We Care Skilled Nursing - Fremont

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a safe environment by not monitoring visitors entering and exiting the facility. This failure potentially compromised the safety of the residents. During a phone interview with Resident 1's Family Member (FM) 1 on 3/20/26 at 2:35 p.m., FM1 stated that she had observed visitors entering and leaving the facility without checking in or out at the front lobby desk. FM 1 stated she was concerned about her mother's safety. During a review of Resident 1's admission record indicated the resident was admitted on [DATE] with diagnoses that included anxiety disorder. During a concurrent observation and interview on 3/23/26, at 9:30 a.m., with the Director of Nursing (DON), in the facility lobby, visitors were observed entering and exiting the facility without signing in or out at the front reception desk. [...]

Inspectors wroteBased on observation, interview and records review the facility failed to ensure to keep one of three sample selected residents (Resident 1) privacy when, resident was taking shower, and the bathroom door was opened by staff multiple times. This deficient practice could result in causing Resident 1 to experience emotional distress, a loss of dignity, and a breakdown of trust in caregivers, potentially leading to anxiety, depression, or withdrawal from necessary medical care. A review of Resident 1's admission Record, printed on 1/15/2026, the admission record indicated Resident 1 was admitted to the facility in September 20205 with multiple diagnosis including Subacute Osteomyelitis (a serious infection and inflammation of the bone) right ankle and foot. During an interview on 1/15/26 At 9: 35 a.m. [...]

Inspectors wroteBased on interview, record review and observation, facility failed to be comply with Federal, State, and Local Laws and Professional Standards for one of three sample selected residents (Resident 1) when resident 1 had unusual occurrence (Fall), skin laceration and hospitalization and the facility did not follow the state regulation (22 CCR S 72541) to report the incident to the California Department of Public Health (CDPH). This deficient practice has the potential to result in negative outcomes for residents including actual harm, serious injury, a decline in quality of life, and putting residents at high risk of similar, potentially more severe, future incidents. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnosis including muscle weakness. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice in four of four sampled residents (Residents 58, 44, 66 and 274) when: 1. PRAFO boot (Pressure Relief Ankle Foot Orthosis - a device worn on the ankle and foot to help manage foot and ankle issues) was not applied to Resident 58 as ordered by a physician. 2. Resident 44's lips were dry, cracked, peeling and tongue had thick build-up of whitish matter. 3. Resident 274 did not receive preferred as needed and scheduled pain medication in a timely manner. These failures had the potential to cause physical discomfort and emotional distress to Residents 58, 44, and 274.

Inspectors wroteBased on observation, interview and record review, for one of one sampled resident (Resident 51) reviewed for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care, the facility failed to ensure phosphate binder (medication that binds/attaches to some of the phosphates in food, reducing one's blood phosphorus levels) was administered as ordered by the physician. This failure had the potential to result in increased blood phosphorus (mineral) levels.

Inspectors wroteDuring a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility in September 2024 with diagnoses that included diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function properly), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) . During a review of Resident 51's Order Summary Report dated 11/30/24, the Order Summary Report indicated a physician's order dated 10/3/24, for Resident 51 to receive dialysis three times weekly every Tuesday, Thursday and Saturday from 5:00 a.m. until treatment is completed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage for hazardous drugs (medications that pose short or long-term harm upon exposure to human via skin or inhalation) of five out five sampled residents (Residents 43, 325, 29, 30 and 28). These failures could contribute unsafe handling of hazardous drugs which could pose health risks to staff and residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when: - Multiple food items, stored in reach-in refrigerators # 1 and # 2, and walk-in refrigerator, were either not dated or stored beyond their use-by dates. - Previously thawed food items were replaced in the freezer. - A scoop with the handle touching the food item was stored inside the flour bin. These failures had the potential to result in cross-contamination and food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for four of four sampled residents (Resident 43, 47, 325, 274 and 66) when: 1. Blood pressure (BP) cuff was not cleaned and disinfected after each use with Residents 43, 47 and 325. 2. Hand hygiene was not performed before administering the pre-filled Enoxaparin injection (a medication that uses a syringe and needle that can help reduce the risk of developing blood clots) to Resident 274. 3. Hand hygiene, wear of Personal Protective Equipment (PPE) and maintaining aseptic technique of equipment were not implemented during a medication administration to Resident 66. These deficient practices had the potential spread of infection at the facility.

