Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Fremont Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure successful and timely reporting of an alleged physical altercation between two residents to required agencies. One resident with osteoarthritis and a history of MI reported being slapped and yelled at by another resident with Alzheimer’s disease, schizophrenia, and bipolar disorder. Although incident documentation was completed and faxed Elder Abuse Report Forms were attempted to the state agency and a local agency, fax communication result reports showed the pages were not sent due to no answer. Staff did not verify successful transmission, and the licensing agency did not receive notice of the alleged abuse until days later, contrary to the facility’s abuse reporting P&P.
Two residents received unnecessary psychotropic medications. One resident with non-Alzheimer’s dementia was given Haldol for behaviors that staff did not observe, despite no documented psychosis or schizophrenia, and the resident had involuntary jerky movements that staff believed could be a side effect of Haldol; the facility also could not document GDR attempts. Another resident with non-Alzheimer’s dementia received PRN Lorazepam for anxiety despite no anxiety diagnosis, and the MAR showed repeated 24-hour totals above the manufacturer’s recommended elderly dose.
Failure to Supervise Residents During Smoking: A resident with oxygen equipment in the room was observed smoking near her room entrance, and four other residents were smoking in a non-designated patio area without smoking aprons or staff supervision. Interviews and record review showed several residents were supposed to smoke in designated areas with supervision, including one resident requiring constant supervision and others with seizure-related diagnoses or oxygen safety precautions. The DON stated residents were not allowed to keep smoking materials in their rooms and that CNAs were supposed to supervise smoking.
Food Service Sanitation and Staff Competency Failures: The facility failed to ensure the RD and CDM had an effective system for sanitation, food safety, staff training, and monitoring. Surveyors observed an unsanitary kitchen with dirty refrigerators, freezers, counters, equipment, high-touch surfaces, and soiled sanitizer rags left on surfaces. Monthly RD inspections documented repeated sanitation issues, while cleaning schedules were unclear and incomplete. Staff competency records showed workers as competent, but survey observations found poor cleaning practices, hand hygiene issues, and other work behaviors inconsistent with policy.
Dietary staff did not consistently meet sanitation, infection control, puree preparation, and cooling documentation standards. Observations showed unclean kitchen equipment and food storage areas, improper hand hygiene, aprons not worn during tray scraping, rags left out of sanitizer, and puree foods that were not smooth and contained pieces. Cooling logs were incomplete, and several prepared salads were found above safe refrigeration temperatures.
Food was not consistently palatable or served at an appetizing temperature. Residents described meals as bland, flavorless, cold, greasy, or poor quality, and staff did not consistently place condiments on trays or offer them during meal delivery. Tray line observations showed hot foods being assembled, but condiments were often absent, and test trays showed mixed temperatures with some items below expected serving temperatures.
Pureed Diets Not Prepared to Required Consistency: The facility failed to prepare pureed foods according to its diet manual and recipe instructions for multiple residents on pureed diets. During meal prep and tray testing, an FSW pureed chicken until it looked like mashed potatoes, but small chunks remained, and the RD and CDM found the pureed chicken, beans, and peppers/onions were not smooth and contained detectable pieces of food or skin. The pureed bread was smooth and acceptable.
Kitchen sanitation, food storage, and staff hygiene practices were not maintained. Surveyors observed damaged and dirty surfaces, rust, mold-like residue, dust, grease, and food debris on equipment, storage areas, and utensils; perishable foods were stored above safe temps; resident foods in the unit refrigerator were missing names and dates; cooling logs were incomplete; and staff were observed failing to wash hands after contamination events and leaving rags and towels unattended in food prep areas.
Improper Storage and Labeling of Resident Food: A resident food refrigerator was found unclean, with food debris and stains, and 9 of 24 items lacked required labeling or dating. Items included ice cream, cookies, shrimp, pizza, lemonade, soymilk, and half & half that were missing resident names, received dates, or opened dates. A CNA was unsure of the labeling requirements, and a resident reported personal food they had purchased was removed from the refrigerator.
Infection control practices were not followed during environmental cleaning and wound care. A housekeeper used a multi-purpose cleaner rather than an EPA-registered disinfectant to mop resident care and common area floors, including areas with known infections. During wound care for a resident with an abdominal wall abscess, an RN did not wash and dry hands thoroughly before, during, or after the procedure and did not use sterile gloves when cleaning the open wound or holding a moist surface over it. Facility policy required EPA-registered disinfectants for environmental surfaces and thorough hand hygiene with sterile gloves for wound care.
