Fortuna Rehabilitation And Wellness Center, Lp

standards of practice for one of six sampled residents (Resident 1) when 72-hour monitoring was not

psychological distress, physical injury, and worsening mental health symptoms for Resident 1.A review of Resident 1's admission record indicated he was admitted to the facility on [DATE] with medical diagnosis which included dementia (severe decline in memory and thinking), major depressive disorder (intense sadness for at least two weeks), post-traumatic stress disorder (a mental health disorder triggered by trauma, causing lasting symptoms like flashbacks, anxiety, and avoidance), and suicidal ideations (thoughts of self-harm).A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 11/4/25, indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 11 which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). Resident 1's MDS also indicated he had felt down, depressed or hopeless nearly every day during this period.A review of Resident 1's Progress Note, dated 1/11/26 at 3:45 p.m., indicated Resident 1 was struck in the left front shoulder twice, with a closed fist, by another resident.A review of Resident 1's Interdisciplinary Team (IDT, a team of professionals from different fields who work together, sharing expertise and information to provide comprehensive care or solve complex problems through collaboration ) Note, dated 1/12/26 at 1:19 p.m., indicated Resident 1 told facility staff, I don't know if I am hurt or just upset.A review of Resident 1's Progress Note, dated 1/13/26 at 8:35 a.m., indicated Resident 1 stated he was upset about the altercation with the other resident.

The note also indicated, [Resident 1] is very worried the other resident will continue to bother him.

During an interview and record review on 2/26/26 at 11:45 a.m. with the Director of Nursing (DON), Resident 1's documentation following the 1/11/26 altercation was reviewed.

The DON acknowledged that although a COC had been initiated for Resident 1 following the altercation, continuous 72-hour monitoring notes were not charted for every shift following the assault incident of 1/11/26, and therefore the monitoring could not be verified as completed.

The DON stated close supervision of Resident 1's condition was important as he had expressed worry and anxiety about further assaults, and because of Resident 1's many serious psychological diagnoses, including suicidal ideations.A review of facility's policy and procedure (P & P) titled, Change in Condition, effective 8/25/22, indicated, a licensed nurse will document each shift for at least seventy-two (72) hours when there is a change in the resident's condition.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE