Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at John C. Fremont Healthcare District Dp/snf during CMS and state inspections, most recent first.
Expired CDM Certification: Dietary services were not directed by a qualified CDM for all residents because the facility CDM's certification had expired. The Cook stated the CDM supervised kitchen staff and provided their training, while the RD said the CDM was responsible for kitchen operations. The CDM acknowledged the lapse, and the IP stated the issue was identified after the DON raised concern and the CDM was found to be short of CEUs needed for renewal.
The facility failed to maintain infection control during laundry services when EVS staff handled residents’ personal clothing in a laundry room where dirty hampers were overflowing and left open, clean and dirty items were stored together, and food and drinks were present. Staff, including the IP and DON, stated these conditions were not acceptable and did not follow infection control standards. The facility also had not completed the annual IPCP review, with the last committee review documented in 3/2023.
An EVS staff member had not received current training on handling, storing, and processing residents’ personal clothing for more than a year, and laundry room observations showed overflowing open dirty hampers, clean items stored near soiled items, items on the floor, and food and drinks in the room. The EVS staff member stated he ate in the laundry room and had not had recent EVS training, while the IP, DON, and EVS Manager stated food was not allowed in the laundry room and clean and dirty items had to remain separated to prevent cross contamination.
An LVN failed to follow the medication administration policy for two cognitively intact residents by using only one identifier, as neither resident had an ID bracelet, and by not explaining the name and indication of the medications before giving them. One resident with polyosteoarthritis received supplements, and another resident with Parkinsonism received pramipexole, while the LVN only stated abbreviated medication names. The DON stated the expectation was to use two identifiers and explain medications before administration.
Expired milk was observed in the resident refrigerator at the nurses' station, which was used for food provided to all 15 residents. Interviews with the CDM, CNA, LVN, IP, and DON confirmed that SNF staff were responsible for cleaning the refrigerator and checking expiration dates, and the facility policy required refrigerated food to be labeled, dated, and monitored so it was used by its use-by date, frozen, or discarded.
Failure to Notify Ombudsman of Transfer and Discharge: The DON stated that a resident with DM2, COPD, chronic AFib, CKD, and HTN was transferred to an acute hospital for a significant change in condition and later discharged from the facility, but the facility did not notify the Office of the State LTC Ombudsman. The facility policy required sending the transfer or discharge notice to the Ombudsman at the same time it was provided to the resident and resident representative.
A resident with dementia, COPD, HF, anemia, and CKD had decreased PO intake, was observed distracted and not eating meals, and had enlarged lower extremities with tight pants and socks. Her weight increased from 141 lbs. to 148.5 lbs. and then to 151 lbs., but staff did not complete a focused assessment for the significant gain, and the existing nutrition care plan addressed weight loss risk rather than the resident’s weight gain. The RD, MDSCN, and DON all acknowledged the care plan lacked person-centered interventions and measurable goals for the resident’s significant weight change.
A resident with dementia, COPD, HF, anemia, and CKD had a significant and continued weight gain while eating poorly and showing enlarged lower extremities. Staff noted the weight trend, but the LVN did not assess the resident for the cause of the gain, the RD stated the resident met criteria for weekly weights and needed a nutritional assessment, and the existing nutrition care plan remained generic and did not address the significant weight gain or include specific interventions.
Expired Fish Oil 1000 mg was found in the medication storage cabinet during observation, and an LPN confirmed it was expired and should not have been stored there. An LPN and the DON stated expired medications should not be kept in the medication cart or medication storage area because they can lead to medication error and decreased effectiveness. The facility’s Medication Storage policy states outdated medications are to be immediately removed from stock and disposed of according to medication disposal procedures.
A resident with polyosteoarthritis, obesity, reduced mobility, and limited transfer ability used a shower chair that was not functional. The chair could not recline or adjust height, had no battery, and staff said it was not in good working condition. The resident stated the chair had been broken for years and was difficult and unsafe to use for bathing. CNA staff and the DON confirmed the malfunction interfered with care and was a safety concern.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week, as required. The Director of Nursing worked full-time during weekdays, but there was no RN coverage on weekends, despite the facility being at full capacity with 16 licensed beds. The facility's RN waiver from CMS expired in February 2024, leading to inadequate staffing and potential risks for residents' medical needs going unrecognized.
