Fortress Nursing and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 57 and Resident #59) reviewed for ADL care. The facility failed to ensure Resident #57 and Resident #59's nails were cleaned and did not have any rough edges on 01/20/2026 and 1/21/2026. This failure could place residents at risk of not receiving services or care, diminished quality of life , and decreased self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide safe transport for Resident #1 on 05/27/25 which resulted in a fall and Nondisplaced fracture of the proximal fibular metaphysis of the left knee. This failure could result in serious injury such as a left knee fracture and a reduced quality of life . The noncompliance was identified as PNC. The PNC began on 5/27/25 and ended on 5/28/25. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care was provided such care, consistent with professional standards of practice, for 3 of 4 residents (Resident #1, Residents #2, and Resident # 3) reviewed for the use of oxygen cannula and nebulizer. The facility failed to ensure: -Resident #1 and Resident #2's nebulizer mask and tubing were in a bag. - Resident #3's oxygen cannula was in a bag This failure could place residents at risk for respiratory infections.

Inspectors wroteBased on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for all residents in the facility. 1. The facility failed to provide activities as scheduled on October 5th- October 6th, October 12th- October 13th , and October 19th to October 20th. These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 4 (Resident#55, #54, #56, and#268) of 6 residents reviewed for narcotic pharmacy services. 1. CMA (F) administered narcotics and did not document in the narcotic book after administering to the residents. This failure placed residents at risk for inadequate therapeutic outcomes, ineffective disease management and a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and include the appropriate -The medication cart for the 400 halls had four unidentified loose pills. -The facility failed to ensure expired medications were removed from the medication carts and medication room. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure the Director of Rehabilitation/PT and LVN D were wearing effective hair restraints, while in the kitchen. This failure could place residents who received meals and/or snacks from the kitchen at risk of foodborne illness due to physical contamination.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident # 24, and Resident #45) out of 8 residents reviewed for call lights. The facility failed to ensure Resident # 24 and Resident #45's call light was within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 (Resident #40) of 25 residents reviewed for care plans, in that: 1. The facility failed to ensure Resident #40's comprehensive care plan addressed a discharge plan. This failure could place the residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of eight residents (Resident #17, Resident #24, and Resident #35) reviewed quality of life. 1. The facility failed to ensure Resident #17 and Resident #24 nails were cleaned. 2. The facility failed to ensure Resident #35 nails were trimmed and did not have any rough edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 8.57 % based on 3 errors out of 35 opportunities, which involved 1 of 8 residents (Resident #34) and 1 of 2 staff (CMA F) reviewed for medication errors, in that: The facility failed to ensure residents were free from medication errors. These failures could place residents at risk of medication errors that could cause a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to prevent Med Aide A, on 6/23/24, from verbally abusing Resident #1 when she used foul language and threatened to keep him up late. The noncompliance was identified on 6/23/24. The facility had corrected the noncompliance before the investigation began and was corrected 06/24/24. These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for abuse. The facility failed to ensure Resident #1 was in a safe environment when LVN A recorded instances of pouring water onto her face, verbally taunting her, and striking her with her knee and sitting on her arm. An immediate jeopardy existed from 03/05/24 - 03/06/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could affect residents by placing them at risk for abuse that could cause diminished quality of life and increased psychosocial harm as well as physical harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary services to maintain personal hygiene for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for ADLs. -The facility did not provide Resident #1 with a shower 8/11/2023 through 8/22/2023, 8/24/2023 through 8/30/2023, and 9/6/2023 through 9/13/2023. -The facility did not provide Resident #2 with a shower 8/1/2023 through 8/4/2023, 8/13/2023 through 8/31/2023. -The facility did not provide Resident #3 with a shower 8/2/2023 through 8/14/2023, 8/16/2023 through 9/12/2023. This failure could place residents who required assistance of 1 or 2 staff or who are dependent on staff for bathing at risk for discomfort, skin breakdown and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the walk-in refrigerator in that: -The facility stored unlabeled and unsealed foods in the refrigerator. This failure had the potential to place residents at risk of serious complications from foodborne illness as a result of their compromised health status

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 waste receptacles reviewed for garbage disposal. -Waste receptacle #1 had its top lid opened when no one was disposing of trash. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on interview and record review the facility failed to immediately consult and notify the resident's physician in an accident including the resident for one (Resident #1) of 7 Residents reviewed for quality of care. The facility nurses failed to immediately consult and notify the Physician when resident #1 sustained a fall with head injury on 09/04/2023 at 04:00 p.m. and the physician was not notified until 09/05/2023 at midnight, 8 hours later. Per the facility policy nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. An Immediate Jeopardy (IJ) situation was identified on 09/06/2023. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of 7 Residents reviewed for quality of care. The facility nurses failed to ensure nurses conducted neurological exams after Resident #1 sustained a fall with head injury on 09/04/2023 at 4:00 p.m., 10 of 12 neuro checks were not conducted. The first documented neuro exam was not until approximately 6 hours after the incident, 09/04/2023 at 9:56 pm. The next neuro exam was not until 09/05/2023 at 2:05 am at which time a change in condition was identified. The resident was not sent to the hospital until 09/05/2023 at 4:43 am. The 04:00 am Neuro check was not done. [...]