Resident 65 told inspectors that Certified Nursing Assistant 2 made her feel afraid during care on the night of September 14. "If I was floating in my urine, I would not call him in [to help me]," she said during a September 15 interview.
The resident, who suffers from heart failure, chronic respiratory failure, and muscle wasting, had asked the aide to be careful with her shoulders because of chronic pain. Instead, the aide told her she needed acupuncture and pushed his fingertips into her right shoulder. When she asked him to stop, he did.
But the encounter escalated. The aide held her feet down while she tried to move herself higher on the bed. She told him to let go but said she didn't understand why he would do such a thing. Then the aide leaned against her so hard that the pain made her scream.
Her roommate heard everything. Resident 49 was wearing ear plugs that night but still heard Resident 65 screaming very clearly: "Ow, ow, ow. You're hurting me."
Resident 65 reported the incident to another nursing assistant the next morning. She told inspectors about it during their visit.
Licensed Nurse 2 acknowledged that residents must be monitored for sadness or pain every shift for 72 hours after an abuse allegation. The facility's policy, revised in May 2024, specifically states that "the resident will be assessed by the licensed nurse for any physical injuries or emotional distress."
Nobody followed that policy.
Licensed Nurse 2 reviewed Resident 65's progress notes from September 14 through September 17 and found no mention that the resident was involved in an abuse allegation. No care plans were created during that period regarding the abuse report.
The inspection occurred more than two months after the incident. Federal inspectors found that the facility's failure to assess Resident 65 for emotional distress "decreased the facility's potential to ensure the safety and welfare of Resident 65 after an allegation of abuse was reported."
Resident 65 had been living at Fortuna Rehabilitation and Wellness Center since September 2023. Her medical conditions include muscle atrophy, making her particularly vulnerable during physical care. The aide's rough handling occurred during what should have been routine assistance.
The resident's fear was palpable in her interview with inspectors. She made clear that the aide's behavior had changed how she would seek help in the future. Rather than call for assistance when she needed it most, she said she would rather remain in her own waste than summon the aide who had hurt her.
Her roommate's account corroborated the resident's version of events. Despite wearing ear protection, Resident 49 could hear the distressed cries from the next bed. The screams were loud enough and distinct enough to penetrate her ear plugs.
The facility's written policy promised protection that never materialized. The May 2024 revision of the abuse prevention policy established clear requirements for post-allegation care. Licensed nurses were supposed to evaluate residents for both physical injuries and emotional trauma within 72 hours.
Three days passed without any documented assessment. The licensed nurse who reviewed the records during the inspection confirmed what was missing. No progress notes mentioned the abuse allegation. No care plans addressed the resident's emotional state after reporting rough treatment.
Federal regulations require nursing homes to develop and implement policies preventing abuse, neglect, and theft. The inspection found that Fortuna Rehabilitation failed to implement its own abuse policy for Resident 65.
The violation was classified as causing minimal harm or potential for actual harm. But for Resident 65, the impact extended beyond the physical pain of that September night. Her statement about avoiding future help from the aide revealed lasting fear and diminished trust in the facility's care.
Licensed Nurse 2's acknowledgment during the inspection highlighted the gap between written policy and actual practice. The nurse knew what should have happened but could find no evidence that anyone had followed through. The required monitoring never occurred. The emotional assessment never took place.
Resident 65's experience illustrates how policy failures can compound the trauma of abuse allegations. The initial rough treatment was concerning enough. The facility's failure to provide required follow-up care meant her emotional distress went unaddressed for weeks.
The inspection covered 28 residents, but only Resident 65's case revealed this particular policy violation. Her willingness to speak with inspectors brought the failure to light. Without her account and that of her roommate, the missed assessments might have remained hidden in the absence of progress notes.
The facility's abuse prevention policy promised systematic protection for vulnerable residents. When Resident 65 needed that protection most, after reporting treatment that made her scream and left her afraid, the system designed to safeguard her well-being never activated.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fortuna Rehabilitation and Wellness Center, Lp from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
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