Fortuna Rehabilitation And Wellness Center, Lp

Based on interviews and record reviews, the facility failed to ensure one resident (Resident 1) of two sampled residents was free from a significant medication error when Resident 1 was administered an incorrect dose of Oxycodone Hydrochloride (medication used to relieve severe pain).This failure decreased the facility's potential to correctly and safely administer medication and prevent adverse side effects.Findings:A review of Resident 1's admission record indicated admission to the facility on 8/18/24 with diagnoses which included dementia (a progressive state of decline in mental abilities) and Asthma (a chronic lung disease which causes arrowed airways and difficulty breathing).A review of Resident 1's progress note dated 11/10/25 at 7:05 p.m., indicated, [Resident 1] was given 20 mg [milligrams, a unit of measurement] oxycodone tab [tablet] that belongs to [Resident 2]. [Resident 1] actual dose ordered is 5 mg.

This error was made on AM [morning] shift given by nurse prior.This error was caught during shift change report 11/10/25 at 7 p.m.A review of Resident 1's order summary report indicated Resident 1 had a physician's order dated 4/29/25 to receive 5 mg of oxycodone hydrochloride (HCL) by mouth two times a day.A review of Resident 1's Medication Administration Record (MAR) dated November 2025 indicated Licensed Nurse 1 (LN 1) administered 5mg of oxycodone HCl to Resident 1 at approximately 9 a.m.During an interview on 11/24/25 at 2:39 p.m., LN 1 acknowledged she administered the wrong medication to Resident 1 and stated it was because she verified Resident 1's name on the MAR but did not look at the medication to verify that it was Resident 1's medication. LN 1 stated she may have picked Resident 2's oxycodone medication instead of Resident 1's.

During an interview on 11/24/25 at 3:20 p.m., the DON (Director of Nursing) acknowledged the medication error occurred.

The DON stated LN 1 did not look at the bubble pack (blister pack cards that contain the medications) a second time and popped the wrong medication from Resident 2's bubble pack.

The DON stated when she investigated, she found out that the two medications were right next to each other.

The DON provided copies of the oxycodone bubble packs for Resident 1 and Resident 2 where the size difference between the two medications was observed.A review of the facility's policy and procedure titled, Medication Administration, dated 6/26/25, indicated, All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations.

The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner.The Licensed Nurse will verify the resident's identity before administering the medication using the 6 rights of medication administration.Right Resident: Confirm with two identifiers.Right Medication: Verify against the MAR and pharmacy label.Right Dose: Ensure accuracy based on provider order.

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

Facility ID: