Inspection·May 7, 2025

F 0645 Level of Harm - Minimal harm or potential for actual harm During a record review of correspondence from State of California Department of Healthcare Services, dated 6/19/24, it indicated Resident 1 did not require a PASRR level II (a more in-depth evaluation of individuals who have been screened positive for a potential mental illness or intellectual/developmental disability. This evaluation determines if a person's needs are best met in a nursing facility and if specialized services are required) screening, due to, no MI (mental illness). Residents Affected - Some During a record review of Resident 2 ' s, admission Record, dated 5/12/25, it indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including toxic encephalopathy, cerebral palsy (a permanent disorder that affects muscle movement and coordination due to damage to the developing brain), depression (a mood disorder characterized by persistent sadness, loss of interest or pleasure in activities, and other physical and cognitive changes), and developmental delay of scholastic skills (difficulties in acquiring or using specific academic skills like reading, writing, or math). During a record review of Resident 2's, MDS-C, dated 4/21/25, it indicated Resident 2 had a BIMS score of 7, indicating moderate cognitive impairment. During a record review of Resident 2 ' s acute hospital ' s, Discharge Summary, dated 7/25/23, it indicated Resident 2 ' s historical diagnoses and current hospital problems included cerebral palsy, developmental delay, and depression. Discharge instructions also noted Resident 2, needs coordination with Regional Center (Department of Developmental Services Regional Center- provides a wide array of services for individuals with developmental disabilities. Each center provides diagnosis and assessment of eligibility, and helps plan, access, coordinate and monitor services and supports). During a record review of Resident 2 ' s, PASSR Level 1 Screening, dated 7/25/23, it indicated Resident 2 had a developmental or intellectual disability which was expected to continue, had received services from the Regional Center in the past, and currently experienced multiple functional limitations (restrictions in a person's ability to perform daily activities due to physical, mental, or cognitive impairments). The PASRR indicated Resident 2 did not have a serious mental disorder when section III, number 10 was answered, no. During a record of review of Resident 2 ' s medical record, it indicated the facility did not complete a PASRR Level 2, as this document was not found in the Resident ' s electronic chart. During a record review of Resident 3 ' s, admission Record, printed 5/6/25, it indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including depression, hemiplegia and hemiparesis following cerebral infarction (a condition where brain tissue dies due to a lack of blood flow), and contusion and laceration of the cerebrum (injuries to the brain tissue that result from blunt force trauma). During a record review of Resident 3's, MDS-C, dated 3/21/25, it indicated Resident 3 had a BIMS score of 9, indicating moderate cognitive impairment. During a record review of Resident 3 ' s untitled facility ' s physician note, dated 3/14/25, the physician diagnosed Resident 3 with the following conditions: Toxic encephalopathy, anxiety disorder, and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest or pleasure, and other symptoms that interfere with daily life). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056361 If continuation sheet Page 2 of 5 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 05/07/2025 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)

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a record review of Resident 3 ' s ,PASRR Level 1, dated 3/13/23, it indicated Resident 3 ' s PASRR result was, positive due to Suspected MI (mental illness). During a record review of correspondence from the State of California Department of Health Care Services, dated 3/21/23, it indicated a PASRR level II screening could not be conducted for Resident 3, due to, no serious MI (mental illness). During an interview on 5/7/25 at 9:36 a.m., with the Director of Nursing (DON), the DON stated if the PASRR process is not properly completed, an individual may be inappropriately placed in a skilled nursing facility. The DON stated she had experienced this situation while working at another facility, and inappropriate placements could result in resident harm. During an interview on 5/7/25 at 10:10 a.m., with the Business Officer (BOM), the BOM states she worked with the MDS Nurse (MDS) to ensure PASRR ' s were completed for each resident, and they were done correctly. The BOM stated, when an acute hospital completed the Level I PASRR when they transfered a resident to the facility, 90% of the time the PASRR was incorrectly completed. The BOM stated the MDS Nurse (MDSN) should have reviewed available documentation and corrected any errors in the Level I PASRR, which would have triggered a Level II PASRR screening for Residents 1, 2 and 3. During an interview on 5/7/25 at 11:08 a.m., with MDSN, the MDSN acknowledged acute hospitals were now responsible to fill out PASRR level 1 ' s prior to resident admission to a skilled nursing facility, and they often answered questions on the PASRR 1 incorrectly. The MDSN also stated, if the PASRR process was not correctly followed, a resident with a mental illness or developmental delay may not receive services from the DDS Regional Center. During a phone interview on 5/7/25 at 2:45 p.m., with the DDS Regional Center Nurse (RCN), the RCN stated the PASRR was enacted in the 1990 ' s to ensure that individuals with mental illness or developmental delays were not inappropriately placed in skilled nursing facilities. During a review of facility policy and procedure (P & P) titled, Pre-admission Screening Resident Review (PASRR), revised 8/15/16, it indicated, Purpose: to ensure all facility applicants are screened for mental illness and mental retardation prior to admission, and, the facility MDS Coordinator will be responsible to access and ensure updates to the PASRR is done per MDS guidelines (e.g. Significant Change of Status MDS). During a record review of facility P & P titled, Pre-admission Screening Level II Resident Review, dated 9/2017, it indicated, The facility staff will coordinate the recommendations from the level II PASRR determination and the PASRR evaluation report with the resident ' s assessment, care planning and transitions of care. The facility will refer all level II residents and all residents with a newly evident or possible serious mental disorder, intellectual disability or a related condition, for level II resident review upon a significant change in status assessment, and, The IDT (Interdisciplinary Team-brings together professionals from various disciplines to provide comprehensive, person-centered care. These teams aim to improve patient outcomes through collaboration, communication, and shared decision-making) will review the level II evaluation report to develop a care plan and arrange the Specialized Services recommended for the resident. Specialized Services are add-on to the facility services- they are of a higher intensity and frequency than the services provided by the facility if the resident ' s PASRR level II report indicates that he/she needs specialized services, and the IDT identifies that he/she is not receiving them, the BOM will notify the MediCal/MediCaid agency for authorization for payment or provision of these services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056361 If continuation sheet Page 3 of 5 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 05/07/2025 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)

