John C. Fremont Healthcare District Dp/SNF

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure dietary services were directed by a qualified Certified Dietary Manager (CDM) for 15 of 15 residents, when the facility CDM's certification expired on 6/1/25. This failure resulted in a lack of oversight by a qualified Certified Dietary Manger, which had the potential risk to affect food safety, infection control practices, and the nutritional well-being of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program when: 1. The Environmental Services Staff (EVSS) failed to handle, store, and process residents' personal clothing to prevent the spread of infection. 2. The facility's written policies and procedures (P&P) for infection prevention and control program (IPCP) -a set of facility's policies and procedures aimed at preventing the spread of infection) was not reviewed annually by the infection control committee members with last reviewed date of 3/8/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective training program for all staff when an Environmental Services Staff did not receive training for proper handling, storing, and processing of residents' personal clothing for more than a year. These failures to follow proper practices in handling, storing, and processing of residents' personal clothing had the potential to result in an increased risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and developing an avoidable facility acquired infection (the invasion of the body by harmful microorganisms). During a concurrent observation and interview on 2/6/26 at 8:51 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedures (P&P) for Medication Administration to meet professional standards of quality for two of six sampled residents (Resident 3 and 13) when Licensed Vocational Nurse (LVN) 1 did not use two resident identifiers prior to administering medications and did not explain the name and indication of the medications being administered for Resident 13 and Resident 3. These failures placed Resident 13 and Resident 3 at risk for medication errors, unrecognized adverse drug reactions, and decrease compliance. During an observation on 2/5/26 at 1:17 p.m. with LVN1, outside Resident 13's room, LVN 1 parked the medication cart, knocked on Resident 13's door and informed Resident 13 she will administer her afternoon medications. LVN 1 started preparing Resident 13's 2:00 p.m. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food stored in the resident refrigerator was consistently monitored and maintained to prevent expired items from being available to residents. This failure affected all 15 residents, as they all received food provided by the facility, and placed them at risk for foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to notify the Office of the State Long-Term Care Ombudsman (an independent official who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preference) of the transfer or discharge for one of one resident sample resident (Resident 2) when Resident 2 was transferred to acute care hospital and discharged from the facility. This failure had the potential for Resident 2 not receiving due process and protection against improper discharge. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled resident (Resident 1) when Resident 1's nutrition care plan for significant weight gain was not developed. This failure resulted in Resident 1 not being assessed for significant weight gain by qualified staff and had the potential for Resident 1 to experience unrecognized negative outcomes including fluid retention, decline in oral intake, worsening of shortness of breath, and decrease in functional mobility. During a concurrent observation and interview on 2/5/26 at 12:15 p.m. with Resident 1, in the dining room, Resident 1 was sitting in a reclining chair, lunch tray was served. Resident 1 was looking at her lunch tray, sitting back on her recliner chair, and was looking around the environment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise a comprehensive person-centered care plan to reflect assessments and interventions to address a significant weight changes for one of four sampled residents (Resident 1) when Resident 1's nutritional care plan was not revised to reflect Resident's 1's significant weight gain of more than five percent in 30 days and continued gradual weight gain. These failures had the potential for Resident 1 not to receive the necessary care and services and put Resident 1 at an increased risk of unintended weight gain. During a concurrent observation and interview on 2/5/26 at 12:15 p.m. with Resident 1, in the dining room, Resident 1 was sitting in a reclining chair, lunch tray was served. Resident 1 was looking at her lunch tray, sitting back on her recliner chair, and was looking around the environment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with the facility's policy and procedures (P&P) Medication Storage to meet professional standards of quality when the medication storage cabinet contained an expired medication with expiration date of 1/2026. This failure had the potential risk for residents to receive expired medications which could result in reduced therapeutic effectiveness, treatment failure and serious health complications. During a concurrent observation and interview on 2/5/25 at 11:03 a.m. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure resident care equipment was maintained in safe and operating condition when the facility's shower chair was not functional to deliver residents' care and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). This failure placed Resident 13 at risk for falls, skin injuries, equipment malfunction, and serious harm during bathing assistance. During a concurrent observation and interview on 2/4/26 at 1:39 p.m. with Resident 13, in Resident 13's room, Resident 13 was sitting on the left side of her bed watching television. Resident 13 was alert and oriented x 4 (names, time, places, and events/situation), pleasant, and well groomed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day, seven days per week, when the facility did not have an RN scheduled to work on weekends (Saturday and Sunday), from [DATE] to [DATE]. The facility did not provide documented evidence of Center for Medicare and Medicaid (CMS-is a federal government agency) approved waiver for this requirement. This failure resulted in an inadequate RN facility staffing and the potential for residents to have their medical needs to go unrecognized by an RN and the potential for serious medical consequences to occur.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (CP -a detailed approach to care customized to an individual resident's needs) for two of five residents (Residents 10 and 14) when Residents 10 and 14 did not have a CP for the used of anti-coagulation medication (medication that prevents blood clots from forming) to monitor for side effects such as bleeding and bruising. This failure had the potential to place Resident 10 and Resident 14 at risk for signs and symptoms of bleeding to go unidentified.

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of practice when: 1. License Vocational Nurse (LVN) 1 during medication administration failed to inform facility residents the names and indications of the medications they are taking for three of eight sampled residents (Resident 3, 6, and 11). This failure had the potential risk for Resident 3, Resident 6, and Resident 11 to not understand the importance of their medication regimen and feelings of being not in control of their health and wellbeing which could lead to noncompliance. 2. Certified Nurse Assistant (CNA) 1's CNA certification expired on [DATE] and the facility scheduled CNA 1 to work and provide direct patient care from [DATE] to [DATE]. This failure had the potential risk to place all facility residents to received unsafe and poor quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) served as the Director of Nursing (DON) and an RN was scheduled and in the facility for at least eight consecutive hours a day, seven days per week when the facility did not have an RN scheduled on 11/15/19 to 10/20/22. The facility did not provide documented evidence of CMS approved waiver for this requirement. This failure resulted in an inadequate RN facility staffing and the potential for residents to have their medical needs to go unrecognized by an RN and the potential for serious medical consequences to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs were stored in accordance with currently accepted professional standards of practice when Licensed Vocational Nurse (LVN) 1 left the medication cart unlocked and unattended. This failure had the potential for unauthorized access to medications and placed residents at risk for actual harm.