Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to develop and implement a comprehensive,
person-centered care plan (CP -a detailed approach to care customized to an individual resident's needs)
for two of five residents (Residents 10 and 14) when Residents 10 and 14 did not have a CP for the used of
anti-coagulation medication (medication that prevents blood clots from forming) to monitor for side effects
such as bleeding and bruising.
This failure had the potential to place Resident 10 and Resident 14 at risk for signs and symptoms of
bleeding to go unidentified.
Findings:
During an observation on 8/6/24 at 10:59 a.m. in Resident 10's room, Resident 10 was observed dressed,
sleeping in bed. No bruising or bleeding was observed on Resident 10.
During a review of Resident 10's admission Records (AR- contains information that helps the healthcare
team understands patient's health status and provide tailored care), dated 8/8/24, the AR indicated
Resident 10 was admitted on [DATE] with diagnoses of dementia (loss of memory, language,
problem-solving and other thinking abilities that are severe enough to interfere with daily life), essential
(primary) hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood
through the arteries] that is not the result of a medical condition), hyperlipidemia (a condition where fats
build up in the arteries, increasing the risk of a stroke [a condition when a blood vessel that carries oxygen
and nutrients to the brain is either blocked or ruptures]or heart attack [a condition with the blood flow that
brings oxygen to the heart is severely reduced or blocked]), and history of transient ischemic attack (TIA - a
short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain)
and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area).
During a review of Resident 10's Minimum Data Set (MDS-standardized assessment tool that measures
health status in nursing home residents), dated 7/12/24, the MDS section C indicated Resident 10 had a
Brief Interview for Mental Status (BIMS- an assessment used in nursing homes to monitor cognition) score
of zero, indicating Resident 10 had severe cognitive impairment.
During a concurrent interview and record review on 8/8/24 at 1:36 p.m. with the Director of Staff
Development (DSD), Resident 10's CP, dated 8/8/24 was reviewed. The CP indicated Resident 10 did not
have a CP for the used of anticoagulant medication. The DSD stated Resident 10 should have had a CP in
place to monitor for bleeding or bruising. The DSD stated Resident 10 did not have an
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
055283
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
individualized CP for the used of anticoagulant medication.
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 10's PO, dated August 2024, the PO indicated, . aspirin [medication used to
reduce the risk for blood clot formation] 81 mg [milligrams- units of measurement] EC [enteric coated- a
protective layer applied in oral medications to prevent from dissolving in the stomach's acidic environment]
tablet 1 tab by mouth daily Hx [history] of CVA [cerebrovascular accident- occurs when blood flow to the
brain is interrupted, cause by broken blood vessels or blood clots] .
Residents Affected - Some
During an observation on 8/6/24 at 11:04 a.m. in Resident 14's room, Resident 14 was observed dressed
sitting in an electric wheelchair, leaning back, and sleeping wearing headphones. No bleeding or bruising
was observed on Resident 14.
During a review of Resident 14's AR, dated 8/8/24, the AR indicated Resident 14 was admitted on [DATE]
with diagnoses of paraplegia (paralysis [the loss of the ability to move and sometimes to feel anything] that
occurs in the lower half of the body), atrial fibrillation (A-fib - an irregular and often very rapid heart rhythm)
and essential (primary) hypertension (abnormally high blood pressure [the amount of force the heart uses
to pump blood through the arteries] that is not the result of a medical condition).
During a review of Resident 14's MDS, dated 6/4/24, the MDS section C indicated Resident 14 had a BIMS
score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired,
13-15 suggests cognitively intact), which indicated Resident 14 was cognitively intact.
During a concurrent observation and interview on 8/6/24 at 12:30 p.m. with Resident 14 in the hallway,
Resident 14 was observed eating his meal sitting with licensed vocational nurse (LVN) 1. Resident 14
stated he had no bruising or bleeding.
During a concurrent interview and record review on 8/6/24 at 4:02 p.m. with the DSD, Resident 14's
Physicians Orders (PO), dated 8/2024, was reviewed. The PO indicated . Apixaban [medication used to
reduce the risk for blood clot formation] 5 mg tablet 1 tab by mouth twice daily. DX [diagnosis]: A-Fib . The
DSD stated there was no order to monitor anticoagulation medication side effects such as bleeding.
During a concurrent interview and record review on 8/8/24 at 1:39 p.m. with the DSD, Resident 14's Care
Plan (CP), dated 8/8/24 was reviewed. The CP indicated Resident 14 did not have a CP in place to monitor
side effects of anticoagulant medication used such as bleeding or bruising. The DSD stated Resident 14
should have a CP for the used of anticoagulation medication to monitor for bleeding and bruising.
