Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 Fortuna Rehabilitation And Wellness Center, Lp during CMS and state inspections, most recent first.
A resident with cognitive decline, gait abnormalities, and documented high fall risk experienced multiple falls while the facility failed to implement and document key fall risk and post-fall care plan interventions. Despite repeated falls and high fall risk scores, required measures such as q2h location checks, q2h toileting while awake, a documented root cause analysis of prior falls with education to the care team, and a PT eval ordered after a serious unwitnessed fall were not supported by documentation. The Administrator confirmed that records of these interventions could not be located, contrary to the facility’s person-centered care planning policy.
A resident with dementia, major depressive disorder, PTSD, and suicidal ideations, and a moderately impaired BIMS score, was struck twice in the shoulder by another resident, triggering a change in condition. Subsequent notes documented that the resident expressed uncertainty about being hurt versus upset and later reported ongoing distress and worry that the other resident would continue to bother him. Although a COC was initiated, the DON confirmed that 72-hour monitoring notes were not documented every shift as required, and completion of the monitoring could not be verified, contrary to facility policy requiring licensed nurse documentation each shift for at least 72 hours after a change in condition.
A resident receiving palliative care with CHF, muscle weakness, hearing loss, and a left below-knee amputation, and with slight memory impairment per MDS, was subjected to verbal abuse by a CNA during a shower. The CNA was overheard yelling and swearing at the resident, who was visibly bothered and later reported disliking how he was treated. The resident’s care plan documented that he was a victim of alleged abuse, with the CNA having called him a derogatory name, in violation of the facility’s abuse prevention policy that prohibits verbal abuse and the use of disparaging or derogatory terms toward residents.
A resident with palliative care needs, CHF, muscle weakness, hearing loss, and a left below-knee amputation was involved in an alleged abuse incident, but staff did not follow the facility’s abuse policy. The DON reported that LNs were expected to complete and document a change of condition assessment, notify the MD and family, update the care plan, and perform 72-hour monitoring with alert charting and psychosocial documentation, with Social Services also conducting daily psychosocial follow-up. Record review and interviews showed that no assessment, progress notes, or required 72-hour checks by nursing or Social Services were documented, despite written policies and lesson plans directing these actions.
A resident with chronic kidney disease had her call light and bed remote removed by an LN while in her room because she was repeatedly adjusting her bed and pressing the call light. The LN documented the removal in a nursing note, indicating an expectation that the behavior would stop. In an interview, the DON stated this action was inappropriate, affirmed that the call light and bed remote were considered the resident’s personal property, and identified the incident as a resident rights issue. Review of the facility’s Resident Rights policy showed staff are required to treat residents with kindness, respect, and dignity and to honor residents’ exercise of their rights, which did not occur in this case.
A resident with significant medical conditions reported severe pain and feeling abused during a treatment performed by a nurse, who did not stop when asked. The incident was documented and reported internally, but the facility failed to submit the required abuse report to authorities within the mandated two-hour window, as confirmed by staff interviews and policy review.
Three residents with mental health or developmental diagnoses did not receive appropriate PASRR evaluations. Despite documented histories of mental illness, cognitive impairment, or developmental delay, PASRR Level 1 screenings were either incorrectly completed or not properly reviewed, resulting in the absence of required Level II screenings. Facility staff acknowledged that errors in hospital-completed PASRRs were common and not always corrected, leading to incomplete assessments for these residents.
Three residents with complex medical conditions did not receive required in-person physician visits at least every 60 days, as only telehealth visits or no visits occurred during the review period. Staff interviews and record reviews confirmed the deficiency, and the facility's administrator acknowledged the issue with the prior contracted physician services.
Licensed nurses did not administer medications on time for two residents, including one receiving palliative care and another with epilepsy, due to severe staffing shortages. Medications were given more than an hour late on multiple occasions, exceeding the facility's policy window. Staff and the DON confirmed that high resident assignments per nurse and failure to meet state staffing requirements made timely medication administration impossible, and a resident reported anxiety and discomfort as a result.
The facility failed to provide adequate staffing to meet residents' wound care needs, resulting in missed treatments for several residents. Interviews and record reviews revealed that treatments were not documented as completed, indicating they were not performed. Staffing challenges, including the absence of a Treatment Nurse, contributed to this deficiency.
