Health inspection·August 8, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to ensure consistent implementation and proper use of personal protective equipment (PPE) when staff members were not wearing the N95 respirator (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), or N95 respirator was worn improperly. Visitors were not aware of the recommendation to use face mask when visiting their family members. These failures had the potential to affect the health and safety of the residents and visitors due to exposure to respiratory illness.During an observation on 08/08/25 at 2:30 p.m., in the facility's reception area, Licensed Vocational Nurse (LVN) 1 and Housekeeper (HS) 1 were not wearing face masks. Receptionist 1 was in the reception area, and her face mask was pulled down and tucked under her chin.During an interview on 08/08/25 at 2:35 p.m., with the Administrator (ADM), ADM stated the Infection Preventionist (IP) was out on leave, and the Assistant Director of Nursing was covering. ADM stated before going on leave, IP communicated with local public health that there was a Covid-19 (infectious disease caused by Corona Virus with symptoms that can feel like cold, flu, or pneumonia. COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. Other people can breathe in these droplets and particles, or these droplets and particles can land on others' eyes, nose, or mouth. In some circumstances, these droplets may contaminate the surfaces they touch. Anyone infected with Covid-19 can spread it, even if they do not have any symptoms.) outbreak in the facility. During a concurrent observation and interview on 08/08/25 at 2:48 p.m., with Assistant Director of Nursing/Infection Preventionist (ADON/IP), ADON/IP identified LVN 1, and HS 1 were not wearing face masks, and Receptionist 1's face mask was pulled down and tucked under her chin. During a concurrent observation and interview on 08/08/25 at 2:54 p.m., in the hallway with Certified Nursing Assistant (CNA) 1, CNA 1 had a N95 respirator worn over a face mask. CNA 1's N95 respirator was worn sideways with the two straps worn behind their ears. CNA 1 stated she needed to wear the N95 respirator for protection, but was unable to describe how to properly wear the N95 respirator. During a concurrent observation and interview on 08/08/25 at 03:09 p.m., in the hallway with CNA 2, CNA 2 had an N95 respirator worn over a face mask. CNA 2's N95 respirator double straps were worn close to the top of her head. CNA 2 was not able to describe how to properly wear the N95 respirator, CNA 2 stated she needed to wear N95 respirator for protection.During a concurrent observation and interview on 08/08/25 at 03:12 p.m., with Resident 1 and Responsible Party (RP) 1, RP 1 was pushing Resident 1's wheelchair and were heading to Resident 1's room. RP 1 and Resident 1 were both not wearing face masks. RP 1 stated when she entered the facility she was not offered or asked to wear a face mask.During a concurrent observation and interview on 08/08/25 at 03:14 p.m., in the nursing station with Registered Nurse (RN) 1, RN 1 was not wearing any face covering. RN 1 stated she had just started her shift and was looking for a face mask. RN 1 states she doesn't know if she should be wearing a face mask before going on the floor.During a concurrent observation and interview on 08/08/25 at 03:18 p.m., in Resident 2's Residents Affected - Some (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: 055885 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive 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)