Inspectors wroteBased on observation, interview and record review, for one (Resident 12) of four sampled residents, the facility failed to implement a person-centered intervention that addressed Resident 12's dementia, mental and psychosocial well-being when Resident 12 was not involved in activity programs as indicated in care plan. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptoms and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure had the potential to increase confusion and distress with Resident 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 12) of five sampled resident was free from unnecessary drugs when; Resident 12 whose diagnoses included dementia was receiving Zyprexa (antipsychotic medication) for continuously calling out causing distress. Antipsychotic medications are drugs used to treat schizophrenia and bipolar disorder and serious mental health disorders. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa is not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). [Reference: https://www.[NAME].com/zyprexa]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure if safe skilled nursing care was provided to all 62 residents residing at the facility when Licensed Nurses (LNs) including, three of three sampled Registered Nurses (RNs) and 12 of 12 sampled Licensed Vocational Nurses (LVNs) who had been working at the facility for more than one year, did not receive an annual competency assessment (a measure of an employee's knowledge, skills and behaviors used in performing specific job tasks) since their date of hire. This failure had the potential to cause compromised skilled nursing care to all 63 residents residing in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure food are stored under sanitary conditions when; The following food items in refrigerator were not labeled and no use by date: One bottle of jalapeno peppers opened 8/8/23 with no use by date One container of garlic in water opened, unlabeled with no use by date One container of beef base opened with no use by date Walk in freezer was cluttered with several boxes of food items. These failures had the potential to result in food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow food safety requirements when following was noted: 1. Food items kept in the refrigerator designated for food brought from outside the facility were not labeled and not separated from staff's food. 2. Facility did not allow heating/ reheating cold food leftovers for residents brought from outside. These failures had the potential to cause foodborne illness for residents in the facility.

Inspectors wroteBased on observation, interviews and record review the facility failed to maintain ice machine in a safe and proper working condition when ice machine located in the kitchen was not sanitized per manufacturers instructions. This failures had the potential to result in food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours for nine weekends during the month of June, July and August of 2023. This failure had the potential to place residents residing at the facility at risk to receive limited nursing assessment and compromised health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label according to accepted professional principle and did not safely store drugs and biologicals under proper temperature controls when: 1. Temperature of medication refrigerator on Stations 1 & 2's Medication Room were not within the recommended temperature range. 2. Expired pharmaceutical products were stored in Medication Cart #2. 3. Pharmaceutical products stored in Med Cart# 2 were opened and not dated. 4. Non-pharmaceutical products were stored in the Medication Cart #2. This failure had the potential for residents to receive ineffective medications and treatments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure three (Resident 12, 28 and 40) of five sampled residents were free from unnecessary drugs when; Resident 12, 28 and 40 with Alzheimer Dementia were administered antipsychotic medications without adequate clinical indication for use: Resident 12 was administered Olanzapin (Zyprexa) an antipsychotic medication for fighting and resisting care. Resident 28 was administered Risperdal an antipsychotic for people conspiring against her. Resident 40 was administered Seroquel an antipsychotic for combativeness and hitting staff for no reasons. {Alzheimer's Dementia-is a progressive disease that destroys memory and other important mental functions}. {Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior}. [...]

Inspectors wroteBased on interviews and record review, the facility failed to coordinate care planning in collaboration with resident, family and hospice care provider for one (Resident 2) of two sampled residents. This failure had the potential to result in residents to not received person centered care.

Inspectors wroteBased on interview and record review, for four (Residents 23, 34, 54 and 59) of 73 sampled residents the facility had no process in place to ensure residents had an Advance Directive (a written instruction relating to the provision of health care when the individual is incapacitated) on file. This failure had the potential for the residents' preference for treatment not to be implemented, in the event the resident was incapacitated.

Inspectors wroteBased on observation, interview and record review the facility failed to serve food under sanitary conditions when the dry food storage room had a box of brown bananas on a shelf with unexpired food. This deficiency practice has the potential to place residents at risk for foodborne illnesses.

Inspectors wroteBased on interviews and record review, the facility failed to follow its theft and loss program policy and procedure to make reasonable efforts to safeguard a resident's property for one (Resident 25) of twenty-four sampled residents when Resident 25's clothing's had bleached patches after a laundry wash. This failure had the potential to cause residents emotional distress.

Inspectors wroteBased on interviews and record review, the facility failed to follow its policy and procedure to provide one (Resident 166) of twenty four sampled residents and their representatives with a summary of the baseline care plan. This failure had the potential to cause miscommunication with the care provided to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 17) of twenty four sampled residents was free of unnecessary drugs, when Resident 1 was administered Ativan (anti-anxiety medication) for tremors/seizures without being monitored for its target behavior manifestations. This failure had the potential for residents to receive unnecessary medication and to suffer adverse medication side effects. Definitions: Ativan is anti-anxiety medication taken to reduce tension or anxiety. Its adverse consequences include increased risk of confusion, sedation and falls.