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Complaint Investigation

Niles Canyon Post Acute

February 23, 2026 · Fremont, CA · 38650 Mission Boulevard
Citations 3
CMS Rating 5/5
Beds 73
Provider ID 055562
Healthcare Facility
Niles Canyon Post Acute
Fremont, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

NILES CANYON POST ACUTE in FREMONT, CA — inspection on February 23, 2026.

Found 3 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

FF0635
Resident Assessment and Care Planning Deficiencies

During a review of

no blood sugar assessments between admission, 3/11/24, and 3/18/25.During a review of Resident

admitted to GACH on 3/9/25 at 3:47 p.m. with altered mental status, including lethargy, confusion, partial responsiveness, and weakness.

During a review of Resident 2's Labs from the GACH, dated 3/9/25 at 6:26 p.m., Resident 2's blood glucose was greater than 800 mg/dl.

During a review of the facility's policy and procedure (P&P) titled, Diabetes Clinical Protocol, the P&P indicated, The provider will order desired glucose targets and monitoring regimens, as well as parameters for reporting information related to blood sugar management.the provider will adjust treatments based on these results and other factors such as glycosuria, weight gain or loss, hypoglycemic episodes, etc.

Assess glycemic status by A1C measurement, blood glucose monitoring by capillary/fingerstick devices.

Examples of blood glucose monitoring for various situations might include the following: For the resident on oral medication(s) who is well controlled monitor blood glucose levels at least twice weekly (or more frequently if there is a change in drugs or drug dosages); monitor A1C on admission (if no results from a previous test are available) or when diabetes is diagnosed and every 6 months thereafter.

055562 02/23/2026

Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536

During a review of the

identify and order diagnostic and lab testing based on resident's diagnostic and monitoring needs.

055562 02/23/2026

Niles Canyon Post Acute 38650 Mission Boulevard Fremont, CA 94536

During a review of Resident 2's Labs from GACH, dated 3/9/25 at 6:26 p.m., Resident 2's blood glucose was greater than 800 mg/dl.

During a review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, the P&P indicated, The practitioner is responsible for.Responding in a timely manner to calls; especially regarding Immediate Notification problems.Communicating sufficient detail to appropriate staff about the assessment and management of the problem and the resident/patient.During a review of the facility's P&P titled, Lab and Diagnostic Test Results-Clinical, the P&P indicated, a Physician can be notified by phone, fax, voicemail, email, mail.

Pager or telephone message to another person acting as the physicians agent.Facility staff should document information about when, how, and to whom the information was provided and the response.

This should be done in the progress notes section of the medical record and not on the lab results report.

Alternatively, the staff and physician may also establish designated times during the day when they will review test results with physician by phone. A physician will respond within an appropriate time frame, based on the request from nursing staff and clinical significance of the information.A physician should respond within one hour regarding a lab result requiring immediate notification, and by the end of the next office day to a non-emergency message regarding non-immediate lab test notification with a request for response.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FREMONT, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from NILES CANYON POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

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.