Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fruitvale Healthcare Center during CMS and state inspections, most recent first.
A resident with chronic pain and systemic lupus erythematosus did not receive scheduled acetaminophen doses as ordered by the physician due to a transcription error in the MAR. The medication was administered at incorrect times, and the nighttime dose was missed for several days, contrary to the resident's care plan and physician orders.
A resident with cognitive impairment and a history of depression and dementia was physically abused by another resident with alcohol dependence and a history of aggression. The incident occurred in the smoking area, where the aggressor, reportedly intoxicated, struck the victim's leg with a walker, causing pain and requiring hospital evaluation. Staff and documentation confirmed prior aggressive behavior by the perpetrator and the presence of alcohol at the scene.
A resident dependent on staff for transfers fell when a CNA attempted to move them without a Hoyer lift or additional staff, contrary to facility policy. The resident, with a history of mobility issues, was hospitalized with a femur fracture. The CNA, on her first shift, was not informed of the resident's transfer needs, leading to the incident.
A resident reported that food was not always served hot, and observations confirmed that meal temperatures were below the required levels. The facility's policy stated that food should be served at appropriate temperatures, but scrambled eggs and sausage were found to be lukewarm, and oatmeal was warm. The DON and Administrator acknowledged the requirement for serving food at correct temperatures.
The facility failed to implement enhanced barrier precautions (EBP) for a resident with pressure ulcers, lacking proper signage and PPE, and staff did not wear gowns during care. Another resident's care involved improper hand hygiene, as a CNA did not change gloves or sanitize hands between tasks. These lapses in infection control practices were confirmed by staff interviews, highlighting risks in infection prevention.
A facility failed to provide necessary behavioral health services to a resident with schizophrenia and substance abuse issues. Despite orders for mental health referrals, no consultations were documented. The resident's care plans were not updated after incidents of drug paraphernalia possession and theft. Social Services documentation was insufficient, and the resident was found unresponsive and later passed away.
A resident with generalized weakness and hemiplegia required substantial assistance for toileting hygiene. During care, a CNA used profanity under his breath, making the resident feel disrespected. The incident was reported to an LVN, and the DON confirmed the CNA's actions as potential verbal abuse, violating the facility's abuse prevention policy.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with systemic lupus erythematosus and chronic pain syndrome did not receive scheduled pain medication as ordered by the physician. The resident's care plan and physician orders specified acetaminophen 1000 mg to be administered three times daily at 6 a.m., 2 p.m., and 10 p.m. However, review of the Medication Administration Record (MAR) revealed that the 10 p.m. dose was not administered from the 1st to the 7th of the month, and the medication was instead given at 10 a.m. and 2 p.m. This discrepancy was confirmed by both the Registered Nurse Supervisor and a Licensed Vocational Nurse, who stated that the medication was not given according to the prescribed schedule. The failure to administer the pain medication as ordered was attributed to a transcription error in the MAR, which was overlooked by the admitting nurse and resulted in the resident not receiving the scheduled nighttime dose. The resident occasionally experienced moderate pain, as indicated by a pain rating of four out of ten, and the facility's policy required administration of pain medication as ordered for such pain levels. The error was identified during interviews and record reviews, where staff acknowledged the incorrect administration times and the potential for ineffective pain management.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of major depressive disorder and dementia was physically abused by another resident with intact cognition and a diagnosis of alcohol dependence. The incident took place in the facility's smoking area, where the aggressor, reportedly intoxicated, grabbed the victim's walker and struck the victim's right shin, resulting in redness, pain, and emotional distress. Staff interviews confirmed that the aggressor had previously exhibited combative and aggressive behavior when intoxicated. Following the altercation, the injured resident complained of moderate pain and requested transfer to an acute care hospital, where treatment for right leg pain was provided. Documentation and staff accounts indicated that the facility was aware of the aggressor's history of alcohol use and aggression, and that staff observed the presence of alcohol at the scene. The facility's policy requires protection of residents from abuse by anyone, but in this instance, the resident was not protected from physical abuse by another resident.
