John C. Fremont Healthcare District Dp/Snf

In the surveyor’s words

From the most serious findings on record at John C. Fremont Healthcare District Dp/Snf, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Feb 10, 2026

  Based on observations, interviews and record reviews, the facility failed to ensure dietary services were directed by a qualified Certified Dietary Manager (CDM) for 15 of 15 residents, when the facility CDM's certification expired on 6/1/25.This failure resulted in a lack of oversight by a qualified Certified Dietary Manger, which had the potential risk to affect food safety, infection control practices, and the nutritional well-being of residents. Findings:During an interview on 2/6/26 at 8:35a.m. with the Cook, the [NAME] stated the CDM was her supervisor and all kitchen staff reported to the CDM. The [NAME] stated the CDM conducted all training for the kitchen staff.During an interview on 2/6/26 at 8:39a.m. with the CDM, the CDM stated her CDM license had lapsed on 6/1/25. […]

• No harm, potential for more than minimal, widespreadF880Feb 10, 2026

  Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program when: 1. The Environmental Services Staff (EVSS) failed to handle, store, and process residents' personal clothing to prevent the spread of infection. 2. The facility's written policies and procedures (P&P) for infection prevention and control program (IPCP) -a set of facility's policies and procedures aimed at preventing the spread of infection) was not reviewed annually by the infection control committee members with last reviewed date of 3/8/23.These failures placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with… […]

• No harm, potential for more than minimal, widespreadF940Feb 10, 2026

  Based on observation, interview, and record review, the facility failed to implement and maintain an effective training program for all staff when an Environmental Services Staff did not receive training for proper handling, storing, and processing of residents' personal clothing for more than a year.These failures to follow proper practices in handling, storing, and processing of residents' personal clothing had the potential to result in an increased risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and developing an avoidable facility acquired infection (the invasion of the body by harmful microorganisms). […]

• No harm, potential for more than minimal, widespreadF727Aug 8, 2024

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day, seven days per week, when the facility did not have an RN scheduled to work on weekends (Saturday and Sunday), from [DATE] to [DATE]. The facility did not provide documented evidence of Center for Medicare and Medicaid (CMS-is a federal government agency) approved waiver for this requirement. This failure resulted in an inadequate RN facility staffing and the potential for residents to have their medical needs to go unrecognized by an RN and the potential for serious medical consequences to occur. […]

• No harm, potential for more than minimal, widespreadF727Oct 20, 2022

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) served as the Director of Nursing (DON) and an RN was scheduled and in the facility for at least eight consecutive hours a day, seven days per week when the facility did not have an RN scheduled on 11/15/19 to 10/20/22. The facility did not provide documented evidence of CMS approved waiver for this requirement. This failure resulted in an inadequate RN facility staffing and the potential for residents to have their medical needs to go unrecognized by an RN and the potential for serious medical consequences to occur. […]