During an interview on 8/8/24 at 2:42 p.m. with the Director of Nursing (DON), the DON stated the DON
was ultimately responsible for making sure residents CPs were completed. The DON stated her expectation
was for CPs to be current and not outdated. The DON stated CPs were important because it helps guide
nursing staff on how to provide consistent individualized care to residents. The DON stated Resident 10
and Resident 14 should have a CP initiated for the used of anticoagulation medication to help monitor for
side effects such as bleeding and bruising.
During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated
2021 indicated, . care plans shall incorporate goals and objectives that lead to the resident's highest
obtainable level of independence . care plan goals and objectives are derived from
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
information contained in the resident's comprehensive assessment . are resident oriented . goals and
objectives are entered on the resident's care plan so that all disciplines have access to such information
and are able to report whether or not the desired outcomes are being achieved .
During a review of the P&P titled, Care Plans, Comprehensive Person-Centered, dated 2021, indicated .
the comprehensive, person-centered care plan: . describes the services that are to be furnished to attain or
maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently
recognized standards of practice for problem areas and conditions .
During a review of the facility's job description (JD) titled, MDS Coordinator/RN, dated 11/28/17, indicated, .
employee's primary responsibility is to conduct and coordinate the development and completion of the
resident's assessments/care plans . completes preliminary and comprehensive assessments of the nursing
needs of each resident . appropriately coordinates the development of a written plan of care (preliminary
and comprehensive) for each resident that identifies the problems/needs of the resident, indicates the care
to be given, goals to be accomplished . assists . in ensuring that all personnel involved in providing care to
the resident are aware of the resident's care plan that nursing personnel refer to resident's care plan prior
to administering daily care to the resident .
During a review of the facility's JD titled, LVN, Level I, II, III, dated 1/13/17, indicated, . major duties and
responsibilities . reads and signs Care Plans . writes and updates long and short-term care plans .
During a review of the facility's JD titled, Director of Skilled Nursing, dated 10/1/19, indicated . major duties
and responsibilities: . assures that the nursing process is carried out (comprehensive assessments, care
planning and documentation) .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide services which met professional standards of
practice when:
Residents Affected - Some
1. License Vocational Nurse (LVN) 1 during medication administration failed to inform facility residents the
names and indications of the medications they are taking for three of eight sampled residents (Resident 3,
6, and 11).
This failure had the potential risk for Resident 3, Resident 6, and Resident 11 to not understand the
importance of their medication regimen and feelings of being not in control of their health and wellbeing
which could lead to noncompliance.
2. Certified Nurse Assistant (CNA) 1's CNA certification expired on [DATE] and the facility scheduled CNA 1
to work and provide direct patient care from [DATE] to [DATE].
This failure had the potential risk to place all facility residents to received unsafe and poor quality of care.
Findings:
1. During a medication pass observation on [DATE], at 12:07 p.m., inside Resident 3's room, LVN 1
administered Acetaminophen (medication use for generalized pain or discomfort) 325 mg (milligram, unit of
measurement) 2 tablets (650 mg) and Lithium carbonate (medication use to stabilize the mood and
extreme behaviors) 150 mg one capsule without explaining the medication and indication to Resident 3.
During a review of Resident 3's admission Record (AR, a document that provides resident contact details, a
brief medical history, level of functioning, preferences, and wishes), dated [DATE], the AR indicated,
Resident 3 was admitted from an acute care hospital on [DATE] to the facility, whose diagnoses included
Bipolar disorder (a mental condition marked by alternating periods of joy and depression), Hypertension
(high blood pressure), History of Falling, Weakness, and Insomnia (difficulty sleeping).
During a review of Resident 3's Order Summary Report (OSR), dated [DATE], the OSR indicated, .
ACETAMINOPHEN 325 MG TABLET 2 TABS (650 MG) BY MOUTH TWICE DAILY FOR PAIN . Order date
[DATE] . LITHIUM CARBONATE 150 MG CAPSULE: 1 capsule by mouth three times every day . Dx
[Diagnosis]: Bipolar Disorder . Order date [DATE] .
During a medication pass observation on [DATE], at 12:10 p.m., inside Resident
11's room, LVN 1 administered Carbidopa-Levodopa (medication for Parkinson's Disease, a disease of the
brain and spinal cord) 25-100 mg 1 tablet without explaining the medication and indication to Resident 11.
During a review of Resident 11's AR, dated [DATE], the AR indicated, Resident 11 was admitted from an
acute care hospital on [DATE] to the facility, whose diagnoses included Parkinson's Disease, Muscle
Weakness, Type 2 Diabetes Mellitus (disorder of blood sugars), and Major Depressive Disorder (a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
mood disorder that causes a persistent feeling of sadness and loss of interest).