Kitchen equipment and maintenance were not kept in sanitary, working condition. Surveyors found cracked and missing floor tiles, damaged walls, baseboards, doors, and air gaps, along with grime and rust throughout the kitchen. Refrigerators and freezers had damaged gaskets, condensation, ice buildup, mold-like residue, and dirty condenser fans, and one unit held food above 41 F. The ice machine was not cleaned per the manufacturer’s instructions, and the facility lacked a formal PM/work order system for kitchen equipment.
Kitchen Air Temperatures Exceeded Acceptable Range: Staff working in the kitchen were observed in uncomfortably warm conditions when the air temperature measured 88.5 F and later 90.5 F, above the facility’s stated acceptable range and above the state limit for indoor work areas. A FSW was also observed sweating at the food prep station, wiping her face with bare hands and a paper towel, then returning to food prep without washing her hands. The DM initially said the hallway thermostat controlled the kitchen, then stated the kitchen used a swamp cooler.
A resident with intact cognition and a history of schizophrenia alleged that staff mistreated her during a discharge planning meeting, resulting in her calling 911. Despite the resident's report and police involvement, facility staff and the administrator did not initiate an internal investigation or report the incident as required by policy, constituting a failure to follow abuse investigation and reporting procedures.
The facility failed to ensure a current PASRR was completed for a resident with schizophrenia, depression, and psychotropic medication use. The DON confirmed prior PASRR reviews showed a positive Level I with a need for Level II evaluation, but the case had been closed due to a duplicate PASRR on file and the resident still did not have a current PASRR in place.
Failure to Ensure Successful and Timely Reporting of Alleged Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse Investigation and Reporting policy by not ensuring that an alleged physical altercation between two residents was successfully reported to the state licensing/certification agency and a local agency. One resident, with diagnoses including osteoarthritis and myocardial infarction, reported that another resident, with diagnoses including Alzheimer’s disease, schizophrenia, and bipolar disorder, slapped her on the left shoulder and yelled at her to move out. An incident report dated 2/24/26 documented this allegation. The facility’s policy required that all alleged violations involving abuse be promptly reported to specified agencies, including the state licensing/certification agency, the Ombudsman, and law enforcement, within defined time frames depending on the nature and severity of the alleged abuse. Record review showed that on 2/25/26 the facility attempted to fax the Elder Abuse Report Form (SOC 341) and cover sheet to the state agency district manager and a local agency, but both fax transmissions failed, with the communication result reports indicating “Page Not Sent” and “No answer.” The Director of Nursing acknowledged that the fax did not go through and that the communication result reports showed an error. The Administrator confirmed that both faxes resulted in failed communication and that the error was not identified at the time, and the Unit Manager stated that someone must have placed the fax communication result report in the Administrator’s box without checking whether the fax had gone through. As a result, the licensing agency did not become aware of the physical altercation until after receiving the facility’s Abuse Investigation Summary on 2/27/26, contrary to the facility’s policy requiring immediate reporting within specified time frames.
Unnecessary Psychotropic Medication Use and Excessive Lorazepam Dosing
Penalty
Summary
The facility failed to ensure two residents were free from unnecessary psychotropic medication use. One resident with non-Alzheimer’s dementia was receiving Haloperidol for “schizophrenia manifested by hitting and grabbing,” even though the resident’s MDS showed intact cognition, no psychosis, no hallucinations or delusions, and no physical, verbal, or other behavioral symptoms directed toward others. The resident’s PASRR showed no serious mental illness, and staff interviews stated the resident had no behavioral problems and no hitting or grabbing. During observation, the resident was seen with uncontrollable jerky movements of the right upper arm stump, and the resident stated the whole body shook and the jerky movement was getting worse. Staff told surveyors the resident had uncontrollable body movements and that the movements could probably be a side effect of Haldol use. The resident’s psychotropic review documented zero behaviors and zero side effects for Haldol, while the consultant pharmacist recommended evaluating the medication, considering dose reduction, and attempting dose reduction to discontinue the afternoon dose. Facility staff stated prior gradual dose reduction attempts had failed, but they could not provide documentation to support that GDR had been attempted. A second resident with non-Alzheimer’s dementia received Lorazepam 1 mg every 6 hours PRN for anxiety manifested by constantly moving in bed, despite the MDS showing no diagnosis of anxiety. The MAR showed the resident received 1 mg doses multiple times across several days, totaling 3 mg in a 24-hour period on those occasions, which exceeded the manufacturer’s recommended daily dose of 2 mg for elderly patients. Staff confirmed the resident mumbled at times and tapped her finger on the mattress, and the consultant pharmacist stated the recommended elderly dose was 2 mg over 24 hours. The facility policy stated psychotropic drugs are to be used only when necessary and at the lowest effective dose, with monitoring for side effects through the MDS process.