A resident with a history of falls and high fall risk was left unsupervised on the toilet by a CNA, resulting in a fall and fracture of the right distal fibula and tibia. The resident's medical history included conditions that increased her fall risk, and her care plan required supervision during toileting. Despite this, the CNA left the resident alone, leading to the incident. Interviews with staff confirmed the need for supervision, which was not provided, resulting in the injury.
The facility failed to report an abuse allegation within the required timeframe after a CNA witnessed a resident hitting another with a shoe. The incident was reported three days late, contrary to the facility's policy requiring a two-hour notification to the Department, Ombudsman, and Law Enforcement. This delay decreased the potential to ensure resident safety and caused a delayed response by enforcement agencies.
A resident fell and broke her arm due to an improperly positioned transition strip at a doorway, which created a trip hazard. The resident was walking without her walker and tripped on the uneven threshold, leading to a fall. Observations confirmed the hazardous condition, and the DON acknowledged the issue, assuming it had been repaired. The facility's safety policy was not effectively followed, contributing to the deficiency.
A resident with Type 2 Diabetes Mellitus and Essential Hypertension did not receive regular showers as scheduled, leading to a missed and infected wound on their shoulder, which developed into sepsis. Despite being dependent on staff for bathing, the resident only received two bed baths in July and none in early August. Facility staff confirmed the lack of documentation and care, acknowledging that shower refusals should be documented. The facility's policies on skin observation during bathing were not followed, contributing to the missed and infected wound.
A resident in a long-term care facility developed an infected wound on the shoulder due to inadequate skin assessments and irregular showering. Despite weekly checks, the wound was not documented or treated, leading to sepsis and hospitalization. Staff were unaware of the wound, and facility policies on skin care and hygiene were not followed.
A resident was administered an extra dose of Oxycodone HCL 5 mg without a physician's order, resulting in a significant medication error. The nurse claimed to have received a verbal order, which the physician could not recall. The facility's policy requires medications to be administered only upon a physician's order.
Failure to Implement and Document Fall Risk and Post-Fall Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document comprehensive, person-centered fall risk and post-fall care plan interventions for one resident. The resident was admitted with diagnoses including progressive cognitive decline with anxiety, generalized muscle weakness, insomnia, impaired communication, and gait and mobility abnormalities. An MDS dated 12/25/25 showed memory impairment on the BIMS and two or more falls since the prior assessment. SBAR forms dated 4/15/25, 4/28/25, 5/3/25, 7/24/25, 10/3/25, and 10/12/25 documented six fall incidents in 2025. Fall risk evaluations from 3/4/25 to 12/12/25 showed scores ranging from 10 to 20, confirming the resident was at high risk for falls. The resident’s care plan, initiated 3/5/25 for high fall risk, included specific interventions such as verifying and documenting the resident’s location every two hours, offering toileting every two hours while awake after a fall on 7/24/25, and performing a root cause analysis of past falls with documentation of possible root causes and education of the resident, family, caregivers, and IDT. Additional post-fall care plans initiated on 1/26/26 and 1/28/26 directed staff to continue fall-risk interventions and obtain a PT evaluation after an unwitnessed fall with serious injury. During interviews, the Administrator confirmed the facility could not produce documentation that the root cause analysis was performed, that the resident’s location was monitored and toileting was offered every two hours, or that a PT evaluation was completed as ordered in the care plan. The facility’s own person-centered care planning policy required development and implementation of a comprehensive care plan describing services to attain or maintain the resident’s well-being, but documentation of implementation of the specified interventions was absent.
Failure to Complete 72-Hour Change-in-Condition Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to complete required 72-hour monitoring and documentation following a change in condition for one resident after an altercation. The resident, who had dementia, major depressive disorder, post-traumatic stress disorder, and suicidal ideations, was admitted with significant mental health diagnoses. His MDS dated 11/4/25 showed a BIMS score of 11, indicating moderately impaired cognition, and documented that he felt down, depressed, or hopeless nearly every day during the assessment period. On 1/11/26 at 3:45 p.m., a progress note documented that the resident was struck twice in the left front shoulder with a closed fist by another resident, constituting a change in condition that triggered the facility’s change in condition process. Subsequent documentation showed that on 1/12/26 at 1:19 p.m., an IDT note recorded the resident stating, "I don't know if I am hurt or just upset," and on 1/13/26 at 8:35 a.m., a progress note indicated he remained upset about the altercation and was very worried the other resident would continue to bother him. During an interview and record review on 2/26/26 at 11:45 a.m., the DON reviewed the resident’s documentation following the 1/11/26 altercation and acknowledged that although a change in condition had been initiated, continuous 72-hour monitoring notes were not charted for every shift after the incident, so completion of the monitoring could not be verified. This failure occurred despite the facility’s policy titled "Change in Condition," effective 8/25/22, which required a licensed nurse to document each shift for at least 72 hours when there is a change in a resident’s condition.
