Inspection·April 10, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 Licensed Nurses (LNs) administered medications to residents per physician's order for two residents (Resident 1 and Resident 2) of four sampled residents when LNs administered medications late. Residents Affected - Some This finding had the potential to result in serious side and adverse effects to the residents receiving late medications. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included palliative care (specialized medical care for people with serious illnesses which is focused on relieving suffering and improving quality of life) and malignant neoplasm of skin (skin cancer). A review of a facility document titled, Medication Audit Admin Report, dated 3/1/25 to 3/31/25 indicated: -On 3/1/25, propranolol (medication used to treat tremors) 60 milligrams (mg, a unit of measurement) was scheduled to be given at 12 p.m. It was documented as administered at 4:14 p.m. -On 3/1/25, methadone (medication used to treat chronic pain) 2.5 mg was scheduled to be given at 12p.m. It was documented as administered at 4:12 p.m. -On 3/2/25, gabapentin (medication used to treat nerve pain) and methadone, were scheduled to be given at 9 a.m. They were documented as administered between 10:47 a.m. to 10:48 a.m. A review of Resident 2's Medication Administration Record for April 2025, indicated Resident 2 was admitted to the facility on [DATE] with medical diagnoses which included Epilepsy (A brain disease which causes seizures). A review of a facility document titled, Medication Audit Admin Report, dated 4/1/25 to 4/10/25 indicated: -On 4/1/25, ropinirole (medication used to treat Parkinson's Disease (a neurological disorder which affects movement)) 2 mg was scheduled to be given at 8 a.m. It was documented as administered at 9:43 a.m. (continued on next page) 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 Page 1 of 2 Event ID: 056361 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fortuna Rehabilitation and Wellness Center, LP 2321 Newburg Road Fortuna, CA 95540 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)