Fortuna Rehabilitation And Wellness Center, Lp
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
of Resident 68's admission record indicated admission to the facility on 8/8/25 with diagnoses which included dementia, depression, and cognitive communication deficit.A review of Resident 68's MDS dated [DATE REDACTED] indicated a BIMS score of 4 which meant Resident 68 was severely cognitively impaired.A review of Resident 68's SBAR summary for providers dated 8/8/25 at 10:19 a.m. indicated, Staff overheard CNA [4] telling [Resident 68] to pee in her pants. RNA [Restorative Nursing Assistant] intervened and too [sic] resident to the bathroom.In an interview on 9/16/25 at 2:41 p.m., RNA stated Resident 68 had been in the dining room with several other residents and CNA 4. Resident 68 had repeatedly asked CNA 4 for assistance to go to the bathroom when the RNA heard CNA 4 instruct Resident 68 to go to the bathroom in her brief. RNA thought it was inappropriate, so she took Resident 68 back to her bedroom and assisted her to go to the bathroom.A review of the facility's policy and procedure titled Abuse Prevention and Management revised 5/30/24 indicated, The Facility does not condone any form of resident abuse, neglect.and/or mistreatment.'Verbal abuse' is define as any use of oral.gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of.ability to comprehend.'Physical abuse' is defined as, but not limited to.hitting, slapping, punching, and/or kicking.'Neglect' and ‘deprivation of.services by staff' are defined as failure to provide.services necessary to attain or maintain physical, mental, and psychosocial well-being.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/13/2025
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-Tag F0605
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-11-13.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0607
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to implement its policy and procedure for abuse for one resident (Resident 65) of 28 sampled residents when licensed nurses and the social service worker did not assess Resident 65 for emotional distress after Resident 65 reported an allegation of abuse.This failure decreased the facility's potential to ensure the safety and welfare of Resident 65 after an allegation of abuse was reported.Findings:A review of an admission record indicated Resident 65 was admitted to the facility in September 2023 with diagnoses which included heart failure, chronic respiratory failure, and muscle wasting and atrophy (muscle shrinking).In an interview on 9/15/25 at 9:54 a.m., Resident 65 stated
a Certified Nursing Assistant 2 (CNA 2) was rough while providing her care the night before. Resident 65 stated CNA 2 made her feel afraid and added, If I was floating in my urine, I would not call him in [to help me]. Resident 65 further stated she reported the incident to CNA 3 this morning.In an interview on 9/15/25 at 4:37 p.m., Resident 65 reported she had asked CNA 2 to please be careful with her shoulders because
she had chronic pain in them. Resident 65 stated CNA 2 proceeded to tell her she needed acupuncture and pushed his fingertips into her right shoulder. Resident 65 asked him to stop, and he did. Resident 65 then stated CNA 2 held her feet down while she tried to move herself up higher on the bed. Resident 65 told him to let go of her feet but did not understand why he would have done it at all. Resident 65 also stated CNA 2 leaned up against her so hard that it caused her so much pain that she screamed out.In an interview on 9/17/25 at 8:43 a.m., Resident 49 stated she remembered Resident 65 screaming, Ow, ow, ow. You're hurting me. Resident 49 stated she had been wearing ear plugs, and she heard Resident 65 scream very clearly.In an interview and concurrent record review on 9/17/25 at 3:59 p.m., Licensed Nurse 2 (LN 2) stated residents are expected to be monitored for sadness or pain every shift for 72 hours after an allegation of abuse. LN 2 reviewed Resident 65's progress notes dated 9/14/25 through 9/17/25 at 3:59 p.m. and acknowledged there were no progress notes that mentioned Resident 65 was involved in an allegation of abuse. LN 2 also acknowledged there were no care plans initiated between 9/14/25 and 9/17/25 at 3:59 p.m. regarding Resident 65's allegation of abuse.A review of the facility's policy and procedure titled Abuse Prevention and Management revised 5/30/24 indicated, .The resident will be assessed by the licensed nurse for any physical injuries or emotional distress.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/13/2025
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-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Resident 68 was originally sent to an incorrect e-mail address that was not the Department's on 8/7/25.A
review of the Department's message log indicated the investigation summary of the abuse between CNA 4 and Resident 68 was received on 9/8/25.7. A review of an SOC 341 dated 9/15/25 indicated the ADM was notified of the allegation of abuse between CNA 8 and Resident 65 on 9/15/25 at 3:30 p.m.In an interview
on 9/15/25 at 4:37 p.m., Resident 65 stated she notified CNA 3 that CNA 8 had hurt her while providing care on the night of 9/14/25 between 11 p.m. and 7 a.m. Resident 65 stated she notified CNA 3 of her concern after breakfast earlier that morning on 9/15/25.In an interview on 9/17/25 at 8:43 a.m., Resident 49 stated she heard Resident 65 notify CNA 3 of her concern with CNA 8 after breakfast on 9/15/25.In an
interview on 9/17/25 at 9:17 a.m., CNA 3 acknowledged Resident 65 had notified her CNA 8 had hurt her while providing her care on the night of 9/14/25. CNA 3 confirmed Resident 65 had notified her of CNA 8
after breakfast at around 9 a.m. CNA 3 stated she notified the Director of Staff Development after she ate her lunch on 9/15/25 at approximately 12 p.m.In an interview on 9/17/25 at 4:21 p.m., the ADM acknowledged she notified the Department of Resident 65's allegation of abuse on the afternoon of 9/15/25 at approximately 3:30 p.m. and had already interviewed Resident 65 about the allegation. The ADM stated
she was unaware Resident 65 had initially reported the allegation of abuse to nursing staff on the morning of 9/15/25 after breakfast. The ADM also acknowledged she had submitted the notifications of the allegations of abuse and investigation summaries for Resident 00, Resident 83, Resident 101, Resident 90, Resident 105, Resident 102, Resident 2, Resident 74, Resident 14, Resident 68 late but stated she had done so because she had not realized the e-mail address she had sent the notifications to was incorrect.A
