Fruitvale Healthcare Center
Inspection Findings
F-Tag F0697
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 assessment tool used to direct resident care) assessment dated [DATE REDACTED], the MDS indicated Resident 2 received scheduled and prn (given as needed) pain medication daily, and occasionally experienced pain rated at four out of 10 (zero as no pain and 10 being the worst pain).During a review of the facility's policy and procedure (P&P), undated, titled Pain Management, the P&P indicated that a pain rating scale of four to six represented moderate pain. The P&P also indicated for the licensed nurse to administer therapeutic interventions, non-drug treatments, or pain medication as ordered by the physician.During a review of Resident 2's pain care plan dated 8/30/25, the care plan indicated approaches to manage pain that included acknowledging Resident 2's pain and administering pain medication as ordered.During a review of the Physician Order Report (POR) dated 8/30/25-9/10/25, the POR indicated a physician order dated 8/30/25 for acetaminophen (Tylenol) 500 milligrams (mg) two tablets by mouth for chronic pain, to be administered three times daily at 6 a.m., 2 p.m., and 10 p.m.During a concurrent interview and record review on 9/18/25 at 10:43 a.m. with Registered Nurse Supervisor (RNS), the Medication Administration Record (MAR) and POR for September 2025 were reviewed. RNS stated, Resident 2 requested two tramadol (opioid/narcotic pain medication) tablets during the night shift, but the physician's order was for only one tablet. RNS stated there was a misunderstanding between the licensed nurse and Resident 2 regarding the pain medication order. The POR indicated Tylenol was to be administered at 10 p.m. but the MAR indicated administration at 2 pm.
RNS confirmed that Resident 2 did not receive the scheduled Tylenol dose at 10 pm, before asking for prn medication. Further review of the MAR indicated Resident 2 did not receive Tylenol 1000 mg dose scheduled for 10 p.m. from 9/1/25 to 9/7/25.During a concurrent interview and record review on 9/18/25 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she administered Tylenol 1000 mg to Resident 2 twice each day shift, at 10 a.m. and 2 p.m. During a follow-up interview on 9/18/25 at 1:25 p.m. with RNS, RNS stated a computer glitch that was overlooked by the admitting nurse. RNS stated the correct administration times were 6 a.m., 2 p.m., and 10 p.m., but this was not transcribed in the MAR. RNS stated that improper administration could result in Resident 2's pain not being properly managed.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
FRUITVALE HEALTHCARE CENTER in OAKLAND, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OAKLAND, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FRUITVALE HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.