Level of Harm - Minimal harm
or potential for actual harm
During a review of Resident 11's OSR, dated [DATE], the OSR indicated, .
Residents Affected - Some
CARBIDOPA-LEVODOPA 25-100 TAB ONE TAB BY MOUTH THREE TIMES A DAY DX: PARKINSON'S
DISEASE . Order date [DATE] .
During a medication pass observation on [DATE], at 1:52 p.m., inside Resident
6's room, LVN 1 administered Calcium Carbonate 500 mg 1 tablet, Sennosides Laxative (medication to
prevent constipation) 1 tablet, Polyethylene Glycol powder (medication to prevent constipation) 17 grams
mix with 4 ounce of water, Vitamin D3 (ergocalciferol, supplement that helps the body to absorb calcium
and phosphorous) 2000 units 1 tablet, Divalproex sodium ER (medication to treat mood episodes and
depression) 125 mg 1 capsule, and Hydrocodone-Acetaminophen 10-325 mg 1 tablet without explaining
the medications and indications to Resident 6.
During a review of Resident 6's AR, dated [DATE], the AR indicated, Resident 6 was admitted from an
acute care hospital on [DATE] to the facility, whose diagnoses included Dementia (impaired ability to
remember, think, or make decisions), Hypertension, Chronic Pain (pain longer than six months), Muscle
Weakness, Constipation, Osteoarthritis (degenerative disease of the bone joints that worsens over time,
often resulting in chronic pain), and Major Depressive Disorder.
During a review of Resident 6's OSR, dated [DATE], the OSR indicated, .
CALCIUM CARBONATE 500 MG 1 TABLET DAILY . Order date [DATE] . SENNOSIDES LAXATIVE TABLET
1 TABLET BY MOUTH TWICE DAILY . Order date [DATE] . POLYETHYLENE GLYCOL POWDER 17
GRAMS MIX WITH 4 OUNCE OF WATER . Order date [DATE] . VITAMIN D3 2000 UNITS 1 TABLET BY
MOUTH DAILY . Order date [DATE] . DIVALPROEX SODIUM ER 125 MG 1 CAPSULE BY MOUTH TWICE
A DAY . Order date [DATE] . HYDROCODONE-ACETAMINOPHEN 10-325 MG 1 TABLET BY MOUTH
THREE TIMES A DAY . Order date [DATE] .
During an interview on [DATE], at 2:10 p.m., with LVN 1, LVN 1 stated she did not explain the medications
and indications when she gave the medications to Residents 3, 6, and 11. LVN 1 stated facility residents
had the right to know the medications they are receiving, and she failed to inform Resident 3, Resident 6,
and Resident 11.
During an interview on [DATE], at 10:07 a.m. with the Director of Nursing (DON), the DON stated LVN 1
should have explain the medications and their use prior to medication administration. The DON stated
facility Residents had the right to know the medications they are taking. The DON stated LVN 1 failed to
follow the facility's expectations and assigned responsibilities during medication pass.
During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, dated 1/17, the
document indicated, . Job Summary: Employee administers appropriate nursing care to residents in the
skilled nursing facility . Performs a variety of direct and indirect patient care duties and activities . D.
Essential Skills . 14. Understanding of the principles and practices of licensed vocational nursing. 15.
Understanding of the pharmaceuticals prescribed for the elderly, and has knowledge of actions of
medications and their side effects .
During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/19,
the P&P indicated . Medications are administered in a safe and timely manner, and as
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0658
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
prescribed . 5. Medication administration times are determined by resident need and benefit . c. honoring
resident choices and preferences, consistent with his or her care plan .
2. During a concurrent interview and record review on [DATE], at 2:22 p.m., with
the Director of Staff Development (DSD), the facility document titled, CNA 1's Personnel File, undated was
reviewed. The DSD stated CNA 1 was hired on [DATE] and her annual evaluation was completed and
signed on [DATE]. The DSD stated CNA 1's CNA certification expired on [DATE] and she did not find a copy
of CNA 1's active CNA certification. The DSD stated the facility failed to ensure CNA 1's CNA certificate
was active prior to scheduling her to work on [DATE]. The DSD stated CNA 1 was working and providing
care to facility residents with an expired CNA certification from [DATE] to [DATE]. The DSD stated the failure
had the potential to place facility residents at risk of receiving unsafe care from CNA 1.
During a concurrent interview and record review on [DATE], at 2:35 p.m., with
the DON, the facility document titled, CNA 1's Personnel File, undated was reviewed. The DON stated CNA
1's CNA certification expired on [DATE] and she did not find a copy of CNA 1's active CNA certification. The
DON stated she completed and signed CNA 1's annual evaluation on [DATE] and failed to obtain a copy of
CNA 1's active CNA certificate prior to scheduling her to work on [DATE]. The DON stated the failure had
the potential to place facility Residents at risk of receiving unsafe care from CNA 1.
