Fruitvale Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), with long and cracked toenails received podiatry treatment services as ordered by the physician. This failure had the potential to place Resident 1 at risk for injuries and infection. During a review of Resident 1's Annual Minimum Data Set (MDS- a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 5/29/26, MDS indicated Resident 1's was admitted to the facility on [DATE]. Resident 1's Basic Interview of Mental status (BIMS- a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided, consistent with the comprehensive resident-centered plan of care and professional standards of practice for one of two sampled residents (Resident 2) when a scheduled pain medication was not administered according to the physician's order. This failure had the potential to result in ineffective pain management. During a review of Resident 2's Resident Face Sheet (RFS), the RFS indicated Resident 2 was admitted to the facility in August 2025 with diagnoses that included systemic lupus erythematosus (a chronic autoimmune disease, causing inflammation and tissue damage, with symptoms like joint and muscle pain) and chronic pain syndrome. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of two sampled residents (Resident 1) from physical abuse when Resident 2 hit Resident 1 ' s right shin with a front wheel walker (a walker is an assistive device used to aid in walking, providing stability and reducing weight bearing on the lower extremities of an individual). This failure resulted in Resident 1 sustaining redness on his right leg, pain, and a transfer to Acute Care Hospital (ACH 1) for follow-up care.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) received adequate supervision and assistance device to prevent falls when Certified Nursing Assistant (CNA) 1 transferred Resident 2, who was totally dependent on staff for activities of daily living, from wheelchair to bed without another staff present and without using a Hoyer lift (interchangeably used with mechanical lift, uniquely designed electronically operated patient lift to transfer patients between two surfaces, for example from their bed to another surface such as a wheelchair or couch). [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide food at an appetizing temperature, which affected 1 (Resident #32) of 4 residents reviewed for food.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #17) of 4 residents reviewed for pressure ulcers. The facility also failed to ensure staff changed gloves and performed hand hygiene between dirty and clean tasks for 1 (Resident #14) of 1 resident observed during incontinence care.

Inspectors wroteBased on interview and record review, for one of two sampled residents (Resident 1), the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being when psychiatric and mental health services were not provided to treat mental and substance use disorders. This failure had the potential to result in significant distress from unresolved psychosocial and mental health issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from verbal abuse for one of three sampled residents (Resident 1) when a staff member used profanity while providing toileting care to Resident 1. This failure resulted in Resident 1 feeling disrespected by the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from verbal abuse when Certified Nursing Assistant (CNA) yelled at Resident 1 I will knock you the 'F' out during a verbal altercation. This failure had the potential to result in psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when a Certified Nursing Assistant (CNA) did not wear gloves and a gown before entering a positive COVID room and did not perform hand hygiene after exiting the room. This failure had the potential for the spread of germs and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sanitary conditions in the kitchen when the solution in two red buckets that contained quaternary ammonium (Quat-a disinfectant) had not been checked and changed for two days. This deficient practice had the potential to spread food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide housekeeping services and linen services to maintain a clean home-like environment for two of 36 sampled residents (Resident 110 and Resident 128). The wall and ceiling in Resident 128's room was dirty with a reddish-brown splatter stain, and the sheets on Resident 110's bed were thin and full of holes. This deficient practice resulted in Resident 110 and Resident 128 not living in a homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to prevent contractures from worsening for one (Resident 111) of 16 sampled residents. This failure had the potential for Resident 111 to develop limitations in range of motion and decrease theability to participate in activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 231), was given foley catheter care every eight hours according to Medical Doctor (MD) orders. This deficient practice had the potential to result in urinary tract infections for Resident 231. Findings During a review of Resident 231's undated facesheet (a document that gives a resident's information at a quick glance), the facesheet indicated Resident 231 was admitted on [DATE] with multiple diagnoses including, neuromuscular dysfunction of the bladder (a lack of bladder control due to brain, spinal cord, or nerve problems), urinary tract infection (UTI), paraplegia (paralysis of the lower legs and body), and encephalopathy (any brain disease that alters brain function or structure). [...]