Failure to Protect a Resident From Verbal Abuse During Shower Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a certified nursing assistant (CNA) yelled and swore at the resident during care. The resident, who had been admitted with diagnoses including encounter for palliative care, acute chronic systolic (congestive) heart failure, muscle weakness, hearing loss, and absence of the left leg below the knee, had a Minimum Data Set indicating slight memory impairment. During a shower, CNA 1 was overheard yelling and swearing at the resident, and the resident was later described as visibly bothered when interviewed about the incident. In a subsequent interview, the resident reported that CNA 1 yelled and swore at him and that he did not like how he was treated. The resident’s care plan documented that he was a victim of alleged abuse related to CNA 1 yelling at him in the shower and calling him an "asshole." The facility’s Abuse Prevention and Management policy, effective 2024, stated that the facility does not condone any form of resident abuse, including verbal abuse, and defined verbal abuse as oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms directed to a resident. The substantiated incident of yelling and use of derogatory language toward the resident constituted a failure to ensure the resident was free from abuse as required by facility policy.
Failure to Implement Abuse Assessment and 72-Hour Monitoring After Alleged Incident
Penalty
Summary
The facility failed to implement its abuse prevention and management policy for one resident following an alleged abuse incident. Resident 1, admitted in October 2025 with diagnoses including encounter for palliative care, acute chronic systolic congestive heart failure, muscle weakness, hearing loss, and absence of the left leg below the knee, had a Minimum Data Set dated 1/10/26 indicating slight memory impairment. After an allegation of abuse on 1/9/26, the DON stated she expected licensed nurses to complete and document a change of condition assessment, including a physical and psychosocial assessment, document when the physician and family were notified, update the resident’s care plan, and initiate 72-hour monitoring. However, record review and the DON’s concurrent interview confirmed there was no documented assessment or progress notes and that the required 72-hour monitoring and alert charting were not completed. The facility’s own Abuse Reporting and Documentation lesson plan directed licensed nurses to complete an assessment and skin assessment of the alleged victim, notify the MD, add the resident to alert charting for 72 hours with appropriate monitors for increased distress, and document psychosocial status every shift, with Social Services documenting psychosocial status daily and the IDT promptly reviewing allegations. The facility’s Abuse Prevention and Management policy, revised 5/30/24, required that the resident be assessed by a licensed nurse for any physical injuries or emotional distress and that the physician be notified and treatment provided as ordered. The DON confirmed that social services 72-hour checks were lacking and that there was no assessment documented or progress notes for Resident 1 following the alleged abuse incident.
Resident Rights Violated When Call Light and Bed Remote Removed
Penalty
Summary
A resident admitted in March 2023 with chronic kidney disease experienced a violation of resident rights when a licensed nurse (LN 1) removed her call light and bed remote while she was in her room. According to LN 1’s nursing note dated 11/30/25, the nurse took these items because the resident had been moving her bed up and down and repeatedly pressing her call light, and the nurse expected this behavior to stop. During an interview, the Director of Nursing stated that LN 1’s actions were inappropriate, acknowledged that the facility is the resident’s home, and considered the call light and bed remote to be the resident’s personal property and a resident rights issue. Review of the facility’s Resident Rights policy, revised 1/1/12, showed that employees are required to treat all residents with kindness, respect, and dignity and to honor the exercise of residents’ rights, which was not followed in this incident. This failure resulted in the resident not having access to her call light and bed remote as documented in the nursing note and confirmed by the DON, constituting a lack of respect for the resident’s dignity and self-determination as outlined in the facility’s own policy.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for one resident. The incident involved an 81-year-old resident with multiple diagnoses, including heart failure and venous insufficiency, who reported that a nurse performed an incorrect treatment using scissors to debride thick dry skin on her legs, causing severe pain. The resident expressed multiple times for the nurse to stop due to 9/10 pain, but the nurse refused. The resident later stated that what happened was abuse and that she felt unsafe. This information was documented in a nurse's progress note and reported internally to the facility administrator. Despite the internal reporting, the facility did not submit the required Report of Suspected Dependent Adult/Elder Abuse (SOC 341) to the Department within the mandated two-hour timeframe. The report was received by the Department nearly two hours after the incident was identified during a chart review. Both the nurse and the administrator acknowledged during interviews that allegations of abuse must be reported to the Department within two hours, as required by facility policy and state regulations. The delay in reporting constituted a failure to comply with mandated reporting requirements.