review of the facility's policy and procedure titled Abuse Prevention and Management effective 6/12/24 indicated, .The facility conducts mandatory staff training during orientation, annually, and as needed on.Reporting abuse.to whom and when to report and to report without fear of reprisal.The Administrator or designated representative will notify law enforcement, by telephone immediately.but no longer than (2) hours of an initial report AND send a written SOC 341 report to.CDPH Licensing and Certification [the Department] within (2) hours.The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken, to the California Department of Public Health Licensing and Certification [the Department].within five (5) working days of the reported allegation.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/13/2025
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-Tag F0655
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0655 during a standard health inspection conducted on 2025-11-13.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0656
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-11-13.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
neurological checks conducted every half hour as directed by the physician.A review of Resident 74's care plan regarding her actual fall with injury on 8/11/25 initiated on 8/12/25 indicated interventions which included, .Continue interventions on the at-risk plan.Monitor/document/report PRN [as needed] x [for] 72 h [hours] to MD [physician] for s/sx [signs and symptoms]: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation.A review of Resident 74's physician order summary conducted on 9/16/25 at 10:24 a.m. showed no active, discontinued, or completed physician's order to conduct neurological checks every half hour between 8/11/25 and 8/14/25.In an interview and concurrent record review on 9/17/25 at 12:10 p.m., Licensed Nurse 1 (LN 1) stated if a resident had an unwitnessed fall, then nurses are expected to conduct an assessment, take vital signs, complete neurological checks, and notify the physician, Director of Nursing, and the Administrator (ADM). LN 1 was not sure the frequency the neurological checks were supposed to be done but stated the computer charting would remind her. LN 1 conducted a record review of Resident 2's neurological checks dated 4/27/25 to 4/30/25. LN 1 confirmed Resident 2 only had neurological checks dated 4/27/25 and 4/28/25; Resident 2 did not have any neurological checks dated 4/29/25 or 4/30/25. LN 1 also conducted a record review of Resident 74 neurological checks dated 8/11/25 to 8/14/25. LN 1 confirmed Resident 74 only had neurological checks dated 8/11/25 and had two neurological checks dated 8/12/25.In an interview and concurrent record review on 9/17/25 at 3:59 p.m., LN 2 stated the purpose of neurological checks was to monitor the resident for delayed injuries. LN 2 also stated neurological checks were usually done for a total of 72 hours. LN 2 reviewed Resident 2's neurological checks dated 4/27/25 to 4/30/25 and confirmed Resident 2 did not have documented neurological checks conducted for a total of 72 hours. LN 2 also reviewed Resident 74's neurological checks dated 8/11/25 to 8/14/25 and confirmed Resident 74 did not have any neurological checks dated 8/13/25 or 8/14/25.In an interview on 9/17/25 at 4:21 p.m., the ADM stated she was aware neurological checks had not been completed as the nurse consultants had recently notified her.A review of the facility's policy and procedure titled Fall Management Program revised 11/7/16 indicated, Post-Fall Response.The Licensed Nurse will complete the.Neurological Flow Sheet for an un-witnessed fall, or witnessed fall with suspected or known head injury for seventy-two (72) hours following
the fall incident. Perform neurological checks at the frequency ordered, or as the following to equal 72 hours.Every 15 minutes x 1 hour then; Every 30 minutes x 1 hour then; Every hour x 4 hours then; Every 4 hours x 66 hours or until the physician states it is no longer necessary or; after 72 hours if the resident's condition is stable and showing no signs or symptoms of neurological injury.
Event ID:
Facility ID:
If continuation sheet
F-Tag F0692
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-11-13.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0727
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0727 during a standard health inspection conducted on 2025-11-13.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0755
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-11-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0761
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-11-13.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0803
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0803 during a standard health inspection conducted on 2025-11-13.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0805
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0805 during a standard health inspection conducted on 2025-11-13.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0812
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-11-13.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0880
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-11-13.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0919
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0919 during a standard health inspection conducted on 2025-11-13.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure that a working call system is available in each resident's bathroom and bathing area.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
F-Tag F0925
Federal health inspectors cited FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, CA for a deficiency under regulatory tag F-F0925 during a standard health inspection conducted on 2025-11-13.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 17 deficiencies cited during this inspection of FORTUNA REHABILITATION AND WELLNESS CENTER, LP.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-08.
FORTUNA REHABILITATION AND WELLNESS CENTER, LP in FORTUNA, 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 FORTUNA, 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 FORTUNA REHABILITATION AND WELLNESS CENTER, LP or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.