Fremont Healthcare Center

In the surveyor’s words

From the most serious findings on record at Fremont Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF760Mar 14, 2022

  Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received PRN (as needed) medications as ordered by the physician. The failure to monitor Resident 1's bowel movements resulted in no administration of ordered PRN bowel regimen medications (a regimen of medications designed to promote bowel movement) even though Resident 1 had no bowel movements for five days. This contributed to Resident 1's development of a fecal impaction (a hard, dry mass of stool which cannot be moved or excreted from the intestines with a normal bowel movement, also known as bowel impaction) which caused compression of internal organs, prevented normal urination, and required critical care treatment to prevent life-threatening urinary obstruction and severe… […]

• Actual harm, isolatedF600Jun 16, 2021

  Based on observation, interview, and record review, the facility failed to ensure one resident in a sample of four (Resident 2) was free from physical abuse when Resident 1, who required monitoring for physical aggression and was observed to have escalating behaviors, attacked Resident 2, and ten minutes later attacked Resident 2 again, which caused an eight-centimeter (cm, a length of measurement; eight cm equals 3.15 inches) laceration (open wound) on Resident 2's forearm. The failure of facility staff to monitor Resident 1 after the first attack on Resident 2 resulted in Resident 2 being sent to the emergency room where her laceration needed stitches to close the wound. […]

• Actual harm, isolatedF689May 20, 2021

  Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was securely fastened in the wheelchair during transportation in a facility van. For Resident 1, this failure resulted in dislodgement from the wheelchair during transportation. The dislodgement caused a fracture (broken bone) of the left leg, which led to a two-day hospitalization , and had the potential to have caused more severe injury and death. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility in 2019 with a diagnosis of [CONDITION(S)] ([CONDITION(S)], loss of blood supply to the brain, commonly known as stroke), which caused a left sided [CONDITION(S)] (paralysis of one side of the body) and… […]

• No harm, potential for more than minimal, patternF605Nov 17, 2025

  Based on observation, interviews and record review, the facility failed to ensure two (Resident 68 and 79) of five sampled residents were free from unnecessary drugs when: 1. Resident 68 with diagnosis of non-Alzheimer's dementia was administered Haloperidol (Haldol an antipsychotic medication) for hitting and grabbing, an inadequate indication for use.Facility did not address Resident 68's involuntary jerky movements as an adverse reaction for the use of Haldol.Facility did not attempt gradual dose reduction (GDR) for Resident 68 use of Haldol. […]

• No harm, potential for more than minimal, patternF689Nov 17, 2025

  Based on observation, interview and record review, the facility failed to provide staff supervision for five sampled residents (Resident 99, 11, 20, 24 and 91 during smoking to ensure an environment free of accident hazards.This failure had the potential to cause fire hazards, injuries, and jeopardize the health and safety of the residents.During an observation on 9/16/25 at 10:15 a.m. Resident 99 smoking a cigarette outside her room by the sliding door leading to the smoking patio. There was an oxygen tank filled with oxygen beside her bed (Bed D) in her room, and an oxygen concentrator with oxygen in her space next to Bed C. Certified Nursing Assistant (CNA) 5 confirmed that Resident was smoking. […]