Fortuna Rehabilitation and Wellness Center, LP

In the surveyor’s words

From the most serious findings on record at Fortuna Rehabilitation and Wellness Center, LP, in the surveyor’s own words.

• Immediate jeopardy, widespreadF802Mar 16, 2022

  Based on kitchen observations, dietary staff interviews, management and administration interviews, and facility document and policy review, the facility failed to ensure sufficient and competent staffing in the dietetic service department when the facility did not have enough trained cooks and enlisted the Activity Director (Director B), Dietary Aide C (a dietary aide, not a trained cook) and Aide F to cook resident meals; Director B, Aide C and Aide F did not possess cooking competencies (verification of skills needed by staff to perform a task); dietary staff were not supervised per facility policy; and dietary staff were not adequately trained prior to cooking independently. […]

• Actual harm, patternF686Jul 27, 2022

  Based on observation, interview and record review, the facility failed to ensure one of six residents sampled for pressure ulcer (a localized injury to the skin and underlying tissue that occurs because of intense and prolonged pressure) review (Resident 199) received care, treatment, and services consistent with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For Resident 199, admitted on [DATE], bed-bound and immobile, with paralysis, admitted with a pre-existing Stage 3/Unstageable pressure ulcer (a wound where the whole skin is gone and the fat layer of tissue that underlines the skin is visible) on his coccyx (tail bone): (1) The facility failed to complete a risk assessment for developing pressure injuries (Braden Scale) upon admission for Resident 199. […]

• Actual harm, isolatedF689Jan 8, 2025

  Based on interview and record review, the facility failed to provide supervision to prevent a fall for one resident (Resident 1) of two sampled residents when Certified Nursing Assistant B (CNA B) left Resident 1 on the toilet unsupervised then left Resident 1 ' s room to attend to another resident. This failure resulted in Resident 1 sustaining a fracture (a complete or partial break of the bone) of the right distal fibula (smaller long bone of the lower leg) and the right distal tibia (larger long bone of the lower leg). […]

• Actual harm, isolatedF677Aug 15, 2024

  Based on interviews and record reviews, the facility failed to regularly provide showers for one out of two sampled residents (Resident 1). This failure was a contributing factor for: 1.staff not identifying Resident 1 wound on top of his right shoulder, 2. the wound on top of Resident 1's right shoulder to become infected (having an infection- invasion or growth of germs in the body) that later developed into sepsis (life threatening condition, a severe form of infection). Findings: A review of Resident 1's face sheet (demographics) indicated Resident 1 was admitted on [DATE] with a diagnoses of Type 2 Diabetes Mellitus (DM, a disease that occurs when your blood glucose, also called blood sugar, is too high) and Essential Hypertension (HTN, high blood pressure). […]

• Actual harm, isolatedF684Aug 15, 2024

  Based on observation, interviews and record reviews, the facility failed: 1. to ensure skin assessments (process of examining entire skin for any abnormalities) was provided thoroughly, accurately documented and ensure treatment was provided when there were skin assessments forms completed but the assessment were inaccurate for one out of two sampled residents (Resident 1) 2. to provide showers regularly and as scheduled for one out of two sampled residents (Resident 1). These failures resulted in: A. inaccurate documentation of Resident 1's skin status, staff not identifying Resident 1 wound on top of his right shoulder, thereby no treatment was rendered on the wound on Resident 1's right shoulder, B. […]