Failure to Supervise Residents During Smoking
Penalty
Summary
The facility failed to provide staff supervision for five sampled residents during smoking and did not maintain a safe smoking environment. On 9/16/25 at 10:15 a.m., Resident 99 was observed smoking a cigarette outside her room by the sliding door leading to the smoking patio, while an oxygen tank was beside her bed and an oxygen concentrator with oxygen was in her room next to another bed. Resident 99 quickly put out the cigarette and dropped the butt on the ground, where two cigarette butts were already present. She did not have a smoking apron, and CNA 5 confirmed she was smoking. In the patio, Residents 11, 20, 24, and 91 were also observed smoking in a non-designated area by the tree, and none had smoking aprons. Resident interviews and record review showed that the residents were not following the facility’s smoking expectations and were smoking without the required supervision. Resident 99 stated she was supposed to smoke in the designated area but was unable to wheel herself out and instead held onto the wall and pushed herself out. She also stated she kept her cigarettes with her and was not following the smoking schedule posted in her room. Resident 20 stated she smoked independently whenever she wanted and kept her cigarettes with her, despite having oxygen concentrator equipment in her room. Resident 91 stated he had no smoking schedule and went out to smoke by himself without staff present, with another resident helping with the lighter. Resident 24 stated she did not have a smoking schedule and acknowledged smoking with Residents 11, 20, and 91. Record review showed Resident 99 had a smoking assessment indicating modified independence and need for supervision, with a diagnosis related to seizure activity, and her care plan included supervised smoking in designated areas. Resident 20’s care plan also included supervision in designated areas and oxygen safety precautions. Resident 91’s smoking assessment indicated modified independence and constant supervision while smoking, and his care plan required supervision in designated areas. Resident 24’s care plan also required supervision in designated areas. The DON stated residents were not allowed to keep smoking materials in their rooms, that it was a fire hazard for residents to keep smoking materials in the room and smoke in non-designated areas, and that CNAs were supposed to supervise residents when they smoked. The facility’s smoking policy stated residents must keep smoking materials at the nurses’ station, may smoke only in the designated smoking area outside the building, and residents with a current diagnosis of documented seizure activity are considered supervised smokers.
Food Service Sanitation and Staff Competency Failures
Penalty
Summary
The facility failed to ensure the Registered Dietitian (RD) and Certified Dietary Manager (CDM) had the necessary skill sets to carry out food and nutrition services. The report states there was not an effective system in place to ensure sanitation and food safety in the food service areas, and there was not an effective system in place to ensure adequate training, competence, and regular monitoring of dietary staff work practices. The CDM stated she had been the Director of Food and Nutrition Services since 2021, and the RD stated she had worked at the facility for one year and conducted monthly kitchen sanitation inspections, with the CDM responsible for addressing concerns identified during those inspections. During the initial tour, the kitchen and its equipment were observed to be unsanitary. The interior and exterior of refrigerators and freezers were not clean, and counters, stoves, ovens, the plate warmer, can opener and mount, and carts were not clean. Knives and serving utensils were stored soiled and/or wet, dry storage containers were grimy, and high-touch surfaces such as light switches, door knobs, door frames, the telephone, and equipment handles and knobs had a thick buildup of grime and/or dust. Soiled sanitizer rags were frequently left unattended on counters and equipment throughout the kitchen. The RD’s four monthly kitchen inspection reports also documented repeated sanitation concerns, including unclean can opener/mount, carts, black fans, coffee machine, refrigerators and freezers, and the plate warmer. Unattended soiled sanitizer rags were not included as an area of focus on the kitchen inspection list. The CDM stated she read the RD’s monthly inspection reports and responded by providing in-service training and instructing staff to follow the cleaning schedule, and she stated she checked staff work during daily rounds. However, the kitchen remained unsanitary during the survey. The cleaning schedules were not clear or updated, included equipment no longer in the kitchen, did not identify which refrigerators and freezers each position was responsible for, and directed staff to wipe off rather than clean equipment such as the grill, steam table, oven/range, ingredient bins, juice machine, carts, garbage cans, and refrigerator doors. Although staff signed off on many daily tasks, weekly and monthly tasks were often incomplete, and the kitchen was still not found clean. The CDM also described new staff training as hands-on with peer training and shadowing, but survey observations identified staff not cleaning equipment according to policy or manufacturer instructions, not washing hands, not wearing aprons, and leaving soiled sanitizer rags on food production surfaces. Competency checklists showed several food service workers were marked competent, yet the kitchen was not clean and multiple staff were observed not meeting competency requirements in several areas.
