Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fortress Nursing And Rehabilitation during CMS and state inspections, most recent first.
Inadequate nail care was identified for two residents who needed ADL assistance. One resident with intact cognition and another resident with severe cognitive impairment had dirty nails with blackish/brownish substance under the fingernails and rough edges, despite care plans directing staff to check, clean, trim, and smooth nails on bath day and as needed. Staff stated CNAs were responsible for most residents’ nail care, while nurses handled nail care for residents with diabetes, and neither resident had refused care.
A resident with significant cognitive and physical impairments, including a recent leg fracture, was injured during van transport when the driver braked abruptly, causing the resident to slide out of her wheelchair and sustain a new fracture and other injuries. The incident revealed failures in ensuring proper supervision and use of safety restraints, as well as insufficient staff training and unclear adherence to transport protocols.
Three residents with respiratory conditions were found with nebulizer masks, tubing, and oxygen cannulas left exposed to the environment rather than stored in protective bags, contrary to facility policy. Equipment was observed on bedside tables and the floor, sometimes near potentially contaminated items. The facility's infection control protocols and physician orders for respiratory care were not followed, as confirmed by staff interviews and record review.
The facility did not provide or document scheduled activities for residents on several weekends, with residents and staff reporting confusion about the activity schedule, lack of suitable options, and no communication regarding weekend activities. Multiple residents expressed feelings of boredom and loneliness due to the absence of activities, and staff indicated they were not informed or able to facilitate activities on weekends. The Activity Director was unaware of relevant guidelines and did not maintain comprehensive participation records, resulting in unmet resident needs.
A CMA administered narcotic medications, including PHENobarbital, Lyrica, and APAP/Codeine, to four residents with severe cognitive impairment and complex medical conditions but failed to document the administration in the narcotic log as required. The lapse was observed during medication passes, and the CMA admitted to forgetting the documentation, which was confirmed by the DON as a deviation from facility policy.
Surveyors found that medications were not properly stored or labeled, with loose unidentified pills present in a medication cart and expired medications, including an inhaler still in use by a resident, remaining in both the medication carts and medication room. Staff interviews revealed inconsistent practices for checking expiration dates, and facility policy lacked clear guidance on removing expired drugs.
Staff, including an LVN and the Director of Rehabilitation/PT, entered the kitchen and handled food without wearing required hair restraints, despite facility policy and prior training. Interviews revealed confusion and lack of awareness about the policy among staff and administration, and signage about hair restraint requirements was missing. These actions resulted in noncompliance with professional food safety standards.
Three residents in an LTC facility did not receive proper nail care, leading to hygiene concerns. A male resident with severe cognitive impairment had dirty nails despite requesting cleaning. Another male resident with similar impairments also had unclean nails. A female resident with multiple sclerosis had long, rough nails causing self-scratching. Staff interviews revealed confusion about nail care responsibilities, with CNAs and nurses unclear on their roles. The facility's nail care policy was not effectively implemented, risking residents' hygiene and health.
Two residents with severe cognitive impairment and total dependence on staff for ADLs did not have their call lights within reach, contrary to their care plans. One resident's call light was found under the bed and inaccessible, while another's soft pad call device was hanging over the side of the bed and out of reach. Staff interviews confirmed the residents could not call for help if needed, and facility leadership acknowledged the lack of a written call light policy and the expectation that all staff ensure call lights are accessible.
A resident with multiple medical conditions and an upcoming discharge did not have a discharge plan documented in her comprehensive care plan. Staff interviews revealed a lack of clarity and training on including discharge planning in care plans, and facility policy requiring timely care plan development was not followed.
A medication aide administered and documented medications for a resident with multiple chronic conditions in a manner inconsistent with physician orders, resulting in a medication error rate of 8.57%. Medications were given outside of prescribed blood pressure parameters, and documentation did not accurately reflect what was administered, violating facility policy and physician instructions.
A medication aide in an LTC facility verbally abused a resident by using foul language and threatening to keep him up late as punishment for using the call light. The incident was confirmed by the resident's roommate and led to the aide's termination. The resident, who had a complex medical history, felt threatened but safe after the aide's removal. The facility conducted an investigation and updated the resident's care plan to reflect the incident.
A facility failed to protect a resident from abuse by an LVN, who was recorded pouring water on the resident's face, verbally taunting her, kneeing her, and sitting on her arm. The resident had a history of depression, stroke, dementia, and kidney disease requiring dialysis. The abuse was reported to the administration, leading to the LVN's suspension and termination.
