interviews, record reviews, and meal testing, the facility failed to ensure that pureed diets were prepared according to the facility's diet manual requirements for 20 of 97 sampled residents who received pureed diets. This deficient practice had the potential to cause swallowing difficulty and choking risk for residents requiring pureed diets for their safety. Review of the facility diet manual, titled Diet Manual for Rehabilitation, Residential, and Long Term Care Communities, Nutrition Therapy Essentials, dated 2023, showed it was reviewed and approved by the facility's Registered Dietitian on 2/5/25. Review of the section titled Puree showed the diet was indicated for individuals who had dysphagia (difficulty swallowing) for reasons such as stroke, head trauma, or Alzheimer's disease. All foods should be smooth and pureed to the consistency of pudding. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure sanitation in the kitchen when: 1. The kitchen was not sanitary or well maintained.2. Food was not stored according to professional standards of practice.3. The Equipment was not maintained clean.4. Staff did not consistently perform their duties according to professional standards of practice to avoid cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).5. Resident food in the resident refrigerator was not adequately or consistently labeled and dated to ensure food safety and resident satisfaction.6. Ambient food cooling was not consistently documented7. Contaminated rags were left unattended in random areas of the kitchen. [...]

Inspectors wroteBased on observation interviews and record review, the facility failed to ensure food that was brought in from outside sources and belonged to residents was properly stored under sanitary conditions when:1. The resident refrigerator was not clean.2. Nine of 24 food items observed did not have proper labeling or dating.3. Nursing staff were unsure of the facility's policy and procedure regarding residents' food brought from outside sources, and the policy was not followed.4. One resident stated they had financial loss because their food recently purchased was discarded from the refrigerator. This failure had the potential to place residents at risk for foodborne illness, cross-contamination and financial loss for residents when their personal food was removed from the refrigerator. (cross-reference F812). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control practices when the following were observed:1. 1. Housekeeper (HK) 1 used non-EPA (Environmental Protection Agency- responsible for the protection of human health and the environment) approved cleaning solution to disinfect floors. 2. 2. Registered Nurse (RN) 2 did not wash and dry hands thoroughly before, during and after Resident 83's wound therapy.3. 3. RN 2 did not use sterile gloves when holding a moist surface over the wound during Resident 83's wound care treatment. These failures had the potential for spread of infections among residents at the facility.1. During a concurrent observation and interview on 9/15/25 at 10:07 a.m. with HK 1, HK 1 was observed mopping floors. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure adequate and effective maintenance of the kitchen, and preventive maintenance of the kitchen's equipment when:1. The physical plant of the kitchen such as walls, floors, doors and air gaps were not maintained in a manner to promote ease of cleaning, sanitation and food safety (Cross Reference F812).2. Refrigerator and freezer units were not well-maintained and had damaged gaskets, condensation, icicles and ice buildup, mold growth on one refrigerator door, and grime on condenser fans and covers.3. Manufacturer's instructions were not followed for cleaning the ice machine.4. There was not an effective preventive maintenance system or documentation in place to ensure proper function and life of the equipment in the kitchen. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a comfortable work environment for staff working in the kitchen when kitchen air temperatures exceeded the acceptable range for air temperatures on two observed days. This failure had the potential to result in staff heat exhaustion, cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of food and equipment from staff sweat, and the potential to impede safe and appealing food temperatures for food safety and resident satisfaction. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Abuse policy and procedures to investigate, and report to local, state, and federal agencies suspected incident of resident allegation of abuse for one (Resident 14) of three sampled residents when Resident 14 screamed out during a visit with three facility staff and Resident 14 called 911. This failure had the potential to place Resident 14 at risk for emotional distress, mistreatment, neglect or abuse. During a review of Resident 14's Annual Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 4/23/25, the MDS indicated Resident 14's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - mental health assessment tool) was completed for one resident out of two sampled residents (Resident 36)This failure placed Resident 36 at risk of not receiving care and services appropriate to her needs. During a review of Resident 36's admission record undated, the admission record indicated Resident 36 was originally admitted on [DATE] and readmitted on [DATE]. During a review of the Minimum Data Set (MDS - an assessment tool to guide care) dated 6/12/25, the MDS section I indicated Resident 36 had a diagnosis of psychotic disorder. During a review of Resident 36 's care plan dated 2/21/25, the care plan indicated Resident 36 with mental illness/psychosis Dx (diagnosis) of schizophrenia with behavioral management interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 35, Resident 69, and Resident 5) were assisted with Activities of Daily Living (ADLs, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) when: 1. Resident 35 had long and chipped fingernails; 2. Resident 69 had long fingernails with black matter underneath; 3. Resident 5 did not received showers as scheduled. These failures resulted in Resident 5 feeling upset; and placed Resident 69 and Resident 35 at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, distribute, and serve food under sanitary conditions when: 1. Multiple food items in freezer #1 and freezer #2 were opened and undated. 2. Food items in freezers #1 and #2 had expired. 3. Multiple individually packaged food items in an opened box in the dry storage had expired. 4. Freezer #3 was not clean. 5. The three-compartment sink was not clean. 6. One scoop from the clean drawer for scoops was not clean. This failure had the potential to cause cross contamination and an outbreak of food borne illness to 90 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the infection prevention and control policy to prevent spread of infection when: 1) Clean personal clothing of residents was not covered and were stored exposed in the laundry room. 2) Housekeeping Staff (HSK) 1 did not perform hand hygiene after cleaning resident rooms and did not perform hand hygiene before entering and exiting room and touched multiple high touch surface areas in resident rooms. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the dignity and privacy of one of 28 sampled residents (Resident 92), when Resident 92's entire back side of body was exposed in the hallway while Certified Nursing Assistant was transferring Resident 92 from shower room. This failure had the potential to negatively affect Resident 92's self-esteem and cause embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 70 and Resident 42) environment remained free of accident hazards when housekeeping staff placed a bedsheet in the bathroom floor in front of the toilet. This deficient practice had the potential to place Resident 70 and Resident 42 at risk for falls and possible injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents for one of three sampled residents (Resident 73) when buspirone (medication that treats anxiety) was not available for medication administration. This failure had the potential to result in ineffective medication regimen and Resident 73 suffering from unnecessary anxiety.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that its medication error rates are less than five percent when four medication errors were observed out of 26 opportunities. The medication error rate was calculated as follows: four divided by 26 then multiplied by 100, which was equal to 15 percent. This failure had the potential to result in ineffective medication regimen for the affected residents (Residents 73 and 74).

