Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country Drive Post Acute during CMS and state inspections, most recent first.
Surveyors found that multiple self-responsible residents did not receive or sign admission agreements at or near the time of admission, contrary to facility policy. One resident’s agreement was signed eight days after admission, another resident had no signed agreement on file, a third resident’s agreement was only provided on the day of discharge and the family reported being unaware of the care and services provided, and a fourth resident signed the agreement more than a month after admission. The admission agreement, which includes resident rights, advance directives, facility and Ombudsman information, arbitration terms, and expectations, was required by policy to be signed at admission and filed in the clinical record.
A resident with anxiety, depression, and intact cognition was assigned a new roommate after the prior roommate was transferred to the hospital, but did not receive advance written notice of this roommate change. The ADON reported that the facility only gives written notice when residents move rooms, not when they receive a new roommate, despite a policy requiring timely advance notice for room or roommate changes. Only undocumented verbal notice was given, and the failure was noted as having the potential to cause avoidable psychosocial distress.
A resident with intact cognition and multiple chronic conditions entrusted a wallet containing cash to the SSD for safekeeping. The SSD stored the wallet in an unlocked office drawer instead of securing it per the facility’s personal funds policy. When the resident’s family later requested a portion of the money, most of the cash was missing, and documentation showed the issue was discussed with the family but not directly with the resident, even though the facility’s policy required proper safeguarding and accounting of resident funds.
A resident admitted with multiple fractures, dementia, gait difficulty, and delirium did not receive a summary of the baseline care plan within 48 hours of admission. The ADON could not confirm that either the resident or the resident’s representative had been given this summary, and the ICC documentation listed only facility staff as attendees and left the section on providing a copy of the care plan summary blank. The resident’s representative reported that the admission agreement was only received on the day of planned discharge and that the family was unaware of the care and services to be provided. The facility’s baseline care plan policy described IDT development of person-centered care but did not specify when or how to provide a care plan summary to the resident or representative.
The facility did not meet the required minimums for Direct Care Service Hours Per Patient Day (DHPPD) and Certified Nursing Assistant (CNA) DHPPD on ten weekend days, as confirmed by staff interviews and payroll record reviews. Staffing levels on these days fell below both the 3.5 DHPPD and 2.4 CNA DHPPD thresholds, in violation of facility requirements.
Surveyors found multiple prescription medications, including insulin and oral tablets, stored in a medication cart without proper labeling or resident identification, and not separated from other medications. Additionally, insulin vials and pens were stored in a medication refrigerator operating at a temperature far below the required range, with staff unaware of the issue prior to inspection.
A resident with cognitive and physical impairments was not provided with individualized activities according to their assessment and care plan. The resident was observed awake in bed without engagement in any activities, and staff could not specify what activities were offered. No activity care plan or assessment of preferences was found in the record, and required follow-up with the family was not completed. Facility policy requiring individualized activity planning was not followed.
A resident with severe kidney disease did not have current physician orders or a medication list in the dialysis communication binder, and there was no follow-up on a recommendation to discontinue a prescribed medication. Facility staff also recorded inconsistent assessments of the resident's dialysis access site, documenting findings inconsistent with the actual type and location of the access. These failures resulted in a lack of proper coordination and documentation with the dialysis center.
A registered nurse failed to follow proper insulin pen injection technique for two different insulin medications administered to a resident, withdrawing the needle too soon and resulting in two medication errors. This led to a medication error rate of 8%, surpassing the allowable federal threshold.
A resident with a right leg immobilizer and moderate risk for pressure ulcers developed an unstageable, facility-acquired pressure ulcer on the right lower leg due to lack of documented skin checks and failure to update the care plan with appropriate interventions. Despite physician orders and facility policy requiring daily monitoring, staff did not assess or document the condition of the skin under the immobilizer, resulting in delayed identification and management of the wound.
Failure to Provide Timely Admission Agreements and Notice of Rights
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with notice of rights, rules, services, and charges prior to or upon admission, as required by facility policy. The Admissions Director stated that the admission agreement is very important because it includes information on resident rights, advance directives, facility and Ombudsman information, arbitration, and expectations, and that it should be signed within 72 hours of admission. However, record review showed that one resident, who was self-responsible and had an emergency contact listed, was admitted on a specified date and transferred to the hospital after a medical emergency, yet the state-specific admission agreement was not signed by the resident representative until eight days after admission. Another self-responsible resident with an emergency contact listed had no signed admission agreement in the clinical record, as confirmed by the ADON during concurrent interview and record review. For a third self-responsible resident, records showed admission on a specified date and discharge home on another date, with the emergency contact listed; the resident’s representative reported that the admission agreement was only given on the day of discharge, and that the resident and family were unaware of the care and services provided while at the facility. The state-specific admission agreement for this resident was dated the day the resident went home. For a fourth self-responsible resident, the admission agreement was signed more than one month after admission. Review of the facility’s policy and procedure titled “Admission Agreement,” last revised December 2025, indicated that each resident must have an admission agreement signed and dated by the resident or resident representative at the time of admission and filed in the clinical record, which did not occur for these four of five sampled residents.
Failure to Provide Required Advance Notice of Roommate Change
Penalty
Summary
The facility failed to honor a resident’s right to receive advance notice of a roommate change when a new roommate was assigned to Resident 2’s room. Resident 2 had been admitted with diagnoses including encounter for removal of an internal fixation device, anxiety disorder, and depression, and had an MDS BIMS score of 13, indicating intact cognition. Resident 2 initially shared a room with Resident 6 until Resident 6 was transferred to the hospital. On a later date, Resident 2 was given a new roommate without advance written notice, and only verbal notice was reportedly provided. During interviews, the ADON stated that the facility does not provide written notice when a resident acquires a new roommate and only provides written notice when a resident is moved to a new room. Review of the facility’s “Room or Roommate Change” policy, effective 6/27/22, showed that residents or their representatives are to receive timely advance notice before a room or roommate change, and that this notice can be verbal, written, or both. The ADON confirmed that when Resident 2 received a new roommate, only verbal notice was given and it was not documented in the clinical record, contrary to the facility’s policy. The report stated this failure had the potential to result in avoidable psychosocial distress.
Failure to Safeguard Resident Personal Funds
Penalty
Summary
The facility failed to safeguard a cognitively intact resident’s personal funds that had been entrusted to staff for safekeeping. The resident, who was self-responsible and had diagnoses including diabetes mellitus, benign prostatic hyperplasia, and chronic gout, had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. According to the Administrator, the resident gave a wallet containing $180 in cash to the Social Services Director (SSD) for safekeeping. The SSD placed the wallet in an unlocked drawer in the SSD office, contrary to the facility’s policy and procedure for management of residents’ personal funds, which required the facility to hold, safeguard, manage, and account for residents’ personal funds when the facility manages them. Later, when the resident’s family requested $140 from the resident’s money, only $40 remained in the wallet, indicating that $140 was missing. The SSD no longer worked at the facility at the time of the investigation. A review of the Social Services Progress Notes from October through December did not show that the resident was informed about the missing $140, although the SSD had discussed the issue with the resident’s family. During an interview, the resident stated that the facility still had the wallet and that a man had visited his room and provided a number to call regarding the missing money. The facility’s policy required written authorization and proper safeguarding of funds when the facility manages a resident’s personal funds, but the wallet and cash were not secured in accordance with these procedures.
Failure to Provide Baseline Care Plan Summary to Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a resident received a summary of the baseline care plan within 48 hours of admission, as required. The resident was admitted with multiple significant diagnoses, including fractures of the left pubis, sacrum, and upper end of the left humerus, as well as dementia, difficulty in walking, and delirium. The admission record indicated the resident was self-responsible and identified a representative as the emergency contact. During review of the resident’s Interdisciplinary Care Conference (ICC) documentation, the Assistant Director of Nursing (ADON) stated she was unsure whether a summary of the baseline care plan had been provided to the resident or the representative, noting that the notes did not indicate this. The ICC form listed only facility staff as attendees, did not identify which representative participated, and left blank the section indicating whether a copy of the care plan summary was provided. In a telephone interview, the resident’s representative reported that the admission agreement was only received on the day the resident was to be discharged and that the resident and family were unaware of the care and services to be provided at the facility. Review of the facility’s policy and procedure titled “Care Plan-Baseline” showed that it described the baseline care plan as including instructions for effective, person-centered care to be developed and implemented by the Interdisciplinary Team for each resident, but the policy did not specify when or how a summary of the baseline care plan should be provided to the resident or their representative. This lack of clear documentation and policy guidance contributed to the failure to provide the required baseline care plan summary to the resident or the representative.
Failure to Meet Minimum Direct Care and CNA Staffing Requirements
Penalty
Summary
The facility failed to provide the required minimum of 3.5 Direct Care Service Hours Per Patient Day (DHPPD) and 2.4 Certified Nursing Assistant (CNA) DHPPD on ten weekend days, as evidenced by interviews and record reviews. Staff responsible for scheduling and staffing, including the Staff Developer Assistant and Director of Staff Development, confirmed awareness of the minimum staffing requirements. Payroll records reviewed with the Payroll Coordinator showed that on multiple dates, both overall DHPPD and CNA DHPPD fell below the mandated levels. Specific staffing data from the facility's census and DHPPD reports indicated that on several days, the DHPPD ranged from 3.07 to 3.49 and CNA DHPPD ranged from 1.79 to 2.23, all below the required minimums. The facility's staffing waiver also stipulated that no less than 3.5 direct care service hours per patient day should be provided, which was not met on the identified dates. This deficiency was identified through interviews and review of staffing records, but no information about specific residents or their conditions was provided in the report.
