Country Drive Post Acute
Country Drive Post Acute in FREMONT, CA — inspection on February 23, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
notice before a change is made.
interview and record review, the facility failed to ensure one of five sampled residents (Resident 2)
This failure had the potential to result in avoidable psychosocial distress.During a review of Resident 2's admission Record (AR) dated 2/23/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis that included encounter for removal of internal fixation device (a medical procedure involving the removal of hardware, such as screws, plates, or rods, that were previously implanted to stabilize a bone or joint), anxiety disorder (a mental health condition characterized by excessive worry, nervousness, or fear that can interfere with daily activities), and depression (a mood disorder marked by persistent feelings of sadness, hopelessness, and loss of interest in activities).During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/11/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A BIMS score of 13-15 is an indication of intact cognitive status.During a concurrent interview and record review on 2/20/26 at 3:54 p.m. with Assistant Director of Nursing (ADON), ADON stated the facility does not provide a written notice when a resident acquires a new roommate. ADON stated a written notice is only provided to residents when they are moving to a new room.During a review of the facility's policy and procedure (P&P) titled Room or Roommate Change, effective date 6/27/22, the P&P indicated that residents or their representatives will receive timely advance notice before a room or roommate change.
This notice can be given verbally, in writing, or both.During a concurrent interview and record review on 2/23/26 at 12:14 p.m. with ADON, facility's daily census from 11/7/25 to 11/23/25 was reviewed. ADON stated Resident 2 was admitted on [DATE] and shared a room with Resident 6, until 11/12/25 when Resident 6 was transferred to the hospital. ADON stated, on 11/17/25, Resident 2 received a new roommate without advanced written notice, only verbal notice, which was not documented in the clinical record.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055885 02/23/2026
Country Drive Post Acute 2500 Country Drive Fremont, CA 94536
had been entrusted to the facility's Social Services Director (SSD), was not secured in accordance
potential for psychosocial outcomes including anxiety, distress, and reduced trust in the facility's ability to safeguard belongings.During a review of Resident 5's admission Record (AR) dated 2/23/26, the AR indicated Resident 5 was admitted to the facility in July 2025 with diagnoses that included diabetes mellitus (a chronic condition characterized by high levels of sugar in the blood due to the body's inability to produce or use insulin effectively), benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland that can cause urinary problems in men), and chronic gout (a long-term form of arthritis caused by the buildup of uric acid crystals in the joints, leading to pain and inflammation).
The AR indicated Resident 5 was self-responsible.During a review of Resident 5's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/25/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A score of 13-15 is an indication of intact cognitive status.During a concurrent interview and record review on 2/23/26 at 11:03 a.m. with Administrator (ADM), ADM stated, on 11/21/25, Resident 5 handed over a wallet with $180 cash to SSD for safekeeping.
The SSD placed the wallet in an unlocked drawer in the SSD office. In December 2025, Resident 5's family requested $140 from Resident 5's money but found only $40 remaining. ADM stated SSD no longer works at the facility.During a review of Resident 5's Social Services Progress Notes from 10/15/25 to 12/26/25, the progress notes did not indicate Resident 5 was informed about the missing $140.
SSD had discussed it with Resident 5's family but not with Resident 5.
During an interview on 2/23/26 at 11:22 a.m. with Resident 5, Resident 5 stated the facility still had the wallet, stated a man had visited his room and provided a number to call to regarding the missing money.During a review of the facility's policy and procedure (P&P) titled Management of Residents' Personal Funds last revised March 2021, the P&P indicated if a resident chooses to have the facility manage his personal funds, a written authorization from the resident or the resident representative is required and documented in the resident's clinical record.
The facility acts as a fiduciary, holding, safeguarding, managing and accounting for the personal funds.
055885 02/23/2026
Country Drive Post Acute 2500 Country Drive Fremont, CA 94536
During a review of Resident 2's AR dated 2/23/26, the AR indicated Resident 2 was admitted to the facility on [DATE].
The AR indicated Resident 2 was self-responsible but listed RR 2 as emergency contact.
The AR also indicated Resident 2 was discharged home on [DATE].During a concurrent interview and review of the clinical records on 2/23/26 at 12:33 p.m. with Assistant Director of Nursing (ADON), ADON stated there was no signed admission agreement for Resident 2 in the clinical records.3.
During a review of Resident 3's AR dated 2/20/26, the AR indicated Resident 3 was admitted to the facility on [DATE].
The AR indicated Resident 3 was self-responsible and listed RR 3 as the emergency contact, Resident 3 was discharged home on [DATE].During a telephone interview on 2/18/26 at 1 p.m. with RR 4, RR 4 stated the admission agreement was given to RR 3 only on the day Resident 3 was discharged . RR 4 also stated Resident 3 and family were unaware of the care and services were provided while at the facility.During a review of Resident 3's SAA, the SAA indicated Resident 3 was issued the admission agreement on 12/5/25, the day Resident 3 was going home.4.During a review of Resident 4's AR dated 2/20/26, the AR indicated Resident 4 was admitted to the facility on [DATE].
The AR indicated Resident 4 was self-responsible.During a review of Resident 4's SAA, the SAA indicated Resident 4 signed the admission agreement on 1/2/26, more than one month after Resident 4 was admitted .During a review of the facility's policy and procedure (P&P) titled admission Agreement last revised December 2025, the P&P indicated that each resident must have an admission agreement, signed and dated by the resident or resident representative at the time of admission and filed in the resident's clinical record.
055885 02/23/2026
Country Drive Post Acute 2500 Country Drive Fremont, CA 94536
During a review of the facility's policy and procedure titled Care Plan-Baseline effective 8/25/21, the P&P indicated the baseline care plan includes the instructions for effective, person-centered care of the resident and be developed and implemented by the Interdisciplinary Team (IDT, a group composed of staff representing different departments of the facility) for each resident.
The P&P did not indicate when or how to provide a summary of the baseline care plan to the resident or their representative.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.