Dietary Staff Competency and Food Safety Failures
Penalty
Summary
The facility failed to provide sufficient competent dietary services staff to consistently carry out food and nutrition service functions safely and in accordance with professional standards of practice. During an interview, a food service worker stated they had worked at the facility for more than 20 years and did not take breaks because, if they did, they would not have enough time to complete their responsibilities. The Certified Dietary Manager stated the kitchen was fully staffed and described a training process in which new staff received hands-on training with a peer and shadowing by the CDM until they were competent to work independently. Facility orientation materials required employees to receive ongoing in-service education and to demonstrate competence before performing assigned duties. Survey observations and interviews showed repeated failures in sanitation and infection control. Kitchen equipment and food storage areas, including refrigerators, carts, floors, doors, switches, knobs, handles, and other high-touch surfaces, were observed to be unclean throughout the survey. Staff described cleaning carts and counters with sanitizer, but one staff member stated they never took everything out of the refrigerator or freezer to clean it and did not use the wash, rinse, sanitize, and air-dry process. Another staff member stated they only used sanitizer to clean counters and meal carts between meals unless they were very dirty. Facility policies required food-contact surfaces and carts to be cleaned and sanitized after each use or meal, and the sanitation logs documented daily cleaning even though observations showed the equipment was not clean. Staff also did not consistently follow professional standards to prevent cross-contamination. One staff member picked up trash from the floor and then returned to food service duties without washing hands, and another wiped sweat from their face and did not wash hands before returning to food preparation. A staff member scraped soiled resident trays without wearing an apron, and cleaning rags were observed left unattended on carts, counters, boxes, and in food preparation areas instead of being kept in sanitizer solution. In addition, staff did not puree foods according to recipe and diet manual specifications. A food service worker pureed lunch items and stated they knew the food was ready when it looked like mashed potatoes, but small chunks remained in the puree. A meal test tray showed pureed chicken, beans, onions, and peppers were not smooth and contained detectable pieces, and the competency checklist for that worker showed they needed more training and re-evaluation in texture modification. The facility also did not complete ambient food cooling logs consistently. Refrigerated tuna salad, egg salad, and chicken salad were observed at temperatures above the acceptable range, and the salads were discarded because they were out of range. Cooling logs were present for some items, but there was no cooling log for the chicken salad prepared on one date and no cooling logs for several salad batches prepared on later dates. The RD stated that the cooling log was being used without consistency.
Food Not Palatable and Hot Foods Not Served at Proper Temperature
Penalty
Summary
The facility failed to ensure food provided to residents was palatable and served at a safe and appetizing temperature. Four of 97 sampled residents stated the food did not taste good, and three of 97 sampled residents stated hot food was not served hot. During interviews, residents described the food as bland, flavorless, cold, greasy, or poor quality, and one resident stated the chicken was either burnt or raw and hard-boiled eggs were soft boiled and could not be peeled. During lunch tray line observations, hot foods were prepared on the steam table, but the tray line did not appear to include additional low sodium versions of foods. Common condiments such as salt, pepper, and sugar were not placed on resident trays during tray assembly observations, although margarine, salad dressings, and occasionally herb seasoning were added. Staff interviews showed differing practices regarding condiments: one dietary staff member stated all foods served on tray line were low sodium, while the Registered Dietitian stated condiments were not placed on trays because that was the facility's protocol and residents could ask nursing for condiments if desired. During meal delivery observations, a CNA delivered trays to residents without offering condiments, and another CNA stated condiments were kept on meal carts and should be offered within diet order limits. The Registered Dietitian also stated nursing provided condiments and that regular gravy should not be low sodium. The facility's diet manual listed a 2-3 gram sodium diet as providing 2000-3000 mg sodium daily, while the regular menu nutrient analysis showed sodium averaging around 3800 mg to 4,292 mg daily. The facility's meal service policy stated condiments were to be placed on a tray according to resident preference, request, or diet order. In addition, test tray observations showed mixed food temperatures and some texture issues, and residents reported that food was often cold.