Failure to Complete Required PASRR Evaluations for Residents with Mental Health and Developmental Diagnoses
Penalty
Summary
The facility failed to ensure that three sampled residents received appropriate PASRR (Preadmission Screening and Resident Review) evaluations as required by federal regulations. For the first resident, documentation showed diagnoses including toxic encephalopathy, post-traumatic stress disorder, anxiety disorder, and chronic pain syndrome, with a BIMS score indicating moderate cognitive impairment. Despite these diagnoses and a history of mental health conditions, the PASRR Level 1 screening marked that the resident did not have a serious mental disorder, and no Level II screening was conducted, as confirmed by correspondence from the state agency. The second resident was admitted with diagnoses of toxic encephalopathy, cerebral palsy, depression, and developmental delay of scholastic skills, and also had a BIMS score indicating moderate cognitive impairment. Hospital records noted the need for coordination with the Regional Center due to developmental delay. The PASRR Level 1 screening indicated a developmental or intellectual disability and past Regional Center services, but did not identify a serious mental disorder, and no Level II PASRR was found in the resident's chart. The third resident had diagnoses of depression, hemiplegia and hemiparesis following cerebral infarction, and brain injuries, with a BIMS score indicating moderate cognitive impairment. Physician notes included toxic encephalopathy, anxiety disorder, and major depressive disorder. The PASRR Level 1 was positive for suspected mental illness, but the state agency determined no serious mental illness was present, and no Level II screening was conducted. Interviews with facility staff revealed that PASRR Level 1 screenings completed by acute hospitals were often incorrect, and the facility did not consistently review or correct these errors, resulting in missed Level II screenings for the affected residents.
Failure to Provide Required Face-to-Face Physician Visits
Penalty
Summary
The facility failed to ensure that residents received required face-to-face physician visits at least once every 60 days, as mandated by federal regulations. For three sampled residents, documentation and interviews confirmed that either the required in-person visits did not occur within the specified timeframes or that only telehealth/virtual visits were conducted instead of face-to-face encounters. Specifically, one resident did not have a face-to-face physician visit for an eight-month period, and for two other residents, all physician visits during the review period were conducted virtually. The residents affected had significant and complex medical histories, including acute respiratory failure, post-traumatic stress disorder, anxiety disorder, chronic pain syndrome, gastro-esophageal reflux disease, post laminectomy syndrome, toxic encephalopathy, quadriplegia, spastic cerebral palsy, depression, developmental disorder of scholastic skills, acute kidney failure, hemiplegia, hemiparesis, muscle weakness, and a history of falls. Their cognitive status ranged from moderately impaired to moderate cognitive impairment, as indicated by their BIMS scores. Interviews with facility staff, including a Registered Nurse Consultant and the MDS Nurse, confirmed that the required face-to-face physician visits were not provided, and that telehealth visits were used instead. The facility administrator acknowledged that the prior contracted physician services were terminated due to failure to provide agreed face-to-face services. Review of federal regulations and facility policy confirmed that in-person physician visits are required and that telehealth visits do not meet this requirement.
Failure to Administer Medications Timely Due to Staffing Shortages
Penalty
Summary
Licensed Nurses failed to administer medications to residents according to physician orders, resulting in multiple instances of late medication administration for two residents. For one resident with diagnoses including palliative care and malignant neoplasm of the skin, medications such as propranolol, methadone, and gabapentin were documented as being given significantly later than scheduled, with delays ranging from over an hour to more than four hours. Another resident with epilepsy experienced late administration of medications including ropinirole, levetiracetam, and aspirin, with delays of over an hour past the scheduled times. The facility's policy allows for medications to be administered within one hour before or after the scheduled time, but these instances exceeded that window. Interviews with nursing staff and the Director of Nursing revealed that the late administration was due to severe staffing shortages, with each nurse assigned to care for 28 to 34 residents per shift. Staff reported that the high number of resident assignments made it impossible to administer all medications on time. The Director of Nursing confirmed that the facility had not met state staffing requirements during the relevant periods. One resident reported experiencing anxiety and discomfort due to the late administration of medications. The facility's own documentation and staff interviews confirmed the pattern of late medication administration and the underlying staffing issues.