Improper Medication Labeling and Storage, Including Unsafe Refrigeration of Insulin
Penalty
Summary
During an inspection of a medication cart, multiple prescription medications were found without proper labeling or resident identification. Items included a Humalog (insulin lispro) KwikPen, a pill organizer containing various oral tablets, and an Albuterol Sulfate Inhaler, none of which had prescription labels or clear identifiers. These medications were not separated from other facility-stocked medications and were stored in a manner that did not prevent potential medication administration errors. A registered nurse acknowledged that these medications were brought in by a resident and admitted they had not been properly labeled or verified for use. Additionally, a medication refrigerator in the facility's medication storage area was observed to be operating at 14°F, well below the required refrigeration range. Multiple insulin vials and pens were stored inside, all labeled to be refrigerated but not frozen. The nursing supervisor confirmed that staff had not previously identified or addressed the unsafe storage condition, and there was no indication that the affected insulin had been evaluated for safety or removed from use.
Failure to Provide Individualized Activities Based on Assessment and Preferences
Penalty
Summary
The facility failed to provide individualized activities for one resident, as required by assessment and care plan, based on the resident's preferences and needs. The resident, who was admitted with diagnoses including pneumonia, weakness, and difficulty walking, was observed lying in bed awake and alert on multiple occasions, with no TV or music playing and no evidence of engagement in any activities. The resident was unable to speak but responded to greetings with a smile. Staff interviews revealed that in-room visits were conducted, but the Activity Director could not specify what activities were provided and acknowledged that activities were anticipated rather than planned according to an individualized assessment. A review of the resident's records showed no activity care plan or individualized activity assessment was present at the time of the observations. The MDS assessment did not document the resident's choices or preferences for activities. The Activity Director admitted that the assessment and care plan had not been completed within the required timeframe and that follow-up with the resident's family regarding preferences had not occurred as needed. Facility policy requires individualized activities and care plans to be developed based on assessment, but this was not done for the resident in question.
Failure to Ensure Consistent Dialysis Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure ongoing and consistent collaboration with the dialysis center for a resident requiring dialysis services. The resident, who had severe kidney disease and a hypertensive emergency, was admitted with physician orders for Clonidine transdermal patches to manage hypertension. The dialysis communication binder for this resident did not contain the current physician's orders or a medication list, despite a request from the dialysis center. Additionally, there was no follow-up on the dialysis center's recommendation to discontinue the Clonidine patches, and the medication continued to be administered. Facility staff also documented inconsistent assessments of the resident's dialysis access site. While the resident had a left chest permacatheter, records incorrectly noted the access site as the right upper arm with findings (bruit and thrill) that would not be present with a permacatheter. The resident confirmed the location of her access site and the ongoing use of Clonidine patches, and staff acknowledged the absence of required documentation and communication in the dialysis binder. These lapses were contrary to the facility's policy, which required regular written communication and collaboration with the dialysis provider and attending physician.
Medication Error Rate Exceeds Federal Threshold Due to Improper Insulin Administration
Penalty
Summary
During a medication administration observation, a registered nurse administered Lantus Insulin and Novolog Insulin to a resident but failed to follow the manufacturer-recommended technique for insulin pen injections. Specifically, the nurse did not hold the insulin pen in place for the required 5 to 10 seconds after injection, instead withdrawing the needle after only 2 to 3 seconds. This incorrect technique was observed for both types of insulin administered to the resident. Each instance of improper administration was counted as a separate medication error, resulting in a medication error rate of 8%, which exceeds the federal threshold of 5%. The nurse acknowledged the error during a follow-up interview, stating she forgot the correct technique.
Failure to Monitor and Prevent Pressure Ulcer Under Immobilizer
Penalty
Summary
A resident with a periprosthetic fracture around an internal prosthetic right hip joint was admitted with a right leg-knee immobilizer and was identified as being at moderate risk for pressure ulcer development, as indicated by a Braden Scale score of 13. The care plan acknowledged the resident's higher risk for pressure ulcers but did not include specific interventions to monitor or protect the skin under the immobilizer. There was no documentation of skin checks under the immobilizer, and the care plan was not updated when a pressure ulcer was later identified on the right lower leg. Despite physician orders to monitor the skin under the right leg brace daily and notify the physician of any changes, there was no evidence in the clinical record or treatment administration record that these checks were performed. Interviews with nursing staff and review of skin monitoring forms confirmed that the skin under the immobilizer was not routinely assessed. When a pressure ulcer was eventually discovered, there was no initial measurement or detailed documentation of the wound, and the care plan was not promptly updated to reflect the new condition. The lack of monitoring and timely intervention led to the development of an unstageable, facility-acquired pressure ulcer on the resident's right lower leg, which caused pain and extended the resident's stay. The facility's own policy required regular risk evaluation, skin inspection, and documentation, but these procedures were not followed in this case. The failure to implement and document appropriate preventive measures and wound assessments directly contributed to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Treatment Center | 0 mi | ★★★★★ | 1 | 0 |
| We Care Skilled Nursing - Fremont | 0.1 mi | ★★★★★ | 3 | 0 |
| Mission Valley Post Acute | 0.1 mi | ★★★★★ | 0 | 0 |
| Niles Canyon Post Acute | 1 mi | ★★★★★ | 6 | 0 |
| Fremont Healthcare Center | 1.1 mi | ★★★★★ | 30 | 0 |
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