Pureed Diets Not Prepared to Required Smooth Consistency
Penalty
Summary
The facility failed to ensure that pureed diets were prepared according to its diet manual requirements for 20 of 97 sampled residents who received pureed diets. The facility diet manual stated that pureed foods should be smooth and pureed to the consistency of pudding, while the facility policy on food preparation stated that pureed foods should be prepared to the consistency and thickness of mashed potatoes. The deficiency involved residents receiving pureed diets for dysphagia, including conditions such as stroke, head trauma, or Alzheimer's disease, as described in the diet manual. During lunch meal preparation observation, a food service worker pureed chicken in a Robo Coupe food processor and stated the puree was finished when it looked like mashed potatoes. After the process was completed, small chunks of chicken remained around the top edge of the container. Review of the recipes for pureed pinto beans, chicken taco meat, and sauteed onions and peppers showed instructions to process until smooth, but during a meal test tray process with the RD and CDM, the pureed chicken contained small detectable pieces of chicken, the pureed beans contained pieces of skin, and the pureed peppers and onions contained pieces of skin. The pureed bread was smooth and softly mounded on the plate.
Kitchen sanitation, food storage, and hygiene failures
Penalty
Summary
The kitchen was not sanitary or well maintained during survey observations. Walls had chipped and missing paint, holes, and damaged flooring with missing tiles, cracks, and damaged coving. Black buildup was seen along floor edges and around stationary equipment, trash can lids had gray grime, and tape and sticker residue was present on surfaces including the shelf above the tray line, refrigerators, carts, and the telephone. Binders used for recipes and sanitation logs were soiled and sticky. A black standing fan near the tray line was coated with dust, and the air gap under the two-compartment sink was rusty and filled with black matter that could be scooped out. A drying rack for insulated lids had multiple rusted areas, and dust and spider webs were observed between the steam table and refrigerator four. The coffee machine water tank opening had black residue on one side and white lime scale on the other. Food storage areas were not maintained according to professional standards. In freezer and refrigerator storage, greasy film was observed on exterior doors and handles, black substance resembling mold was present on one freezer door and frame, and one refrigerator had greasy film on the exterior doors and handles. Inside one refrigerator, food debris and brown grainy residue were present on shelves and condenser fans, and another refrigerator had rust on shelves and grime on condenser fans. Perishable foods stored in that refrigerator included tuna salad, chicken salad, and egg salad with temperatures above 41 F. Dry storage areas also had damage and grime on walls, trims, doors, light switches, and storage bins. Scoops were found with food debris and stored in the bins, and multiple round bins containing dry foods were soiled with dust, grime, and food particles. A large cart used to store insulated mugs had buildup of food debris, tape residue, and grime, and the mugs were wet and half full of water. Equipment and staff practices were also inconsistent with sanitation and cross-contamination standards. The pot and pan rack above the three-compartment sink was fuzzy with grease and dust, the plate warmer had sticky gray residue and a damaged switch, and the stove and ovens had grime and burned-on grease. Utility carts had grime and food debris around edges, corners, handles, and wheels. In drawers and storage areas, scoops, utensils, containers, biscuit cutters, a grater, cardboard wrap dispensers, the knife rack, spatulas, knives, and the tray line utensil holder were soiled or damaged. Staff were observed handling a soiled napkin and returning to tray line duties without washing hands, wiping sweat from the face and returning to food preparation without handwashing, and scraping resident trays without an apron. Resident food stored in the unit refrigerator was also not consistently labeled or dated, with multiple items lacking resident names, received dates, or opened dates. Cooling logs were incomplete for chicken salad and egg/tuna/chicken salad, and unattended rags and towels were repeatedly observed in the dish room, cooking area, utility cart, and food preparation area, including a sanitizer bucket with very little sanitizer and rags not submerged in the solution.