During a review of the facility's document titled, Job Description: Certified Nurse Assistant, dated 6/20, the
document indicated, . Job Summary: Employee performs various non-professional patient/resident care
duties in the skilled nursing department. Maintains and operates hospital and nursing equipment, provides
bedside care and assists in the treatment of patients Minimum Qualifications . 2. Successful completion of
nursing assistant course . B. Follows District and Skilled Nursing Department policies and procedures . 8.1
Demonstrates and understanding of policies, procedures, State and Federal regulations .
During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent
Nursing, dated 8/22, the P&P indicated . Our facility provides sufficient numbers of nursing staff with the
appropriate skills and competency necessary to provide nursing and related care and services for all
residents in accordance with resident care plans and facility staff . Nurse aides are individuals providing
nursing or related services to residents in the facility .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.
Findings:
During a concurrent interview and record review on [DATE], at 9:14 a.m., with Director of Staff Development
(DSP), the facility document titled, Monthly Staff Schedule, dated from [DATE] to [DATE] was reviewed. The
DSD stated she had been at the facility since [DATE] and the facility did not have an RN coverage on
weekends. The DSD stated the facility had an RN waiver from CMS that expired in February 2024. The
DSD stated the DON who is a Registered Nurse served as a Charge Nurse, from Monday to Friday. The
DSD stated the facility has 16 licensed beds and currently on full capacity. The DSD stated RNs were
necessary when residents needed intravenous (IV) medication or an in-depth assessment.
During an interview on [DATE], at 3:55 p.m., with the Director of Nursing (DON), the DON stated she
worked as a fulltime DON, 40 hours a week, Monday to Friday, and the designated Charge Nurse for the
Skilled Nursing Facility (SNF). The DON stated they do not have a Registered Nurse to work on weekends
for several years. The DON stated the facility had an RN waiver from CMS but it expired in February 2024.
The DON stated RNs were necessary when residents needed in-depth assessment due to change in
condition or treatments requiring intravenous drugs.
During a review of the facility's document titled, Monthly Staff Schedule dated from [DATE] to [DATE], the
staff schedule indicated no RN scheduled to work for the following days:
February 2024
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE]
[DATE] and [DATE] (16 hours)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
[DATE] and [DATE] (16 hours)
Level of Harm - Minimal harm
or potential for actual harm
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
Residents Affected - Many
[DATE] and [DATE] (16 hours)
[DATE]
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE]
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE]
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE]
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
[DATE] and [DATE] (16 hours)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055283
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
John C. Fremont Healthcare District Dp/Snf
5189 Hospital Road
Mariposa, CA 95338
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
[DATE]
Level of Harm - Minimal harm
or potential for actual harm
[DATE] and [DATE] (16 hours)
Residents Affected - Many
During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent
Nursing dated 8/22, the P&P indicated, .Our facility provides sufficient numbers of staff with the skills and
competency necessary to provide care and services for all residents in accordance with resident care plans
and the facility assessment . 1. Licensed nurses and certified nursing assistants are available 24 hours a
day to provide direct resident care services . 2. A licensed nurse is designated as a charge nurse on each
shift . c. The director of nursing services (DNS) may serve as the charge nurse only when the average daily
occupancy of the facility is 60 or fewer residents . 3. A registered nurse provides services at least eight (8)
consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8)
hours depending on the acuity needs of the resident .
During a professional reference review retrieved from https://cmscompliancegroup.com titled, F727 RN 8
Hours/7 days/Week, Full Time DON dated 4/2018, the professional reference indicated, . The regulation
states that unless a waiver is in place: A facility must use the services of a registered nurse for at least 8
consecutive hours a day, 7 days a week. The facility must designate a registered nurse to serve as the
director of nursing on a full-time basis (35 or more hours per week). The Interpretive Guidance states that
the DON requirement can be fulfilled by using two or more RNs so long as the roles and responsibilities for
all RN staff serving as the DON are clearly defined and facility staff understand how the responsibilities are
shared. The director of nursing may only serve as a charge nurse when the facility's average daily census is
60 or fewer residents .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055283
If continuation sheet
Page 9 of 9
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the August 8, 2024 survey of JOHN C. FREMONT HEALTHCARE DISTRICT DP/SNF?
This was a inspection survey of JOHN C. FREMONT HEALTHCARE DISTRICT DP/SNF on August 8, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at JOHN C. FREMONT HEALTHCARE DISTRICT DP/SNF on August 8, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full tim..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.