Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Niles Canyon Post Acute during CMS and state inspections, most recent first.
A resident with type 2 DM, malnutrition, and severe cognitive impairment was admitted on oral sitagliptin but did not receive physician orders for HbA1c monitoring every 6 months or capillary blood glucose checks at least twice weekly, as required by the facility’s diabetes protocol. The DON confirmed that no blood glucose monitoring orders were in place, and record review showed no blood sugar assessments for over a year after admission. The attending MD reported that an order set for HbA1c monitoring should have been automatically placed for residents on oral diabetic medications but was not entered for this resident. The resident was later transferred to a hospital with altered mental status and weakness, where labs showed a blood glucose level greater than 800 mg/dL.
A resident with severe cognitive impairment, malnutrition, and type 2 DM was admitted on oral sitagliptin, but the MD did not provide ongoing lab orders or independently review abnormal glucose-related labs. A hemoglobin A1C of 10.8% and later a CMP glucose of 273 mg/dL were documented in the EHR and described by the DON and MD as very high and warranting additional orders, yet the MD relied solely on nursing staff to notify him of abnormal results and did not follow up on ordered labs. Facility policies required the provider to order individualized glucose monitoring and necessary diagnostic testing, but no additional routine monitoring orders were documented, and the resident was later hospitalized with altered mental status and a blood glucose level over 800 mg/dL.
A resident with severe cognitive impairment and type 2 DM had repeatedly elevated blood glucose levels documented in lab reports, including a markedly high HbA1c and elevated CMP glucose. Nursing staff filed the labs in the EHR and documented that the MD was notified, including sending photos of the results by text, but the MD did not review or sign the lab reports or issue new orders. The resident was later hospitalized with altered mental status, weakness, and a blood glucose level over 800 mg/dL, while facility policies required timely MD response and documentation for abnormal lab and diagnostic results.
A resident with intact cognition and a care plan for altered cardiovascular status was receiving Metoprolol with an order to hold the dose if SBP was below 100 or HR below 60, and facility policies required reporting hypotension and SBP below 90 to a physician. Over multiple days, the resident had at least ten SBP readings under 100 mmHg that were not reported, and on one evening was documented with hypotension and altered mental status after routine night medications, with repeated BP readings in the 70s–80s systolic and 30s–40s diastolic before being sent to a hospital for low BP and confusion. In interviews, an LVN, ADON, and DON acknowledged that several of these low readings met criteria for physician notification and that there was no documentation that the physician had been notified, demonstrating a failure to follow physician parameters and facility guidelines for reporting hypotension.
An LVN was found to be working without current Basic Life Support (BLS) certification, despite facility policy requiring all clinical staff, including non-licensed personnel, to obtain and maintain BLS/CPR credentials consistent with American Heart Association guidelines. Review of the LVN’s competency file showed the BLS card listed a renewal due date that had passed, and the DSD confirmed that LVNs are required to have BLS and CPR training to ensure competency in life-saving measures during critical situations.
A resident with moderately impaired cognition who required assistance with toileting was assisted to the floor after being unable to ambulate from a bedside commode. The resident reported mild pain and later showed non-verbal pain cues and increasing right ankle swelling, for which Tylenol was administered. An LVN notified the physician, who ordered a STAT X-ray of both knees and the right ankle, but the imaging was not completed within the expected STAT timeframe and was still outstanding at the end of the evening shift. The night-shift LVN observed swelling, pain, and purple discoloration of the right ankle and found the STAT X-ray had still not been done; the resident was later transferred to the hospital, where a tibia/fibula fracture related to the fall was diagnosed. The DON reported that STAT orders were to be completed within four hours and that unmet timelines required physician notification per facility policy.
A resident with depression and limited English proficiency experienced anxiety after their cell phone went missing. Despite the caregiver notifying staff, no Theft and Loss Report was completed, and the Social Services Director was not informed, resulting in a lack of investigation and delayed resolution.
The facility failed to store food safely and sanitarily, with expired prune juice, improperly stored rice and flour, and unsealed, unlabeled, or expired items in freezers. The Dietary Manager was unaware of storage requirements, while the Registered Dietician highlighted the importance of sealing and proper labeling to prevent contamination.
