Inspection·June 2, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review of Resident #1's face sheet, dated 06/02/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included a left proximal fibular fracture (a break in the fibula bone, located on the outside of the lower leg, near the knee, often caused by twisting or blunt force injuries to the leg or foot), dementia (deterioration of brain and memory loss), diabetes mellitus type 2, rheumatoid arthritis (auto-immune disorder affecting major joints) , major depressive disorder, hypertension, and anxiety . Record review of Resident #1's care plan, revised 05/28/25, reflected, Resident #1 had a skin tear to right shin and right knee, and sustained a left knee fracture (left proximal fibular metaphysis) related to fall with interventions of splint to left knee, and teach the purpose of and the procedure for performing isometric and flexion/extension exercises, and pain treatment as indicated by MD. The care plan further reflected Resident #1 was at risk for trauma that may have a negative impact, related to a van incident. Interventions included a Licensed Mental Health Provider, consult with family regarding her condition, identify situation/event/images that trigger recollections of the traumatic event and limit Resident #1's exposure to these as much as possible, monitor for escalating anxiety, depression, or suicidal thought and report immediately to the nurse, mental health provider, and physician. The care plan further reflected Resident #1 had a potential for uncontrolled pain due to fracture of her left knee. Interventions included administration of analgesia per physician orders, and give ½ hour before treatments or care, anticipate her need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 455589 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 06/02/2025 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)