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Health Inspection Summary
Fortuna Rehabilitation and Wellness Center, LP
2321 Newburg Road
Fortuna, CA 95540
(707) 725-4467

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Deficiency Category
Inspection Date:
7/27/22
Complaint Reporting Period:
3/1/24 - 2/28/25
Inspection Date:
4/12/19
Complaint Reporting Period:
3/1/23 - 2/29/24
Inspection Date:
3/7/18
Complaint Reporting Period:
3/1/22 - 2/28/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies300
Quality of Life and Care Deficiencies864
Infection Control Deficiencies312
Resident Assessment and Care Planning Deficiencies045
Nursing and Physician Services Deficiencies211
Resident Rights Deficiencies225
Nutrition and Dietary Deficiencies005
Pharmacy Service Deficiencies250
Environmental Deficiencies110
Administration Deficiencies015

Detailed result for inspection on 7/27/22
Date of last standard health inspection:7/27/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25
Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:21
Average number of Health Deficiencies in California:16.4
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

1/8/251/28/25
2 - Minimal harm or potential for actual harm
Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Few

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

1/8/251/28/25
3 - Actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

8/15/249/30/24
3 - Actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/27/229/16/22
3 - Actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some

Provide safe and appropriate respiratory care for a resident when needed.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

7/27/229/16/22
3 - Actual harm
Some

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

8/15/249/30/24
3 - Actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some

Provide and implement an infection prevention and control program.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Many

Implement a program that monitors antibiotic use.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Many

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that residents are free from significant medication errors.

7/27/229/16/22
3 - Actual harm
Few

Ensure medication error rates are not 5 percent or greater.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

11/21/2412/21/24
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 4/12/19
Date of last standard health inspection:4/12/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24
Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:21
Average number of Health Deficiencies in California:17.2
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

4/12/196/28/19
3 - Actual harm
Few

Provide routine and 24-hour emergency dental care for each resident.

4/12/197/25/19
2 - Minimal harm or potential for actual harm
Some

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/13/239/4/23
3 - Actual harm
Few

Provide appropriate foot care.

4/26/235/30/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/25/238/25/23
3 - Actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Implement a program that monitors antibiotic use.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives an accurate assessment.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

7/25/238/25/23
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

7/25/238/25/23
2 - Minimal harm or potential for actual harm
Some
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Some
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

4/18/234/27/23
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

8/23/239/23/23
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that residents are free from significant medication errors.

2/15/245/2/24
2 - Minimal harm or potential for actual harm
Few

Ensure medication error rates are not 5 percent or greater.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Few

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.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

4/11/234/25/23
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

8/23/239/23/23
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Keep all essential equipment working safely.

4/12/196/28/19
2 - Minimal harm or potential for actual harm
Many
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

8/23/239/23/23
2 - Minimal harm or potential for actual harm
Many

Detailed result for inspection on 3/7/18
Date of last standard health inspection:3/7/18Read the full report (PDF)
Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23
Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:27
Average number of Health Deficiencies in California:15.1
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

3/7/185/3/18
3 - Actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

3/7/185/3/18
3 - Actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

3/7/186/11/18
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Some
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Many

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives an accurate assessment.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Some

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Some

Ensure services provided by the nursing facility meet professional standards of quality.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Some

Assure that each resident’s assessment is updated at least once every 3 months.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Many
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

3/7/185/3/18
4 - Immediate jeopardy to resident health or safety
Many

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

3/7/185/3/18
3 - Actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

4/13/225/18/22
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

3/7/186/11/18
2 - Minimal harm or potential for actual harm
Few

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Many

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Few

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

3/16/226/9/22
4 - Immediate jeopardy to resident health or safety
Many
Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

3/16/226/9/22
2 - Minimal harm or potential for actual harm
Many

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Many

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

3/7/185/3/18
2 - Minimal harm or potential for actual harm
Many

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

1/8/251/28/25
2 - Minimal harm or potential for actual harm
Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

1/8/251/28/25
3 - Actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

8/15/249/30/24
3 - Actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/27/229/16/22
3 - Actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

8/15/249/30/24
3 - Actual harm
Few

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some

Provide and implement an infection prevention and control program.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Many

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Many

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

7/27/229/16/22
2 - Minimal harm or potential for actual harm
Some

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

11/21/2412/21/24
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/13/239/4/23
3 - Actual harm
Few

Provide appropriate foot care.

4/26/235/30/23
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

7/25/238/25/23
3 - Actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

7/25/238/25/23
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

7/25/238/25/23
2 - Minimal harm or potential for actual harm
Some

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

4/18/234/27/23
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

8/23/239/23/23
2 - Minimal harm or potential for actual harm
Some

Ensure that residents are free from significant medication errors.

2/15/245/2/24
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

4/11/234/25/23
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

8/23/239/23/23
2 - Minimal harm or potential for actual harm
Some

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

8/23/239/23/23
2 - Minimal harm or potential for actual harm
Many

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

4/13/225/18/22
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

3/16/226/9/22
4 - Immediate jeopardy to resident health or safety
Many

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

3/16/226/9/22
2 - Minimal harm or potential for actual harm
Many

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

6/14/227/11/22
2 - Minimal harm or potential for actual harm
Some
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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