Inadequate Staffing Leads to Missed Wound Care Treatments
Penalty
Summary
The facility failed to ensure adequate staffing with appropriate competencies to meet the physical needs of the residents, specifically in providing wound care treatments as ordered by physicians. This deficiency was identified through interviews and record reviews, revealing that treatments for wound care were not provided as ordered for four of nine sampled residents. The lack of documentation for wound care treatments on specific dates for these residents indicated that the treatments were not performed, which could potentially delay wound healing and increase the risk of infection. Resident 1 had multiple orders for wound care, including treatments for a malignant breast wound and pressure ulcers on the coccyx and sacro-coccygeal areas. However, the Treatment Administration Record (TAR) showed that these treatments were not documented as completed on several occasions. Similarly, Resident 2's TAR indicated missed treatments for a pressure ulcer on the right below-knee amputation stump. Resident 3's TAR also showed incomplete documentation for pressure ulcer treatments on the coccyx and upper buttocks. Resident 4's TAR revealed missed treatments for wounds on the left calf and right leg. Interviews with facility staff, including the Infection Preventionist and licensed nurses, highlighted staffing challenges, such as the absence of a Treatment Nurse and the inability of other staff to consistently perform wound care treatments. The Infection Preventionist noted that several staff members, including the Treatment Nurse, had quit simultaneously, leaving the facility unable to schedule a nurse specifically for treatments. Licensed nurses reported being unable to complete all required dressings due to time constraints and lack of documentation, further contributing to the deficiency.
Failure to Supervise Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident who was left unsupervised on the toilet by a Certified Nursing Assistant (CNA). The resident, who had a history of falls and was identified as high risk for falls, was left alone in the bathroom while the CNA attended to another resident. This lack of supervision resulted in the resident falling and sustaining a fracture of the right distal fibula and tibia. The resident's medical history included hemiplegia, hemiparesis, epilepsy, and memory deficits following a cerebral infarction, all of which contributed to her high fall risk. The resident's care plan and assessments consistently indicated the need for supervision during toileting due to her fall risk and history of noncompliance with using the call light. Despite these documented needs, the CNA left the resident unsupervised, leading to the fall. Interviews with facility staff, including the Director of Nursing and Licensed Nurse, confirmed that the resident required assistance and supervision in the bathroom. The facility's policy on fall management emphasized the need for supervision for residents at high risk of falls. However, the CNA's actions did not align with these guidelines, resulting in the resident's injury.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for two residents involved in an incident. A Certified Nursing Assistant (CNA) witnessed one resident hitting another resident on the face with a shoe. This incident occurred at approximately 11:30 p.m. on November 15, 2024. However, the facility did not report this allegation of abuse to the California Department of Public Health until November 18, 2024, which was three days after the incident. During interviews, the Director of Staff Development (DSD) and the Administrator confirmed that the facility's policy required allegations of abuse to be reported to the Department within two hours. The DSD and the Administrator acknowledged that the incident was not reported within this timeframe. The facility's policy, revised in March 2018, also indicated that the Administrator or a designated representative should notify the Department, the Ombudsman, and Law Enforcement by telephone within two hours, followed by a written report. The delay in reporting decreased the facility's potential to ensure resident safety and caused a delayed response by enforcement agencies.
Unsafe Flooring Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to maintain a safe and functional environment, as evidenced by the improper positioning of transition strips at two doorways, which resulted in a hazardous threshold. This deficiency was directly linked to an incident where a resident fell and broke her arm. The resident was ambulating without her walker and tripped on the uneven threshold strip while attempting to return to her room to retrieve her walker. The fall caused her to land on her right side, resulting in a fracture of the right arm. The incident was documented in the resident's medical records, and the facility's investigation report noted the need for repairs at the affected doorways. Observations conducted by surveyors confirmed the hazardous conditions at the doorways, with uneven flooring and inadequate repairs, such as the use of black tape that did not effectively smooth the transition between different flooring types. The Director of Nursing acknowledged the trip hazard and expressed an assumption that the maintenance staff had already addressed the issue. The facility's policy on resident safety, which mandates immediate reporting of unsafe conditions, was not effectively implemented in this case, contributing to the deficiency.