Failure to Obtain Diabetic Monitoring Orders for a Resident on Oral Hypoglycemics
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to obtain and implement physician orders for hemoglobin A1C monitoring every 6 months and blood glucose capillary/fingerstick assessments at least twice weekly for one resident with type 2 diabetes. The resident was admitted in March 2024 with diagnoses including type 2 diabetes and malnutrition and was prescribed oral sitagliptin. The resident’s MDS dated 2/14/25 documented severe cognitive impairment with a BIMS score of 6/15. Review of the admission record and the Order Listing Report showed no physician orders for A1C monitoring or blood glucose testing at admission or thereafter, despite the facility’s Diabetes Clinical Protocol requiring the provider to order glucose targets and monitoring regimens, including A1C on admission and every 6 months and at least twice-weekly blood glucose monitoring for residents on oral diabetic medications who are well controlled. The DON confirmed during interview that a physician’s order is required to perform blood glucose capillary/fingerstick testing and acknowledged that the resident had no such orders, even though it was important to assess blood glucose to determine blood sugar status and monitor the treatment plan. The attending MD stated that residents with stable type 2 diabetes on oral medications should have an order set in the EHR for A1C monitoring every 6 months and that this was a standard order set automatically placed on admission, but the resident did not receive it for reasons the MD could not explain. Medical Records and the Administrator reported that the MD had access to the facility EHR but used a personal EHR system, with relevant documents uploaded monthly by Medical Records. Review of the resident’s Weights and Vitals Summary showed no blood sugar assessments between admission on 3/11/24 and 3/18/25. The resident was later admitted to a general acute care hospital with altered mental status, including lethargy, confusion, partial responsiveness, and weakness, where labs showed a blood glucose level greater than 800 mg/dL.
Failure to Monitor and Follow Up Abnormal Glucose Labs for Diabetic Resident
Penalty
Summary
The deficiency involves the failure of the attending physician to provide appropriate laboratory orders and follow-up for a resident with type 2 diabetes who was receiving oral sitagliptin. The resident, who had severe cognitive impairment (BIMS score 6/15), malnutrition, and type 2 diabetes, was admitted in March 2024 with an order for sitagliptin. A lab report dated 3/16/2024 showed a hemoglobin A1C of 10.8% and an estimated average glucose of 263 mg/dL, which the DON and MD both described as elevated and very high, warranting additional orders. The lab results were reviewed in the EHR by the ADON, and the facility’s process was that abnormal labs should be communicated to the MD via fax, phone, or text. However, the MD stated that the 3/16/2024 lab report was not reviewed by him and that he relied on nursing staff to notify him of abnormal results, and he did not follow up on ordered lab results independently. A subsequent Comprehensive Metabolic Panel collected on 2/21/2025 showed a glucose level of 273 mg/dL, which the MD also stated was high and warranted MD notification for additional orders. Medical Records and the Administrator reported that although the MD had access to the facility’s EHR, he used a personal EHR system, and MR uploaded SOAP notes, history and physicals, lab results, past medical history, and current medications into that system monthly per the MD’s request. The facility’s diabetes clinical protocol required the provider to order desired glucose targets and monitoring regimes and to assess glycemic status by A1C and blood glucose monitoring, and the lab/diagnostic testing policy required the physician to identify and order diagnostic and lab testing based on residents’ needs. Despite these policies and the abnormal lab findings, there were no documented additional lab orders for routine monitoring, and the resident was later admitted to a general acute care hospital with altered mental status, lethargy, confusion, partial responsiveness, and weakness, where a lab result showed blood glucose greater than 800 mg/dL.
