Fountain View Nursing: Missed Eye Medication - CA
The nurse, who served as both charge nurse and medication administration nurse for the day shift on November 24, admitted to federal inspectors that although the resident's ordered eye medication was present in her medication cart, she had not administered it as scheduled.
The missed 6 AM dose was never mentioned during shift report, the nurse told inspectors. She also acknowledged that she did not assess the resident's pain level at any point during her shift.
The facility's Director of Nursing told inspectors during a concurrent interview that the medication omission should have been documented, explained, and endorsed by the licensed nurses. The nursing director said the facility should have initiated a comprehensive care plan for the resident's left eye blindness to ensure continuity of care between shifts.
Without proper care planning, the director acknowledged, the resident was placed at risk for unmet needs and worsening health condition due to lack of interventions.
Federal inspectors found the facility violated care planning requirements. According to the facility's own policy dated August 25, 2021, the interdisciplinary team is responsible for developing an individualized comprehensive care plan for each resident within seven days of completing the comprehensive assessment.
The facility's nursing documentation policy, dated June 27, 2022, requires nursing documentation to include information about the patient's status, nursing assessment, interventions and expected outcomes, evaluation of patient's outcomes, and responses to nursing care.
None of this happened for the resident with left eye blindness.
The inspection was conducted in response to a complaint. Federal inspectors determined the violations caused minimal harm or potential for actual harm and affected few residents.
The nursing director's admission that the resident was at risk for worsening health condition highlights how medication errors compound when facilities fail to implement basic care planning protocols for vulnerable residents with existing disabilities.
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 9, 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 missed 6 AM dose was never mentioned during shift report, the nurse told inspectors.
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.