Inspectors wroteBased on interview and record review, the facility failed to inform one of two sampled residents (Resident 1) of the applicable Medicaid items and services, specifically bed availability, when Resident 1 became Medicaid eligible. The failure to provide Resident 1 and Resident 1 ' s Representative 1 (RR 1) with accurate information about potential charges resulted in Resident 1 ' s premature discharge home with the need for hospitalization two days after discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functional bathroom sink for the use of one (Resident 8) of 12 sampled residents. This failure resulted in Resident 8 being unable to maximize her independent performance of activities of daily living (ADL, activities such as eating, dressing, personal hygiene, locomotion).

Inspectors wroteBased on interview and document review, the facility failed to transmit the completed annual assessments for three residents (Residents 21, 25, and 26), and failed to transmit the quarterly assessments for 19 residents of 26 residents (Residents 6, 16, 11, 7, 17, 14, 29, 19, 8, 18, 28, 13, 9, 15, 23, 24, 10, 22, 12) within required timeframes. This failure resulted in lack of monitoring of quality measures and resident status with a potential for inadequate care plan revision and care provision.

Inspectors wroteBased on observation and interview, the facility failed to keep the environment free from accident hazards when: 1. The facility hallways' flooring from room [ROOM NUMBER] to room [ROOM NUMBER] was warped and had adhesive tape applied to the warped flooring. This failure created a tripping hazard for 29 of 29 residents who could ambulate. 2. One (Resident 119) of two sampled residents who smoked, stored smoking materials (cigarettes and lighter) on his person. This failure had the potential to result in physical injury to Resident 119 or other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when: 1. Refrigerator #1 had: a. An opened bag of English muffins and an opened bottle of soy sauce were not labeled with opened-on dates. b. An open tub on the top shelf, collected water leaking from a rusted evaporator. c. The bottom shelf had a box of raw, unwashed cabbage. On top of the box of cabbage was a tray of ready-to-serve sliced pies. Adjacent to the box of cabbage and stacked sliced pies was an opened carton of thawing, raw, chicken leg quarters. 2. Refrigerator# 5 had: a. Rusty interior walls. b. An opened bottle of soy sauce was not labeled with an opened-on date. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to support one (Resident 120) of 12 sampled residents in the development of a person-centered care plan which incorporated his cultural preferences when the facility failed to honor Resident 120's request for a male certified nursing assistant (CNA) to help him with his personal hygiene in accordance with his religious beliefs. This failure resulted in Resident 120 not receiving a shower for three weeks which made him feel angry and frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice to assess and treat itchy rashes on the feet of one (Resident 13) of 12 sampled residents. This failure resulted in Resident 13 having physical and mental discomfort from intense itching and scratching her feet to the point of causing breaks in the skin and had the potential to result in a foot infection due to Resident 13's increased risk of foot infection from having diabetes mellitus. (Diabetes mellitus is a chronic condition resulting in increased blood sugar levels.)

Inspectors wroteBased on interview and record review, for one (Resident 119) of two residents who smoked, the facility failed to complete a smoking care plan. This failure had the potential to result in unsafe smoking practices which resulted in injury to residents or property.

Inspectors wroteBased on observation and interview, the facility failed to post daily staffing information in a prominent place readily accessible to residents and visitors. This failure had the potential to result in the lack of information for residents and family about facility's staffing.