Inadequate Nail Care for Two Residents
Penalty
Summary
The facility failed to ensure that two residents who were unable to complete activities of daily living received needed nail care to maintain cleanliness and smooth nail edges. Resident #57 was admitted with diagnoses including anemia, generalized anxiety disorder, and vitamin D deficiency. His MDS assessment showed a BIMS score of 15, indicating intact cognition, and he did not refuse care. His care plan identified an ADL self-care performance deficit and directed staff to check nail length, trim, and clean nails on bath day and as necessary. On observation and interview, Resident #57 was found lying in bed with nails on both hands that were not smooth around the edges and with a blackish/brownish substance under the middle and fore fingernails on the right hand. He stated he had asked someone over the weekend to file and clean his nails and was told it would be done sometime during the week. The resident did not recall the staff member’s name or whether the person was a CNA or nurse. Resident #59 was admitted with diagnoses including type 2 diabetes, hypothyroidism, and depression. His MDS assessment showed a BIMS score of 6, indicating severely impaired cognition, and he did not refuse care. He required supervision or touching assistance with eating, oral hygiene, personal hygiene, showers, dressing, and toileting hygiene. His care plan also directed staff to check nail length, trim, and clean nails on bath day and as necessary. On observation, Resident #59 was sitting near the nurses’ station in a wheelchair with blackish/brownish substance under fingernails on both hands and rough edges around the fingernails on the right hand. He stated he did not like his nails to be dirty and reported they had been dirty and rough for the past 4 or 5 days.
Failure to Provide Adequate Supervision and Safe Transport Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including dementia, diabetes, rheumatoid arthritis, and a recent left proximal fibular fracture, was not provided with adequate supervision and assistance devices during transport to a medical appointment. The resident, who required extensive assistance for mobility and transfers and was non-ambulatory, was being transported in a facility van operated by a staff member who had only received 30 minutes of training from another driver. During the trip, the driver braked abruptly for a red light, causing the resident to slide out of her wheelchair and fall onto the van floor, resulting in a nondisplaced fracture of the left proximal fibular metaphysis, as well as abrasions and skin tears to both knees and other minor injuries. Interviews and record reviews revealed inconsistencies regarding the use of safety restraints. The driver stated that all wheelchair straps and seat belts were secured, while the resident's responsible party believed the resident had not been properly strapped in, as she slid forward and hit her head on the back of the driver's seat. The resident herself could not recall whether a seat belt was in use at the time of the incident. Maintenance staff confirmed that the van's equipment, including seat belts and wheelchair tie-downs, was in good working order following the incident. The resident was assessed at the hospital, where imaging confirmed the left knee fracture and other injuries. The facility's documentation indicated that the resident's care plan included interventions for pain management and trauma risk, and that she required two-person assistance for transfers. The incident report and subsequent interviews highlighted that the driver was the only staff member present during transport, and that the responsible party assisted in repositioning the resident after the fall. The event demonstrated a failure to ensure adequate supervision and proper use of assistance devices during resident transport, directly resulting in the resident's injuries.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring oxygen therapy and nebulizer treatments, as evidenced by improper storage of respiratory equipment. Specifically, three residents with diagnoses including COPD, acute respiratory failure, and other chronic conditions were observed with their nebulizer masks, tubing, and oxygen cannulas left exposed to the environment rather than stored in protective bags as required by facility policy. In one instance, a nebulizer mask and tubing were found on a bedside table next to a urinal bottle, and in another, an oxygen cannula and tubing were observed lying on the floor. Record reviews confirmed that these residents had physician orders for oxygen therapy and nebulizer treatments, and their care plans included interventions for respiratory support. However, the equipment used for these therapies was not stored according to infection control protocols, which require such items to be bagged when not in use. Interviews with the residents indicated that they relied on staff for assistance with respiratory treatments and that the equipment was used as needed for symptoms such as shortness of breath or wheezing. During interviews and observations, the Director of Nursing acknowledged that the respiratory equipment was not stored properly and confirmed that staff were expected to follow the facility's infection control policies. The facility's policies outlined the need to change or properly store respiratory equipment to prevent contamination and the spread of infection, but these procedures were not followed in the cases observed.
