Inspection·April 16, 2025

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review on 04/16/25 of Resident #2's care plan dated 04/08/25 reflected he had COPD, and the relevant intervention was administering bronchodilators and oxygen therapy as ordered by the physician . Record review on 04/16/25 of Resident #2's physician's order reflected: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for Wheezing/SOB. 3. Record review of Resident #3's face sheet on 04/16/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were Hypertension, Type 2 diabetes mellitus, Chronic obstructive pulmonary disease, Heart failure, and End stage renal disease. Record review on 10/16/24 of Resident #3's quarterly MDS assessment, dated 03/27/25 revealed a BIMS score of 15 indicating her cognition was intact. Record review on 04/16/25 of Resident #3's care plan dated 03/28/24 revealed there were no care plan for oxygen therapy. Record review on 04/16/25 of Resident #3's physician's order on 04/26/25 reflected:. 1.Check O2 sat Q shift and PRN every shift. 2.Oxygen 2-5L PRN for comfort/keep oxygen saturation >92% as needed for SaO2 < 92%. Record review of Resident #3's April 2025 MAR on 04/16/25 at 11:30am revealed the O2 level was checked on every day in April,2025, every shift. The last check was on 04/16/25 in the day shift. During an observation and interview on 04/16/25 at 10:50 a.m., Resident #1 was lying in his bed . He was using oxygen through a cannula. There was a nebulizer on the bed side table. The mask and tubing of the nebulizers were exposed to the environment as they were not stored in a protective bag. There was a male urinal bottle sitting next to the exposed nebulizer mask of Resident #1. He stated the staff administer medication via nebulizer occasionally. He stated he could not remember when had used it lately. Resident #1 stated he used the urinal bottle regularly as he was not able to get out of bed for toileting. He stated he used the bottle about 30 minutes ago. During an observation and interview on 04/16/25 at 11:10 a.m., Resident #2 was lying in bed in his room. There was a nebulizer on his bedside table that was not secured in a protective bag. Resident #2 stated he had breathing difficulties and used inhalers and oxygen therapy regularly. During an observation and interview on 04/16/25 at 11:25 a.m., Resident #3 was in her room lying in her bed. Her oxygen cannula and tubing were laying on the floor. She stated she was not able to get up from bed and the staff assisted her to administer oxygen via a canula occasionally on request. During an observation and interview with DON on 04/16/25 at 11:35 a.m., it was revealed the nebulizers and oxygen canula were at the same places as the previous observations, exposed to the open air . The DON who observed the masks and canula stated they were supposed to be stored in protective bags whenever not in use. The DON stated all staff were supposed to be compliant with the facility policy for using the oxygen cannula and nebulizers. She stated she noted down this deficiency in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455589 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fortress Nursing and Rehabilitation 1105 Rock Prairie Rd College Station, TX 77845 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infection control practices among the staff and stated they needed more in services and training on oxygen and nebulizer therapies, sooner than later. She stated bagging the masks and cannulas while not in use was necessary to minimize the risk of spreading respiratory diseases among the residents. Record review of the facility's policy, titled Protocol for Oxygen administration revised on 03/21/2023 reflected: change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. Record review of facility's policy titled Infection Control policy and procedure manual 2019 updated in March,2024 reflected: The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455589 If continuation sheet Page 3 of 3