Inspectors wroteBased on observation, interview and record review, the facility to assist two (Resident 55 and 117) out of 36 sampled residents in obtaining prescription glasses. This failure had the potential to result in Resident 55 and Resident 117's limitation in performing their activities of daily living due to their inability to see their surroundings clearly.

Inspectors wroteBased on interview and record review, the facility failed to monitor the signs and symptoms of bleeding for one of one sampled residents (Resident 43) that received heparin (anticoagulant-a medicine used to decrease the clotting ability of the blood). This deficient practice had the potential to result in Resident 43's care needs not being addressed and delay initiation of appropriate treatment in a timely manner.

Inspectors wroteBased on observation, interview and record review, for three of four sampled residents who were smokers (Residents 6, 73 and 126), the facility failed to ensure residents' environment were free from accident hazard when smoking materials were not stored securely. This failure had the potential to result in accidents such as cigarette burns and fire hazard in resident rooms where smoking materials were stored.

Inspectors wroteBased on observation, interview and record review, for two of 27 sampled residents (Resident 133 and 128), facility failed to ensure its medication error rate did not exceed five percent. There were two medication errors out of 24 opportunities for error that totaled 8.33%. 1. For Resident 133, Licensed Vocational Nurse (LVN) 2 did not give instructions on how to use budesonide formoterol (an inhaled medication used to treat asthma) inhalation prior to administration of the medication. 2. For Resident 128, LVN 1 did not give instructions for use prior to administration of Incruse Ellipta (an inhaled medication that relaxes muscles of the airways making it easier for an individual to breathe). This failure had the potential to result in Residents 133 and 128 not getting the maximum therapeutic benefits of the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with palatable meals when hot meals were served warm and cold meals were served warm. This failure resulted in residents not receiving their meal preferences, lost appetite and not wanting to eat their meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on the times they serve meals to their residents. This failure resulted in hungry residents not having a substantial meal on time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. several food items were expired, unlabeled, and undated; 2. two of two ice machines were not cleaned and maintained per facility's policy; 3. staff were not monitoring freezer temperature; 4. Dishwasher (DW1) did not wear hair net while working inside the kitchen; 5. staff were using dishwasher sanitizer test strips with no expiration dates. These failures had the potential to cause food contamination or food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the personal care equipment (wash basin) for residents in three rooms (room [ROOM NUMBER], 106 and 107) were labeled and stored at the resident's bedside cabinet. This failure resulted in residents at risk for contacting disease-causing organism.

Inspectors wroteBased on interview and record review, for one of one sampled resident (Resident 49) who complained of abuse, the facility failed to ensure Resident 49 was free from physical abuse when Resident 100 threw water at Resident 49. Resident 49 had behavioral issues, that potentially provokes physical retaliation from other residents, that were not addressed appropriately by the facility. This failure had the potential to result in Resident 49's emotional distress and future incidents of abuse from other residents in reaction to Resident 49's verbal aggression.

Inspectors wroteBased on interview and record review the facility failed to notify the Ombudsman of residents discharges for three of 27 sampled residents (19, 35 and 129). This failure had the potential to result in residents 19, 35 and 129 not being afforded the services of the Ombudsman.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 27 sampled residents (Resident 133) received treatment and care as the physician's order when Resident 133 was taking oxygen four liter per minute per nasal [NAME] and the physician's order was for two liters per minute. As a result of this deficient practice Resident 133 was at risk for physical damage due to oxygen toxicity.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide pain management for one (Resident 105) of 27 sampled residents, when: 1. a routine pain medication was not reordered; 2. a pain medication available at the facility was not used. These failures resulted in unnecessary pain and suffering which affected Resident 105's ability in maintaining his highest practicable physical, mental, and psychosocial well-being.