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits. 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 provide face-to-face physician visits at least once every 60 days for three sampled residents (Resident 1, Resident 2, and Resident 3). Residents Affected - Some This deficient practice had the potential to result in a decline in medical, health or psychosocial condition and lead to a delay in necessary care, treatment and services. Findings: A review of Resident 1 ' s, admission Record, dated 5/6/25, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot adequately provide oxygen to the blood or remove carbon dioxide), post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event. Symptoms include intrusive memories, nightmares, flashbacks, avoidance of triggers, negative thoughts and feelings, and hypervigilance), anxiety disorder (excessive worry and fear that significantly interferes with daily life), chronic pain syndrome (a broad term for pain that persists beyond the expected healing time of an injury or illness, or is associated with a chronic health condition), gastro-esophageal reflux disease (a chronic condition where stomach acid flows back up into the esophagus, causing heartburn and other symptoms), and post laminectomy syndrome (a complex condition with multiple potential causes, including scar tissue, nerve root compression, and psychological factors. Symptoms can range from dull aches to sharp, stabbing pain, and can include numbness, tingling, or weakness in the legs). A review of Resident 1 ' s, Minimum Data Set ([MDS] a resident assessment tool), dated 4/3/25, indicated Resident 1's BIMS (Brief Interview for Mental Status score is a tool used to assess a resident's cognitive function) score was 8, indicating moderately impaired cognitive skills. During a concurrent interview and record review on 5/6/25 at 2:27 p.m., with the Registered Nurse Consultant (RNC), Residents 1 ' s physician visit notes titled, Housecall MD, Inc,. with the following dates, were reviewed: 7/11/24, 10/16/24, 11/23/24, 1/3/25, 3/12/25, and 3/31/25. The RNC confirmed between 7/11/24 and 3/12/25, the facility physician did not have a face-to-face visit with Resident 1, equal to a period of eight months. A review of Resident 2 ' s, admission Record, dated 5/12/25, indicated Resident 2 was initially admitted to the facility on [DATE], with diagnoses including toxic encephalopathy (a brain disorder caused by exposure to toxic substances, leading to altered mental status and other neurological symptoms), quadriplegia (a condition characterized by the paralysis of all four limbs and the torso due to a spinal cord injury or other neurological damage), spastic cerebral palsy (characterized by increased muscle tone and stiffness, making movements appear awkward and jerky), depression (a serious mood disorder characterized by persistent feelings of sadness and a loss of interest or pleasure in activities), and developmental disorder of scholastic skills (difficulties in acquiring and using academic skills despite normal intelligence, adequate schooling, and motivation). During a review of Resident 2 ' s MDS, dated 4/28/25, the MDS indicated Resident 2's BIMS score was 7, indicating moderately impaired cognitive status. During a concurrent interview and record review on 5/7/25 at 12 p.m., with the MDS Nurse (MDSN), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056361 If continuation sheet Page 4 of 5 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 05/07/2025 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)

F 0712 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 2 ' s physician visit documentation titled, Housecall MD, Inc., for the following dates were reviewed: 10/9/24, 11/9/24, and 1/3/25. The MDSN stated each of these visits were tele-health/virtual visits. During a review of Resident 3 ' s, admission Record, dated 5/13/25, it indicated Resident 3 was initially admitted to the facility on [DATE], with diagnoses including acute kidney failure (a sudden and significant loss of kidney function, often within hours or days), hemiplegia and hemiparesis (hemiplegia refers to complete paralysis, while hemiparesis refers to partial weakness), muscle weakness and history of falling. During a review of Resident 3 ' s, MDS, dated 3/21/25, the MDS indicated Resident 3's BIMS score was 9, indicating moderate cognitive impairment. During a concurrent interview and record review on 5/7/25 at 12 p.m., with MDSN, Resident 3 ' s physician visit documentation titled, Housecall MD, Inc., for the following dates were reviewed: 10/9/24, 11/9/24, 12/12/24 and 1/3/25 were reviewed. The MDSN stated each visit was a tele-health/virtual visit. During a phone interview with on 5/7/25 at 2:30 p.m., with the facility Administrator (ADM), the ADM stated that the facility terminated prior contracted physician services in February 2025, for not providing agreed face-to-face services with facility residents. A review of the federal regulations governing physician visits in Skilled Nursing Facilities, Code of Federal Regulations, Title 42, §483.30(c) and (c)(1), indicated that physicians must see their residents in person, and telehealth visits are not allowed, as follows: §483.30(c)(1) The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter . DEFINITIONS §483.30(c) Must be seen, for purposes of the visits required by §483.30(c)(1), means that the physician or NPP must make actual face-to-face contact with the resident, and at the same physical location, not via a telehealth arrangement . A review of facility policy and procedure titled, Physician Services and Visits, dated 1/1/12, indicated, the Facility must ensure that all residents admitted to or accepted for care by the Facility are under the care of a physician .the Attending Physician must: Evaluate the resident as needed and at least every 30 days ., and, physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056361 If continuation sheet Page 5 of 5