Two residents on anticoagulation medication did not have comprehensive care plans to monitor for side effects such as bleeding and bruising. One resident, with severe cognitive impairment and a history of cerebrovascular issues, was on aspirin without a care plan. Another resident, cognitively intact and diagnosed with atrial fibrillation, was on Apixaban without monitoring orders. The Director of Nursing acknowledged the oversight, which contradicted facility policies requiring comprehensive care plans.
A facility failed to meet professional standards when an LVN did not inform residents about their medications during administration, and a CNA worked with an expired certification. The LVN administered medications without explaining their purpose to three residents, while the CNA provided care without an active certification. Both the Director of Nursing and the Director of Staff Development acknowledged these oversights, which were contrary to the facility's policies and job descriptions.
Expired CDM Certification
Penalty
Summary
Dietary services were not directed by a qualified Certified Dietary Manager (CDM) for 15 of 15 residents because the facility CDM's certification expired on 6/1/25. During an interview, the Cook stated the CDM was her supervisor, all kitchen staff reported to the CDM, and the CDM conducted all training for kitchen staff. The Registered Dietitian stated he did not oversee the kitchen and that the CDM was responsible for kitchen operations, and he had recently become aware that the CDM's license was expired. The CDM stated her certification had lapsed and that she was required to submit continuing education hours to the Certifying Board of Dietary Managers for renewal every three years. She stated the Infection Preventionist had asked to review her renewed license in November, and in January she verified online in the IP's presence that the license status was expired. The Infection Preventionist stated the issue had first been raised by the DON when the CDM had not provided her certification during the last recertification survey, and that she later learned the CDM was short of two CEUs needed for renewal. The IP stated the CDM's responsibilities included assisting with nutritionally balanced meals, overseeing infection control and food safety practices, supervising kitchen staff, participating in the IDT, and completing resident preference documentation.
Laundry Room Infection Control and IPCP Review Deficiencies
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program when Environmental Services staff handled residents’ personal clothing in the laundry room in a manner that did not prevent cross-contamination. During observation, the dirty hamper was overflowing with bagged soiled and dirty residents’ personal clothing, and the hamper lids were open. Clean clothing was stored in the same room as dirty laundry, including a clothing cart with clean items positioned near the dirty hamper, a basket of personal blankets and residents’ clothing on the floor, and clean clothing hanging near the dryer. Food and drinks were also observed in the laundry room, including cookies on the counter, bread and coffee on the dryer, and staff stated they ate in the room while working. Interviews confirmed that the observed conditions were inconsistent with the facility’s expectations and infection control practices. The LVN, IP, DON, EVS Manager, and EVS staff all stated that dirty hampers should remain closed and not overflow, clean and dirty items should be separated, and food should not be stored or consumed in the laundry room. The EVS staff also stated he did not have current environmental services training and could not remember when his last training occurred. The IP stated the facility was providing laundry services for all residents and acknowledged that the staff were not adhering to infection control standards of practice during laundry tasks. The facility’s written policies for Laundry and Bedding, Soiled, and Standard Precautions required soiled laundry to be handled and processed using infection prevention and control practices, with clean linen stored separately from contaminated linen and workflow designed to prevent cross-contamination. The facility’s IPCP binder showed the infection control committee last reviewed the IPCP in 3/2023, and the IP stated the IPCP should be reviewed every year. The DON also stated the IPCP should be reviewed by the committee every year and as needed to ensure compliance with regulation and infection control standards of practice.
Lack of EVS Training and Improper Laundry Room Practices
Penalty
Summary
The facility failed to implement and maintain an effective training program for all new and existing staff when an Environmental Services staff member did not receive training for proper handling, storing, and processing of residents’ personal clothing for more than a year. During observation and interview, the laundry room contained an overflowing dirty hamper with bagged soiled and dirty residents’ personal clothing, and a container of cookies was placed on top of the counter. Licensed Vocational Nurse 2 stated the dirty hamper should not be overflowing, should remain closed, and that food should not be stored in the laundry room because of cross contamination concerns. During a later observation, the laundry room again showed multiple infection control concerns. A clothing cart rack with a cover was positioned near an overflowing dirty hamper, two dirty hampers were completely open, clean clothing was hanging at the corner of the dryer, a basket containing personal blankets and residents’ clothing was stored on the floor, and bread and coffee were on top of the dryer. The Environmental Services staff member stated he ate in the laundry room, that the clean clothing cart was not empty when he opened it, and that the basket on the floor contained clean resident items. He also stated he should not eat inside the laundry room, dirty hampers should remain closed and not overflowing, and clean items should not be exposed to contamination from dirty items. The Infection Preventionist, DON, and EVS Manager all stated that food was not allowed in the laundry room, dirty hampers should remain closed and not overflowing, clean clothing should be kept separate from dirty items, and clean items should not be stored on the floor. The EVS staff member stated he did not have current EVS training and that his last environmental services training was years ago. Review of the facility’s Laundry and Bedding, Soiled policy showed that soiled laundry must be handled, transported, and processed according to infection prevention and control practices, with clean linen stored separately from soiled linen and workflow designed to prevent cross-contamination. Review of the EVS custodian classification and EVS manager job description showed responsibilities related to following policies and procedures and completing annual employee safety review, annual skills review, and compliance and quality improvement activities.