Failure to Act on Abnormal Blood Glucose Labs for Diabetic Resident
Penalty
Summary
Facility staff notified the attending physician on two occasions about a resident’s elevated blood glucose levels but the physician did not review the laboratory results, discuss the resident’s status with nursing staff, or change the treatment regimen. The resident, who had severe cognitive impairment with a BIMS score of 6/15 and a diagnosis of type 2 diabetes, had an admission record and MDS documenting these conditions. The DON stated that lab results were filed in the EHR after being received and reviewed by nurses, that physicians had access to the EHR, and that nurses were responsible for placing lab results in the paper chart and documenting physician notification with date, time, and signature on the lab results after communication. The physician reported relying on nursing staff to communicate abnormal lab results by phone or text and stated that abnormal results warranted additional orders. A lab report dated 3/16/2024 showed a hemoglobin A1C of 10.8% and an estimated average glucose of 263 mg/dL, which the physician described as very high and warranting additional orders, but this report was not sent or reviewed by the physician. A CMP dated 2/21/2025 showed a glucose level of 273 mg/dL, which the physician also stated was high and required notification for additional orders. The physician indicated that all orders and new orders were based on communication from nurses during resident assessments and emphasized the importance of abnormal lab results being communicated for proper interventions. Record review showed that the physician did not sign the 3/16/2024 lab results to indicate review or initiate new orders, despite facility text message records showing that the physician was notified of the lab results with three photos and did not respond. Similarly, the CMP from 2/21/2025 had a notation that the physician was notified by an LVN, but the physician did not sign the lab results or initiate new orders. Subsequently, the resident was admitted to a general acute care hospital with altered mental status, including lethargy, confusion, partial responsiveness, and weakness, and hospital labs documented a blood glucose greater than 800 mg/dL. Facility policies on physician notification and lab/diagnostic test results required timely physician response and documentation of when, how, and to whom information was provided, as well as the physician’s response, but the physician did not document review or respond with new orders for the abnormal lab results.
Failure to Report Repeated Hypotension to Physician
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of repeated episodes of hypotension for one resident with known cardiovascular issues and an order for antihypertensive medication. The resident had an MDS BIMS score of 15/15, indicating intact cognition, and a care plan identifying altered cardiovascular status related to persistent hypotension with a goal to remain free from complications of cardiac problems. The physician’s order for Metoprolol Tartrate 100 mg (two tablets at bedtime) included parameters to hold the medication if systolic blood pressure (SBP) was less than 100 or heart rate less than 60. The facility’s own Blood Pressure Measuring policy defined hypotension as BP less than 100/60 mmHg and required that hypotension be reported to the physician, and its Guidelines for Notifying Physicians of Clinical Problems directed staff to report SBP less than 90 mmHg. Despite these parameters and policies, the resident’s Weights and Vitals Summary from 12/1/25 to 12/9/25 showed ten separate instances of SBP less than 100 mmHg that were not reported to the physician. On 12/9/25, documentation of a change of condition noted the resident with hypotension and altered mental status after routine night medications around 2030, with a blood pressure of 75/44 and pulse 76 at 11:30 p.m., and repeat readings mostly in the range of 73–85 systolic and 37–46 diastolic. The resident was subsequently sent to a general acute care hospital that night for low blood pressure and confusion, where a physical exam documented a blood pressure of 87/39 mmHg. During interviews, an LVN stated that SBP less than 90 mmHg should be rechecked and reported to the physician, and the ADON acknowledged that specific low readings (90/56, 86/56, and 86/56) should have been reported and that there was no documentation of physician notification for two hypotensive episodes on 12/8/25. The DON stated that reportable blood pressure was defined in physician orders and that nurses should follow ordered parameters, while also recognizing the importance of reporting hypotension so physicians are aware of resident blood pressure assessments. These observations, interviews, and record reviews show that the facility did not follow its policies or physician parameters to report hypotension to the physician for this resident.
Failure to Ensure LVN Maintained Required BLS Certification
Penalty
Summary
Surveyors identified that an LVN did not hold current Basic Life Support (BLS) certification as required by facility policy. Review of the LVN’s competency and skills folder showed documentation indicating the BLS certification was due for renewal by 07/2024, with no evidence presented that renewal had occurred. In a concurrent interview and record review, the Director of Staff Development stated that LVNs are required to have BLS and CPR training and emphasized the importance of BLS to ensure staff competency in life-saving measures during critical situations. Review of the facility’s policy and procedure titled “Emergency Procedures–Cardiopulmonary Resuscitation” showed that all clinical staff members, including non-licensed personnel, are required to obtain and/or maintain BLS/CPR certification in accordance with American Heart Association guidelines. The report states that this failure to ensure the LVN maintained current BLS certification had the potential to result in residents’ increased risk of adverse events during life-threatening cardiac or respiratory emergencies.
