Health inspection·June 26, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to protect one of 15 sampled residents (Resident 164's) property from loss when their cell phone went missing. Residents Affected - Few This failure had the potential to cause Resident 164 anxiety and stress. Findings: During a review of Resident 164's admission Record, printed 6/25/25, the record indicated Resident 164 was admitted to the facility in June 2025 with a diagnosis of Depression and Chinese as their primary language. During a review of Resident 164's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 6/18/25, the MDS indicated, Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. The MDS also indicated, Ability To Understand Others . Usually understands misses some part / intent of message but comprehends most conversation. During an interview on 6/23/25, at 3:04 p.m., with Resident 164 and their caregiver (CG) 1, CG 1 stated Resident 164's cell phone went missing on 6/21/25. CG 1 stated they told staff, but no one did anything or got back to them. CG 1 stated Resident 164 was anxious because Resident 164 couldn't call their family with their cell phone. Resident 164 stated they needed to talk to their daughter and family, but they couldn't because their cell phone was missing. During a concurrent interview and record review on 06/25/25, at 09:57 a.m., with Social Services Director (SSD), the Theft and Loss Binder, dated 2025, was reviewed. The binder indicated Resident 164's missing cell phone was not reported. SSD stated Resident 164's cell phone was not reported to them. SSD stated they were responsible for investigating and resolving theft and loss issues. SSD stated staff should have filled out a Theft and Loss Report and notified SSD as soon as possible when Resident 164's cell phone went missing. SSD stated it was important to resolve Resident 164's missing cell phone immediately because it could have caused Resident 164 frustration if they could not talk to their family. During an interview on 6/25/25, at 4:49 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CG 1 told LVN 1 Resident 164's cell phone went missing on 6/22/25. LVN 1 stated they did not fill out a Theft and Loss Report and did not notify SSD. During an interview on 6/26/25, at 12:16 p.m. with Director of Nursing (DON), DON stated it was important to resolve Resident 164's missing cell phone as soon as possible so Resident 164 could have had peace of mind and Resident 164 really needed their cell phone because of their language barrier. (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 2 Event ID: 055562 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 055562 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536 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)