Inadequate Supervision and Equipment Use Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and use of an assistance device for a resident who was totally dependent on staff for activities of daily living. The resident, who had a history of polyneuropathy, chronic pain syndrome, abnormalities of gait and mobility, and osteoarthritis, required a Hoyer lift and the assistance of two staff members for transfers. However, a CNA attempted to transfer the resident from a wheelchair to a bed without the necessary equipment or additional staff, resulting in the resident's fall. The incident occurred when the CNA, who was working her first shift at the facility, attempted to lift the resident without using a Hoyer lift. The CNA was not informed that the resident required a mechanical lift and assistance from another staff member. During the transfer, the resident, unable to bear weight, began to slide down, and the CNA eased the resident to the floor. The resident's roommate, who was cognitively intact, witnessed the event and offered assistance, but the CNA proceeded alone. Following the fall, the resident was transferred to the hospital with a closed displaced subtrochanteric fracture of the right femur. The resident underwent surgery and returned to the facility with multiple incisions and staples. The facility's policy required documentation of the type of transfer and assistance needed, which was not adequately communicated to the CNA, leading to the deficiency in care.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature, affecting one resident. The facility's policy on meal service indicated that residents should receive food at appropriate temperatures and with an appetizing appearance. However, during an interview, a resident reported that the food was not always served hot, and if they were the last one served, the food was cold. This was confirmed during an observation where meal trays were passed, and the last tray removed from the cart had scrambled eggs and a sausage patty at 102 degrees Fahrenheit, and oatmeal at 122 degrees Fahrenheit, which were considered lukewarm and warm, respectively. The Registered Dietitian and Dietary Supervisor confirmed the temperatures of the food items. The Director of Nursing stated that the facility followed federal and state requirements for food temperatures and that food should be served warm to residents at the correct internal temperature. The Administrator also stated that food served to residents should be hot. Despite these statements, the resident continued to report that scrambled eggs were usually served lukewarm, indicating a failure to adhere to the facility's policy and regulatory requirements for food service.
Infection Control Deficiencies in EBP and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with pressure ulcers, as required by their policy. The resident, who had a medical history of functional quadriplegia and severe cognitive impairment, was dependent on staff for personal hygiene and had multiple open wounds, including a Stage 2 pressure ulcer. Despite the care plan indicating the need for EBP, there was no signage or personal protective equipment (PPE) in the resident's room, and staff did not wear gowns during incontinence care. Interviews with staff, including the Infection Preventionist and Director of Nursing, confirmed the oversight and acknowledged the expectation for EBP implementation. Additionally, the facility did not ensure proper hand hygiene practices during incontinence care for another resident. The resident, who had intact cognition and required assistance with toileting hygiene, was observed receiving care without the CNA changing gloves or sanitizing hands between dirty and clean tasks. The CNA admitted to not following hand hygiene protocols, and interviews with the Director of Nursing and Director of Staff Development confirmed the expectation for staff to change gloves and wash hands between tasks. These deficiencies highlight lapses in infection prevention and control practices, specifically in the implementation of EBP and adherence to hand hygiene protocols. The lack of proper PPE usage and hand hygiene during resident care activities poses a risk of spreading infections, particularly for residents with open wounds or incontinence issues.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizophrenia, auditory hallucinations, and substance abuse. Despite physician orders for mental health referrals and psychiatric evaluations, there was no documentation indicating that these services were provided. The resident's care plans, which included interventions for schizophrenia and substance abuse, were not updated or revised following incidents of drug paraphernalia possession and theft. The resident's clinical records showed multiple behavioral incidents, including dropping drug paraphernalia and stealing from other residents, yet there were no documented psychiatric or mental health consultations. The facility's Director of Nursing confirmed the absence of such documentation. Additionally, the resident was allowed to leave the facility on several occasions without proper documentation of their status upon return. Social Services documentation was also lacking, with only two progress notes recorded, and no follow-up after significant behavioral incidents. The facility's assessment acknowledged the prevalence of psychiatric disorders among residents, but there were no policies in place to address substance use disorders. The resident was eventually found unresponsive and passed away after being taken to the hospital.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure the right to be free from verbal abuse for a resident when a staff member used profanity while providing toileting care. The incident involved a resident who was admitted with generalized weakness and hemiplegia affecting the dominant side of the body. The resident, who had intact cognitive status as indicated by a BIMS score of 15, was always incontinent of both bowel and bladder and required substantial assistance for toileting hygiene. On the day of the incident, the resident experienced diarrhea after receiving a laxative and required a brief change. During the provision of care, the Certified Nursing Assistant (CNA) used profanity under his breath, which made the resident feel disrespected. The resident reported the incident to the Licensed Vocational Nurse (LVN) the next morning, expressing that it was inappropriate for the CNA to use such language and requesting not to work with that CNA again. The CNA admitted to cursing under his breath out of frustration due to the workload, which included getting the resident in and out of bed multiple times that day. The Director of Nursing (DON) reviewed the resident's progress notes and confirmed that the use of profanity by the CNA was unacceptable and constituted potential verbal abuse. The facility's policy on abuse prevention clearly states that residents have the right to be free from verbal abuse, making the CNA's actions a violation of this policy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garfield Neurobehavioral Center | 0.1 mi | ★★★★★ | 22 | 1 |
| Mercy Retirement & Care Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Oakland Heights Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| Marina Garden Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Bellaken Skilled Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.