Regency at Fremont

In the surveyor’s words

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

• Actual harm, isolatedF684Feb 4, 2026

  This citation pertains to intake #2715766Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (Resident #6) out of 3 residents reviewed for quality of care, resulting in a delay in medical treatment and surgical intervention for an unstable sacral fracture with spinopelvic dissociation and left superior/inferior ramus fractureFindings:Resident #6 (R6)Review of an admission Record revealed R6 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: sacral and pelvic fractures from fall and Parkinson's Disease.Review of a Minimum Data Set (MDS) assessment for R6, with a reference date of 11/6/25 revealed a Brief Interview for Mental Status (BIMS) score of… […]

• Actual harm, isolatedF689Aug 16, 2023

  This citation is related to intake #MI00137878 Based on interview and record review, the facility failed to follow facility policy and best practice standards related to fall management for two residents (Resident #3 and Resident #2) by (a) not providing increased supervision, (b) not notifying the physician of low blood pressures, (c) not completing and/or maintaining neurological assessments after falls, (c) not correctly completing a fall assessment, (d) moving a resident after a fall before being assessed by a nurse, and (e) not updating or accurately completing care plans, resulting in falls with injury. […]

• Actual harm, isolatedF686Jun 30, 2022

  Based on observation, interview and record review, the facility failed to prevent a pressure ulcer and prevent the worsening of a pressure ulcer for 2 Residents (R51 and R62), resulting in R51 developing an unstageable pressure ulcer on her buttock and R62's pressure ulcer on his left heel increasing in size. Findings include: R51 Review of R51's face sheet dated 6/28/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R51 was not her own responsible party. […]

• Actual harm, isolatedF580Dec 3, 2021

  Based on interview and record review, the facility failed to notify the physician and responsible party in a timely manner of an acute change in condition for 1 resident (Resident #1) resulting in ongoing, untreated pain and functional limitations from an undiagnosed comminuted and displaced intertrochanteric proximal right femoral fracture. Findings: Review of a facility Admission Record reflected Resident #1 (R1) admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R1 was severely cognitively impaired and needed extensive assistance from one person for bed mobility, transfers, walking, dressing, eating, toileting and personal hygiene. […]

• Actual harm, isolatedF656Dec 3, 2021

  This citation pertains to intake MI- 3 Based on interview and record review, the facility failed to implement care plans based on a comprehensive assessment for 1 resident (Resident #1) resulting in a delay in physician notification, assessment, and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of a facility Admission Record reflected Resident #1 (R1) admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R1 was severely cognitively impaired and needed extensive assistance from one person for bed mobility, transfers, walking, dressing, eating, toileting and personal hygiene. […]