Failure to Provide Regular Showers Leads to Infected Wound and Sepsis
Penalty
Summary
The facility failed to regularly provide showers for a resident, which contributed to the development and infection of a wound on the resident's right shoulder. The resident, who was admitted with diagnoses of Type 2 Diabetes Mellitus and Essential Hypertension, was dependent on staff for activities of daily living, including bathing. Despite being scheduled for showers twice a week, the resident only received two bed baths in July and no documented showers or bed baths in early August. Interviews with facility staff, including licensed nurses and certified nursing assistants, confirmed that the resident was not receiving showers as scheduled. Staff acknowledged that shower refusals should be documented, and if care was not documented, it was not provided. The lack of regular showers and skin assessments led to the resident's wound being missed and subsequently becoming infected, resulting in sepsis. The facility's policies on skin and wound management and showering and bathing emphasized the importance of skin observation during bathing. However, these procedures were not followed, as evidenced by the lack of documentation and care provided to the resident. The Assistant Director of Nursing verified the discrepancies in shower documentation and acknowledged that the failure to provide regular showers and assess the resident's skin contributed to the missed and infected wound.
Failure in Skin Assessment and Hygiene Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure thorough and accurate skin assessments for a resident, leading to a missed wound on the resident's right shoulder. Despite weekly skin checks, the wound was not documented or treated, resulting in the wound becoming infected. The resident was eventually hospitalized with a diagnosis of sepsis secondary to cellulitis and a small abscess on the right shoulder. The treatment nurse admitted that the skin assessments were inaccurate and that the wound was acquired at the facility. Additionally, the facility did not provide regular showers as scheduled for the resident, which contributed to the missed identification of the wound. The resident was supposed to receive showers twice a week, but documentation showed that only two bed baths were given in a month, and no showers or bed baths were provided in the days leading up to the resident's hospitalization. This lack of regular hygiene care was a factor in the development and worsening of the wound. Interviews with staff revealed a lack of awareness about the resident's wound, with both a CNA and a licensed nurse expressing surprise upon discovering the wound. The assistant director of nursing confirmed that the infection likely started at the facility and was not treated, leading to the resident's hospitalization for sepsis. The facility's policies on skin and wound management and showering were not followed, contributing to the oversight and subsequent health issues for the resident.
Significant Medication Error Involving Oxycodone Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an extra dose of Oxycodone HCL 5 mg was administered without a physician's order. The resident had an order for Oxycodone HCL 5 mg to be given every 6 hours as needed for pain, only when non-narcotic options were ineffective. On the day of the incident, the resident was given Oxycodone HCL 5 mg at 6:30 a.m. and again at 10 a.m., with the latter dose being a one-time dose ordered on that day. However, the Individual Narcotic Record indicated that another dose was administered at 9:15 a.m. by a different nurse, Licensed Nurse A, who claimed to have received a verbal order from an on-call physician, which the physician later could not recall giving. During an interview, Licensed Nurse A stated that she administered the extra dose because the resident was in excruciating pain and claimed to have received a verbal order from Physician C. However, Physician C could not recall giving such an order. The Director of Nursing (DON) confirmed that the administration of the extra dose was a medication error and that Licensed Nurse A was terminated as a result. The resident's progress notes and an investigation by the Medical Director confirmed that the extra dose was given without a proper physician's order. The facility's policy on medication administration, dated January 1, 2012, states that medications should be administered by a licensed nurse upon the order of a physician or licensed independent practitioner. The failure to adhere to this policy resulted in the administration of an unscheduled dose of Oxycodone HCL 5 mg, which was determined to be a medication error. Although the error did not result in physical harm to the resident, it had the potential to affect the resident's health and safety.
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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.
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Nursing homes near Fortuna
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seaview Rehabilitation & Wellness Center, Lp | 10.3 mi | — | 10 | 0 |
| Granada Rehabilitation & Wellness Center, Lp | 13.2 mi | — | 6 | 0 |
| Eureka Rehabilitation & Wellness Center, Lp | 13.6 mi | — | 27 | 0 |
| Jerold Phelps Comm Hosp Snf | 38.4 mi | — | 16 | 0 |
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