Fountain View Subacute: Medication Failures, Blind Resident - CA
The facility's own director of nursing acknowledged both failures.
Inspectors reviewed medication records for Resident 3 during a complaint investigation completed November 24, 2025. What they found was a pattern of incomplete documentation around the resident's eye drops, medication that by its nature requires precise timing and consistent administration to do any good. There was no record explaining why doses were missed or delayed. There was no notation of refusals. There was no documentation of what happened when the scheduled hour passed.
The director of nursing told inspectors that any time a medication is withheld, refused, or given outside its scheduled window, a licensed nurse is responsible for documenting the reason and endorsing the record. That hadn't happened.
What also hadn't happened was the creation of a Comprehensive Care Plan for Resident 3's left eye blindness. A care plan is the document that follows a resident from shift to shift, the mechanism that tells a nurse coming on at 11 p.m. what the nurse leaving at 7 p.m. already knew. Without one, each shift started without a formal record of the resident's visual impairment or the interventions needed to address it.
The director of nursing said the missing care plan placed Resident 3 at risk for unmet needs and a worsening health condition.
Inspectors tagged the violation at the F0760 level, citing potential for harm to a few residents. The citation covers medication errors and the obligation to administer drugs on time, document exceptions, and report errors through the facility's quality review process.
The facility's own written medication policy, reviewed during the inspection, states that medications are administered within one hour of their prescribed time, that any deviation must be documented with a reason, and that medication errors are reported to a quality committee to determine whether additional staff training is needed. The policy does not have a date on it.
None of that process appeared to have been applied to Resident 3's eye drops.
A person who is blind in one eye is dependent on whatever vision remains. Eye medications prescribed for such a resident carry obvious stakes. Whether the drops were meant to manage pressure, prevent infection, or treat another condition, the inspection report does not say. What it does say is that the nurses responsible for giving them were not consistently writing down what happened after they did, or didn't.
The gap in the care plan compounded the problem. A nurse unfamiliar with Resident 3's history, picking up a shift without a documented care plan in place, would have had no formal prompt to consider what the resident's blindness meant for her daily care, her safety, or her medication needs. The director of nursing's own words to inspectors captured the consequence: lack of interventions, risk of worsening condition, unmet needs.
Fountain View Subacute and Nursing Center operates in Los Angeles. The inspection was conducted in response to a complaint.
Resident 3 is still there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fountain View Subacute and Nursing Center from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 27, 2026 · Our methodology
FOUNTAIN VIEW SUBACUTE AND NURSING CENTER in LOS ANGELES, CA was cited for violations during a health inspection on November 24, 2025.
The facility's own director of nursing acknowledged both failures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.