Medication Administration Without Two Identifiers or Medication Explanation
Penalty
Summary
The facility failed to follow its Medication Administration policy for two residents when an LVN did not use two resident identifiers before giving medications and did not explain the name and indication of the medications being administered. During an observation, the LVN prepared and administered afternoon medications to one resident with a diagnosis of polyosteoarthritis and a BIMS score of 15. The resident had no identification bracelet, stated her full name when asked, and received Vaccinium macrocarpon, Calcium Carbonate Cholecalciferol, and Glucosamine Complex, while the LVN referred to the medications only as "two cranberries, GNP and calcium." The resident stated, "I don't know what they are," and the LVN did not explain the type and indication of the medications. During another observation, the LVN administered a medication to a second resident with Parkinson's disease and dyskinesia, who also had a BIMS score of 15 and no identification bracelet. The LVN asked the resident to state her name, prepared one tablet of Pramipexole Dihydrochloride, and handed the medication cup to the resident while stating, "one tablet of Mirapex." The medication was given with water, and the LVN did not explain the type and indication of the medication before administration. The LVN later stated she used one resident identifier by asking each resident to state her name and acknowledged that the facility was not using identification bracelets. She also stated she did not explain the type and indication of the medications to one resident. The DON stated her expectation was that licensed nurses follow the facility's medication administration policy, use two resident identifiers, and explain medications before administration. The facility policy titled Medication Administration General Guidelines required residents to be identified using at least two resident identifiers and required staff to explain the type of medication being administered and the procedure.
Expired Milk Found in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that food stored in the resident refrigerator was consistently monitored and maintained so that expired items were not available to residents. During an observation of the resident refrigerator located at the nurses' station, two cartons of milk were found with use-by dates of 2/3/26. The refrigerator was part of the food supply used by all 15 residents, and the expired milk was present in the unit refrigerator at the time of the survey observation. Interviews confirmed that the refrigerator was stocked by kitchen staff after SNF staff submitted requests, but once delivered, responsibility for the food items transferred to SNF staff. The CDM, CNA, LVN, IP, and DON all stated that the refrigerator should be cleaned routinely and expiration dates checked so no outdated food items were present. The facility policy titled Food Receiving and Storage stated that refrigerated food are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.
Failure to Notify Ombudsman of Transfer and Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge for one resident after the resident was sent to an acute care hospital and later discharged from the facility. Resident 2’s admission record dated 10/1/24 showed diagnoses of type 2 diabetes mellitus, COPD, chronic atrial fibrillation, chronic kidney disease, and essential hypertension. The resident was discharged on 1/26/26 after being transferred to the hospital for a significant change in health condition. During an interview on 2/6/26, the DON stated the resident was transferred to the acute hospital on 1/26/26 and that the resident was discharged from the facility on 2/6/26 after belongings were packed. The DON stated she failed to notify the Ombudsman regarding the resident’s transfer and discharge, and stated that regulation requires notification of the Long-Term Care Ombudsman for resident transfers and discharges so the Ombudsman is aware of where the resident was transferred or discharged to. The facility policy titled Transfer and Discharge Notices, dated 3/2025, stated that a copy of the transfer or discharge notice is sent to the Office of the State LTC Ombudsman and that notice to the Ombudsman occurs at the same time as notice is provided to the resident and resident representative.