Improper Storage and Labeling of Resident Food
Penalty
Summary
The facility failed to ensure food brought in from outside sources and belonging to residents was properly stored under sanitary conditions. During an observation of the resident refrigerator with the Infection Preventionist, the refrigerator was noted to be unclean, with brown stains, food debris on the shelves, and yellow stains on the interior door storage. The Infection Preventionist stated that housekeeping cleaned the refrigerator and that she checked for proper food labeling. Nine of 24 food items in the refrigerator did not have proper labeling or dating. Items observed included ice cream, Oreo Thin Cookies, cooked shrimp, frozen pizza, raw shrimp, Breyer's Ice Cream, Brisk Pink Lemonade, Your Good Foods Soymilk, and Good & Gather Half & Half, with several items missing the resident name, received date, opened date, or use-by information. A CNA stated that resident food should be checked for expiration dates and labeled with the resident's name and received date, but was unsure about labeling the date an item was opened. A resident stated that food they had purchased, including sausage and hard-boiled eggs, had been removed from the refrigerator after the refrigerator door was locked and the refrigerator was cleaned out.
Infection Control Failures During Environmental Cleaning and Wound Care
Penalty
Summary
The facility failed to observe infection control practices during environmental cleaning and wound care. A housekeeper was observed mopping resident care area floors with a mixture of water and Fabuloso multi-purpose cleaner, and stated that this mixture was used for all resident care area floors, including rooms with known infections. The maintenance assistant was unsure whether Fabuloso was a disinfectant, and the infection preventionist acknowledged that the cleaning solution used was not EPA approved. The infection preventionist stated that EPA-approved disinfectants were important to stop the spread of infection between residents and resident rooms, especially with a COVID-19 case in the facility. Resident 83 was admitted and later readmitted to the facility and had diagnoses that included cutaneous abscess of the abdominal wall. During wound care observation, the RN did not wash and dry hands thoroughly before applying gloves, did not wash hands between glove changes, and did not wash hands after the wound therapy. The RN stated that she used alcohol-based hand rub instead of soap and water before, during, and after wound therapy. The infection preventionist stated that the expectation was for the RN to wash hands with soap and water before and after wound therapy. During the same wound care observation, the RN did not wear sterile gloves when cleaning the resident’s open wound with wet gauze or when holding a moist surface over the wound. The RN later stated she was unaware that sterile gloves were required for touching the open wound and did not know where to obtain sterile gloves. Facility policies reviewed during the investigation stated that environmental surfaces were to be disinfected with EPA-registered hospital disinfectants and that wound care required thorough handwashing and sterile gloves when physically touching the wound or holding a moist surface over it.
Kitchen Equipment and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen physical plant and equipment in a clean, sanitary, and functional condition. During the initial tour and follow-up observations, the kitchen had cracked and missing floor tiles, grime around floor edges and stationary equipment, damaged black floor coving around a refrigerator, chipped and missing paint on walls, patched but unpainted holes in the dry storage area, damaged baseboards, and doors with missing paint and accumulated grime. The air gap at the food preparation sink was severely rusted and had black debris and rust particles present when wiped with a paper towel. The Maintenance Assistant stated the air gap was very old, rusted, and needed replacement, and the Director of Maintenance stated the department did not keep a list of work orders or a history of completed kitchen work orders. Multiple refrigerators and freezers were observed with damaged or deteriorated components and poor sanitation. One freezer had condensation and icicle drips around the door frame. Another freezer had black substance resembling mold at the top of the door/frame and on the gasket, along with ice buildup along the side gaskets. A combination refrigerator/freezer had brown grainy substance on the shelves and condenser fans. A utility refrigerator used for dairy, egg salad, chicken salad, and tuna salad had grime on condenser fans and hinges, rust on shelves, and food temperatures above 41 F. Another refrigerator near the tray line had a broken gasket hanging down, rust on the shelves, and grime around the doors, hinges, and handles. The Director of Maintenance stated maintenance only checked temperatures of refrigerators and freezers and did not perform other maintenance, and there was no regularly scheduled preventive maintenance for kitchen equipment. The ice machine was not cleaned according to manufacturer instructions. The Maintenance Assistant stated he cleaned it with warm water every month or two, did not use chemicals, and did not empty the ice from the bin. He also stated the vendor cleaned it with chemicals twice a year. The manufacturer’s manual required the ice machine and storage bin to be kept sanitary, cleaned and sanitized at least twice per year or as often as needed, and included steps for scale removal, sanitizing removable parts, and removing all ice from the storage bin. The facility’s documentation showed prior cleaning issues and discoloration on the ice machine, but there was no documentation after the new ice machine was installed. The Director of Maintenance stated the vendor cleaned the ice machine twice annually only when called. The facility also lacked an effective preventive maintenance system and documentation for kitchen equipment. Monthly quality assurance reports identified ongoing concerns such as dusty black fans, a refrigerator that would not hold temperature, torn gaskets with black discoloration, and rusty shelves, but these issues remained unresolved at the time of survey. The facility’s preventive maintenance documents listed some equipment and general tasks, but refrigerators, freezers, and ice machines were not included in the monthly checklist beyond temperature checks. The Director of Maintenance stated there was no formal work order system, requests were often not written down or tracked, and kitchen maintenance was handled when staff verbally asked for help.