Failure to Complete STAT X-Ray Order After Resident Fall
Penalty
Summary
The facility failed to follow a physician’s STAT order for diagnostic imaging after a resident fall, resulting in a delay of more than 10 hours before appropriate evaluation occurred. The resident, who had moderately impaired cognition per a BIMS score of 9 and required supervision or touching assistance with toileting transfers, was assisted to a bedside commode by a CNA. After toileting, the resident was unable to turn or walk back to bed and was assisted to the floor. The assigned nurse assessed the resident at that time, documented pain rated three out of ten, and administered Tylenol. Later in the afternoon, the evening-shift LVN observed non-verbal pain cues and increased swelling of the resident’s right ankle, administered additional Tylenol, and notified the physician. At approximately 4:00 p.m., the physician ordered a STAT X-ray of both knees and the right ankle related to the fall and swelling, but the imaging was not completed during the LVN’s shift despite the nurse’s understanding that STAT orders should be completed within four hours. The night-shift LVN subsequently noted swelling, pain, and purple discoloration of the right ankle and found that the STAT X-ray still had not been performed. The resident continued to receive Tylenol for pain throughout the evening and night. The resident was ultimately sent to the emergency department after midnight, where hospital records later documented a fracture of the right tibia and fibula related to the fall. The DON stated that STAT orders were expected to be completed within four hours and that if this could not be achieved, the physician should be notified to determine if there was a significant change or need for hospital transfer, consistent with the facility’s policy on acute condition changes.
Failure to Protect Resident Property and Promptly Investigate Loss
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's property from loss, specifically the resident's cell phone. The resident, who was admitted with a diagnosis of depression and primarily spoke Chinese, was assessed as usually able to understand and communicate with some difficulty. The resident's cell phone went missing, and their caregiver reported the loss to staff. However, staff did not take further action or communicate back to the caregiver. The missing cell phone was not reported in the facility's Theft and Loss Binder, and the Social Services Director, who was responsible for investigating such incidents, was not notified. The resident experienced anxiety due to being unable to contact family members because of the missing phone. Interviews with staff revealed that although the caregiver informed an LVN about the missing phone, the LVN did not complete a Theft and Loss Report or notify the Social Services Director. The Director of Nursing acknowledged the importance of resolving the issue promptly, especially given the resident's language barrier and need for communication. A review of the resident's inventory confirmed the cell phone was listed as a personal effect, and facility policy required prompt investigation of all theft or misappropriation reports, which was not followed in this case.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure that resident food was stored in a safe and sanitary manner, as observed during a survey. In the dry food storage and freezer room, several items were found to be improperly stored. Sixteen prune juice cups with expired use-by dates were found on a shelf. Additionally, an open box of bananas, and containers of brown rice, white rice, and flour were stored only 3.5 inches above the floor, which is below the required minimum height. In the freezers, various food items such as frozen dinner rolls, strawberry ice cream, fish fillets, chicken, bacon, and meat were found unsealed, unlabeled, or undated, with some items also having expired use-by dates. Interviews with the Dietary Manager (DM) and Registered Dietician (RD) revealed a lack of adherence to the facility's policies and procedures. The DM was unaware of the minimum storage height for food and incorrectly believed that unsealed frozen food was acceptable. The RD emphasized the importance of sealing frozen food to prevent freezer burn and contamination, and stated that food should be stored at least 6 inches above the floor. The facility's policies required all food to be labeled with received, opened, and use-by dates, and to be stored in a manner that protects it from contamination. The failure to follow these procedures had the potential to cause infection and foodborne illness among residents receiving food from the kitchen.
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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) |
|---|---|---|---|---|
| Mission Valley Post Acute | 0.9 mi | ★★★★★ | 0 | 0 |
| We Care Skilled Nursing - Fremont | 1 mi | ★★★★★ | 3 | 0 |
| Country Drive Post Acute | 1 mi | ★★★★★ | 4 | 0 |
| Crestwood Treatment Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Fremont Healthcare Center | 2.1 mi | ★★★★★ | 30 | 0 |
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