Failure to care plan significant weight gain
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a significant weight gain. The resident had diagnoses including dementia, COPD, heart failure, anemia, and chronic kidney disease, and was observed during multiple meals sitting in a reclining chair, distracted, and not eating her meals. Staff observed that she had decreased oral intake, required cueing to eat, and had ongoing oxygen at 2 liters per minute via nasal cannula. Her bilateral lower extremities were enlarged, and her pants and socks were tight with visible skin indentation above both ankles. Record review showed the resident’s weight increased from 141 lbs. on 11/1/25 to 148.5 lbs. on 12/1/25, and then to 151 lbs. on 2/1/26. The weight note documented a 5.5 lb. increase and a 3.8% change, and staff identified that the resident had a gradual weight gain. The LVN who reviewed the weights stated she notified the physician and responsible party based on the numbers, but did not assess the resident related to the significant weight gain and continued gradual weight gain. She stated there was no weekly weight meeting and no formal discussion regarding significant weight changes. The RD stated the resident had a 13 lb. weight gain over 6 months, a low albumin level of 2.8, a history of edema, and that the resident’s significant weight gain met the criteria for weekly weights. The RD also stated the resident was not on weekly weights until 2/10/26 and that the significant weight gain should have been care planned. Review of the nutrition care plan showed it addressed risk for impaired nutrition and focused on preventing weight loss, with interventions such as monitoring for drooling, coughing, choking, and pain in swallowing, but it did not address the resident’s significant weight gain. The MDSCN stated the care plan was generic, did not include interventions related to significant weight gain, and should have been updated to reflect current interventions and measurable goals. The DON stated the resident was not assessed for significant weight gain and that licensed nurses were expected to follow the facility’s weight policy when a 5% gain occurred.
Failure to Update Nutrition Care Plan for Significant Weight Gain
Penalty
Summary
The facility failed to review and revise a comprehensive person-centered care plan to reflect assessments and interventions for a resident with significant weight gain. Resident 1 had diagnoses including dementia, COPD, heart failure, anemia, and chronic kidney disease. During observations, the resident was sitting in a reclining chair in the dining room, was alert and able to state her name, wore glasses, had difficulty hearing, was on oxygen at 2 lpm via nasal cannula, and was not eating her meals. Staff also observed that the resident’s bilateral lower extremities were enlarged and her pants and socks were tight. Record review and staff interviews showed the resident’s weight increased from 141 lbs. on 11/1/25 to 148.5 lbs. on 12/1/25, which was documented as a significant gain of more than 5% in 30 days, and then continued to rise to 151 lbs. by 2/1/26. The LVN who reviewed the weights stated the resident had a significant weight gain in 30 days and a gradual increase in weight, but also stated she did not assess the resident related to the weight gain. The LVN stated the resident should have been assessed from head to toe to determine whether fluid buildup was contributing to the change. The RD stated the resident had a 13-lb. weight gain over 6 months, described the trend as upward, and stated the resident should have had a nutritional assessment when the significant weight gain was triggered. The RD also stated the facility’s protocol was to place residents with significant gain or loss on weekly weights, that the resident met criteria for weekly weights, and that the resident was not on weekly weights until 2/10/26. The existing nutrition care plan, dated 10/8/24, identified the resident as at risk for impaired nutrition and included monitoring weights monthly or weekly as ordered, but it did not address the resident’s significant weight gain or include interventions specific to the ongoing weight increase. The MDS coordinator and DON both stated the care plan was generic, did not address the significant weight gain, and should have been updated to reflect current interventions and measurable goals.
Expired Medication Found in Medication Storage Cabinet
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with its Medication Storage policy and procedures when an unopened bottle of Fish Oil 1000 mg with an expiration date of 1/2026 was found inside the medication storage cabinet during observation and interview. The expired medication was identified by LVN 1, who confirmed it was expired and stated it should be destroyed and not stored in the medication storage cabinet to prevent medication error. During interviews, LVN 2 stated that storing expired medication in the medication cart or medication storage area could potentially result in administration to residents and medication error, and that expired medications should not be kept in those areas because their effectiveness decreases. The DON also stated that licensed nurses were expected to follow the Medication Storage policy so expired medications would not be stored in the medication storage cabinet ready for resident use. A review of the facility’s Medication Storage policy dated 1/23 stated that outdated medications are to be immediately removed from stock and disposed of according to medication disposal procedures.