Kitchen Air Temperatures Exceeded Acceptable Range
Penalty
Summary
The facility failed to ensure a comfortable work environment for staff working in the kitchen when kitchen air temperatures exceeded the acceptable range on two observed days. Review of facility documents showed the acceptable air temperature range was 70 to 81 F, and California regulations stated indoor work area temperatures should not exceed 82 F. During an observation in the kitchen on 9/15/25 at 2:42 p.m., the kitchen felt uncomfortably warm, and the Certified Dietary Manager agreed it was warm. The surveyor measured the air temperature in the center of the kitchen at 88.5 F. During another observation on 9/16/25 at 11:15 a.m., Food Service Worker 2 was working at the food preparation station with a red, sweaty face. She wiped her face with her bare hands, walked to the handwashing sink, wiped her face again with a paper towel, and returned to food preparation without washing her hands. On 9/17/25 at 1:48 p.m., the surveyor again measured the kitchen air temperature at 90.5 F, and the tray line area measured 89.9 F. In interviews, the Director of Maintenance first stated the hallway thermostat controlled the kitchen temperature, then said that was a mistake and that the kitchen used a swamp cooler. He later stated the swamp cooler was working after he found a loose wire on the roof.
Failure to Investigate and Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse policy and procedures by not investigating or reporting a resident's allegation of abuse to the appropriate local, state, and federal agencies. During an incident involving a resident with intact cognitive status and a diagnosis of schizophrenia, three staff members met with the resident to discuss discharge planning. The resident reported that one staff member told her she was not wanted in the facility, swung her around in her wheelchair, and hurt her left arm, prompting her to call 911. Staff interviews confirmed a meeting took place and that the resident became agitated and screamed, but staff denied the alleged abuse. Despite the resident's clear report and the involvement of law enforcement, no internal investigation was initiated, and the incident was not reported as required by facility policy. The administrator acknowledged hearing the resident scream and being aware of the police response but chose not to investigate further, citing the resident's dislike of him and his belief that no abuse had occurred. The facility's policy required assignment of an investigation for any reported or suspected incident of abuse, mistreatment, neglect, or injury of unknown source, but this process was not followed. The failure to investigate and report the resident's allegation constituted a breach of the facility's abuse investigation and reporting procedures.
PASRR Not Completed for Resident With Schizophrenia
Penalty
Summary
The facility failed to ensure that a PASRR was completed for one resident, Resident 36, who had a diagnosis of psychotic disorder. The admission record showed the resident was originally admitted and later readmitted, and the MDS dated 6/12/25 identified a psychotic disorder in Section I. The care plan dated 2/21/25 also documented mental illness/psychosis with a diagnosis of schizophrenia and behavioral management interventions. During interview and record review on 9/18/25, the DON stated the resident had a PASRR Level I dated 5/20/23 that was positive and required a Level II evaluation, and that a 5/25/23 DHCS letter stated the case was closed because of a duplicate PASRR on file and a new Level I screening would be needed to reopen it. The DON also reviewed a prior PASRR Level I dated 2/1/23 with an Individualized Determination Report dated 2/14/23 indicating recommended specialized services. The DON acknowledged the resident was supposed to have a current PASRR and stated the resident had schizophrenia and depression diagnoses and was receiving psychotropic medications, including Mirtazapine and Olanzapine.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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 Manor - Fremont | 0.7 mi | ★★★★★ | 0 | 0 |
| Crestwood Treatment Center | 1 mi | ★★★★★ | 1 | 0 |
| Country Drive Post Acute | 1.1 mi | ★★★★★ | 4 | 0 |
| We Care Skilled Nursing - Fremont | 1.1 mi | ★★★★★ | 3 | 0 |
| Mission Valley Post Acute | 1.2 mi | ★★★★★ | 0 | 0 |
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