Fortress Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Fortress Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 13, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF580Sep 7, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF684Sep 7, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF689Jun 28, 2023

  Based on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervisions and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards, in that:supervision. The facility failed to conduct two-hour checks and Resident #1 eloped from the facility without facility knowledge and Resident #1 was found on a busy roadway a mile from the facility by a passer-by. An IJ was identified on 06/28/2023. The IJ began on 06/18/2023 and was removed on 06/20/2023. The facility took action to remove the IJ before the survey began. […]

• Immediate jeopardy, isolatedF580Jun 25, 2022

  Based on interview and record review, the facility failed to immediately inform a resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #15) reviewed for notification of changes in that: The facility failed to fully notify Resident #15's primary care physician of all of Resident #15's status including ongoing elevated blood pressures and increased [CONDITION(S)]. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. […]