Broken Shower Chair Not Maintained in Safe Working Condition
Penalty
Summary
The facility failed to ensure resident care equipment was maintained in safe and operating condition when the shower chair used for bathing was not functional. During observation and interview, Resident 13 stated the shower chair had been broken since admission and could not recline or adjust height, making it difficult to transfer and sit safely. Resident 13 said she used the chair for showers and described it as a safety concern because she could only sit at the edge of it and could fall while using it. Resident 13’s record showed she was admitted with polyosteoarthritis, obesity, reduced mobility, cramp and spasm, and paresthesia of the skin. Her MDS indicated a BIMS score of 15 and that she required supervision or touching assistance for chair/bed-to-chair transfers. Her care plan identified her as at risk for falls and injury related to impaired mobility, function, ROM, and pain, and also noted she had limited mobility and required assistance with ADLs and transfers. During interviews, CNA 1 and CNA 3 stated the shower chair could not be lowered or reclined and that it was not in good working condition. CNA 1 stated the battery had gotten wet during a shower and was broken, and both CNAs stated the malfunction made bathing care difficult and was a safety concern. The DON also stated the shower chair was not in good working condition and interfered with resident care. The SDFO observed the chair had no battery and stated it was not mechanically functioning and not in good working condition.
Lack of RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled and present for at least eight consecutive hours a day, seven days a week. This deficiency was identified during an interview and record review, which revealed that the facility did not have RN coverage on weekends from a specified date range. The Director of Staff Development (DSD) confirmed that the facility had an RN waiver from the Centers for Medicare and Medicaid Services (CMS), but it expired in February 2024. The facility's Director of Nursing (DON), who is a Registered Nurse, worked full-time from Monday to Friday and served as the Charge Nurse, but there was no RN coverage on weekends for several years. The facility's policy and procedure document indicated that a registered nurse should provide services at least eight consecutive hours every 24 hours, seven days a week. However, the staff schedule showed no RN scheduled to work on weekends throughout February 2024. The facility had 16 licensed beds and was at full capacity, necessitating RN presence for tasks such as intravenous medication administration and in-depth assessments. The lack of RN coverage on weekends resulted in inadequate staffing and the potential for residents' medical needs to go unrecognized, posing a risk of serious medical consequences.
Failure to Implement Comprehensive Care Plans for Anticoagulation Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents who were on anticoagulation medication. Resident 10, who had severe cognitive impairment and a history of cerebrovascular issues, did not have a care plan in place to monitor for side effects such as bleeding and bruising. This was confirmed during a review of Resident 10's care plan and physician orders, which indicated the use of aspirin without a corresponding care plan to monitor potential side effects. Similarly, Resident 14, who was cognitively intact and diagnosed with conditions including atrial fibrillation, also lacked a care plan to monitor the side effects of anticoagulation medication. The review of Resident 14's care plan and physician orders showed the use of Apixaban without an order to monitor for side effects like bleeding. Interviews with the Director of Staff Development confirmed the absence of these necessary care plans for both residents. The Director of Nursing acknowledged the responsibility for ensuring that care plans are completed and current, emphasizing their importance in guiding nursing staff to provide individualized care. The facility's policies and job descriptions outline the necessity for comprehensive care plans that incorporate goals and objectives derived from resident assessments, yet these were not adhered to in the cases of Residents 10 and 14.
Medication Administration and Certification Lapses
Penalty
Summary
The facility failed to meet professional standards of practice during medication administration by not informing residents about the names and indications of their medications. Specifically, a Licensed Vocational Nurse (LVN) administered medications to three residents without explaining the purpose and names of the medications. This oversight was observed during medication pass observations, where the LVN did not communicate the details of medications such as Acetaminophen, Lithium Carbonate, Carbidopa-Levodopa, Calcium Carbonate, and others to the residents. The Director of Nursing (DON) acknowledged that the LVN should have informed the residents about their medications, as it is their right to know. Additionally, the facility allowed a Certified Nurse Assistant (CNA) to work with an expired certification. The CNA's certification had expired, yet she continued to provide direct patient care for a period of time. The Director of Staff Development (DSD) and the DON both confirmed that the CNA's certification was not active during this time, which was a failure on the facility's part to ensure that all staff had the necessary qualifications to provide safe care. The facility's policies and procedures, as well as job descriptions for both the LVN and CNA, emphasize the importance of adhering to professional standards and ensuring that staff are qualified and informed about their responsibilities. The failure to follow these guidelines resulted in potential risks to the residents' understanding of their medication regimens and the quality of care they received.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mariposa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Mountain Care Center | 21 mi | ★★★★★ | 7 | 0 |
| Franciscan Post-acute Care Center | 30.2 mi | ★★★★★ | 3 | 0 |
| Golden Merced Care Center | 30.4 mi | ★★★★★ | 4 | 0 |
| Merced Nursing & Rehabilitation Ctr | 30.5 mi | ★★★★★ | 4 | 0 |
| La Sierra Care Center | 30.5 mi | ★★★★★ | 16 | 0 |
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