Fruitvale Healthcare Center

In the surveyor’s words

From the most serious findings on record at Fruitvale Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 11, 2024

  Based 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). […]

• Actual harm, isolatedF684Nov 2, 2022

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of Type 2 Diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel) received comprehensive skin monitoring and assessment, when Resident 1's left foot wound with infection was not monitored, assessed and evaluated. This failure resulted in Resident 1 ' s left foot developing gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) and Resident 1 ' s left foot being amputated (the action of surgically cutting off a limb). […]

• No harm, potential for more than minimal, patternF812Dec 10, 2021

  Based 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. Findings: During the initial kitchen tour observation on 12/6/21 at 8:29 a.m., two red buckets that contained a dark, cloudy liquid were observed on the stainless steel counter top near the three way sink. During an interview and concurrent record review with the Dietary Manager (DM) on 12/6/21 at 8:33 a.m., DM stated the red buckets were sanitation buckets that contained quaternary ammonium solution. […]

• No harm, potential for more than minimal, isolatedF687Jul 23, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF697Nov 17, 2025

  Based 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.During a review of Resident 2's Minimum Data Set (MDS, an… […]