Failure to Provide and Document Resident Activities on Weekends
Penalty
Summary
The facility failed to provide scheduled activities for residents on multiple weekends in October, as evidenced by the absence of documented activities and participation records for those dates. The activity calendar did not include times for weekend activities, and residents reported confusion about the schedule and the nature of the activities listed. Several residents expressed that they did not enjoy the activities offered, such as football, puzzles, or dominoes, and noted that many residents were unable to leave their rooms or participate in these types of activities. Residents also stated that there was a lack of communication regarding the timing and content of weekend activities, leading to feelings of boredom, sadness, and loneliness. Interviews with staff, including CNAs and RNs, revealed that no one had discussed the expectation of conducting activities on weekends with them, and they felt too busy with direct care duties to facilitate activities. The Activity Director confirmed that she was not aware of CMS guidelines regarding weekend activities, had not recently reviewed facility policy, and had not conducted in-services with nursing staff about weekend activity responsibilities. She also acknowledged that not all residents could participate in the available activities and that there were no alternative options for those unable to join group or physical activities. The Activity Director's documentation system for participation was limited to highlighting activities on individual calendars kept in a binder, with no electronic or alternative record-keeping. The facility's policies require ongoing activity programs based on resident assessments and preferences, including both group and individual activities, and mandate accurate participation records. However, the lack of weekend activities, insufficient documentation, and failure to tailor activities to residents' interests and abilities resulted in unmet physical, mental, and psychosocial needs. Residents and staff consistently reported that the absence of weekend activities contributed to increased boredom, sadness, and behavioral issues among residents.
Failure to Document Narcotic Administration in Medication Log
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for four residents reviewed for narcotic pharmacy services. Specifically, a Certified Medication Aide (CMA) administered narcotic medications to several residents but did not document the administration in the narcotic book as required. This lapse was observed during medication passes, where medications such as PHENobarbital, Lyrica (Pregabalin), and APAP/Codeine were given to residents without immediate documentation in the narcotic log. The residents involved had significant medical histories, including severe cognitive impairment, chronic heart failure, neurodegenerative diseases, and chronic pain conditions. For example, one male resident with Gerstmann-Straussler-Scheinker Syndrome and severe cognitive impairment received PHENobarbital, while another female resident with chronic respiratory failure and severe cognitive impairment received Lyrica. Additional residents with complex medical needs, such as heart disease, diabetes, and post-stroke complications, were also affected by the lack of proper narcotic documentation. During interviews, the CMA admitted to forgetting to log the administered narcotics and acknowledged the potential for medication errors. The Director of Nursing confirmed that the expected procedure is to document narcotic administration in both the narcotic count sheet and the electronic medical record immediately after administration. Review of facility policy also indicated that medications should be charted immediately after administration, but this was not followed in the observed instances.
Failure to Properly Store and Remove Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of medications in accordance with professional standards. On the 400 hall medication cart, four loose, unidentified pills were found in a drawer, and the RN present was unable to identify them. The RN stated that loose pills sometimes fall out of punctured packets and are occasionally found at the bottom of the cart. The DON acknowledged that loose pills should not be present in the carts and that this could lead to medication errors if not addressed. Additionally, the facility's medication room contained expired medications, including a bottle of Aspirin and a bottle of Daily Vitamin formula and Iron, both past their expiration dates. Further review revealed that an expired Advair Diskus inhaler was still present on the medication cart and being used by a resident. The CMA responsible for the cart confirmed that the resident continued to use the expired inhaler and that there was no set schedule for checking expiration dates, relying instead on staff to remember to check periodically. The facility's policy on medication administration did not specify procedures for checking or removing expired medications, contributing to the presence of expired drugs in both the medication carts and medication room.
Failure to Enforce Hair Restraint Use in Kitchen
Penalty
Summary
The facility failed to ensure that all staff entering the kitchen wore effective hair restraints, as required by both facility policy and professional food safety standards. Observations revealed that an LVN entered and exited the kitchen multiple times to retrieve meal trays without wearing a hair restraint, and the Director of Rehabilitation/PT was present in the kitchen near the steamtable with long, uncovered hair. Interviews with these staff members confirmed that they were aware of the policy but either forgot to comply or misunderstood the areas where hair restraints were required. The Director of Rehabilitation/PT believed hair restraints were not necessary in the front area of the kitchen, while the LVN admitted to forgetting to put one on. Further interviews with dietary staff and the DON confirmed that the facility's policy mandates hair restraints for anyone entering the kitchen, and that this policy is in place to prevent hair from contaminating food. The Director of Food and Nutrition and other staff indicated that training on hair restraint use had been provided, but there was confusion about which areas of the kitchen required compliance. Additionally, signage regarding hair restraint requirements was missing at the time of the survey, and the new administrator was unaware of the policy. These lapses in adherence to food safety protocols were observed and corroborated through staff interviews and record reviews.
Inadequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for three residents, leading to concerns about personal hygiene and potential health risks. Resident #17, a male with severe cognitive impairment and neuroleptic-induced parkinsonism, was observed with a blackish/brownish substance under his fingernails. Despite requesting assistance, his nails were not cleaned, and staff indicated that nail care would be provided during his shower. Resident #24, also with severe cognitive impairment and a history of traumatic brain injury, had a similar substance under his nails. He reported the issue but could not recall to whom or when, and his nails remained uncleaned. Resident #35, a female with multiple sclerosis and moderate cognitive impairment, had long nails with rough edges, which she reported had caused her to scratch herself. She requested nail trimming and filing, but staff informed her that only nurses could perform such tasks, despite her not being diabetic. Interviews with CNAs and an RN revealed a lack of clarity regarding responsibilities for nail care, with CNAs stating they were responsible for non-diabetic residents' nails, while nurses handled diabetic residents. However, nail care was not consistently provided as needed, leading to the observed deficiencies. The facility's policy on nail care, dated 2003, emphasized regular care to prevent infection and injury, yet the policy was not effectively implemented. Staff interviews indicated a lack of awareness about the residents refusing nail care, and there was confusion about the roles of CNAs and nurses in providing this care. The facility's failure to ensure proper nail care for these residents could lead to poor hygiene and potential health issues, as noted by staff concerns about bacteria under the nails potentially causing illness if ingested.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents, both with severe cognitive impairment and dependent on staff for activities of daily living (ADLs), had their call lights within reach as required by their care plans. For one male resident with diagnoses including unspecified lack of coordination, dementia, and a history of traumatic brain injury, the call light was observed to be under the bed and not accessible while he was lying in bed. The resident was unable to identify the location of his call light and could not respond to questions about how he would call for help if needed. A female resident with severe dementia, mood disorder, and Alzheimer's disease was also found without her call device within reach. She used a soft pad call device due to her inability to use a standard call light button, but the device was hanging over the side of the bed and not accessible to her. Staff interviews confirmed that both residents would be unable to call for help if needed, as one had a very soft voice and the other could not reach the device. Staff acknowledged that all call lights should be within reach and that it was the responsibility of all staff to check call light placement when entering resident rooms. Despite in-service training on call light placement, staff could not recall the dates of these trainings, and the facility did not have a written policy on call lights. Leadership, including the Administrator, Corporate Regional Director, and DON, confirmed that call lights not being within reach could prevent residents from obtaining timely assistance and that it was expected for all staff to ensure call lights were accessible to residents at all times.
Failure to Include Discharge Plan in Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for one resident included a discharge plan, as required by facility policy. Record review showed that the resident, an older woman admitted with multiple diagnoses including C. difficile infection, acute osteomyelitis, cellulitis, type II diabetes, major depressive disorder, and generalized anxiety, was scheduled for discharge but did not have a documented discharge plan in her care plan. The care plan focused on current interventions for her health conditions but omitted any discharge planning details, despite the resident being cognitively intact and aware of her upcoming discharge. Interviews with facility staff revealed a lack of clarity and training regarding the inclusion of discharge plans in the comprehensive care plan. The MDS nurse acknowledged that discharge should be documented in the care plan and noted potential negative effects when this information is missing. The social worker admitted that discharge planning had not been part of the care plan and was unsure if staff would be aware of discharge plans without it being documented. The DON stated that discharge planning is initiated at admission and should be included in the care plan, but confirmed that this was not consistently done. Facility policy required care plans to be developed within seven days of the comprehensive assessment, but this was not followed in this case.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration and Documentation
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with an observed rate of 8.57 percent based on 3 errors out of 35 opportunities. During medication administration, a certified medication aide (CMA) administered medications to a male resident with multiple diagnoses, including hypertension, Parkinson's disease, and diabetes. The resident's physician orders specified that certain antihypertensive medications were to be held if the resident's blood pressure or heart rate fell outside defined parameters. On the observed occasion, the resident's blood pressure was below the threshold for administration of Nifedipine, but the CMA administered it regardless. Additionally, the CMA failed to administer Toprol XL as ordered but documented that it was given, and administered Chlorthalidone but documented it as not given. These actions resulted in inaccurate medication administration and documentation, directly violating physician orders and facility policy. The errors were identified through observation, record review, and staff interview, confirming that medications were not administered or documented according to the prescribed parameters and the facility's medication administration policy.
Verbal Abuse Incident Involving Medication Aide
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a medication aide and a resident. On the evening of June 23, 2024, the medication aide used foul language and threatened a resident by stating she would keep him up late as a form of punishment for using the call light excessively. This incident was corroborated by the resident's roommate, who overheard the aide's comments. The resident involved had a medical history that included metabolic encephalopathy, cerebral infarction, epilepsy, and aphasia, and required extensive assistance with activities of daily living. The facility's investigation confirmed the verbal abuse, and the medication aide was subsequently terminated. Interviews with the resident revealed that he felt threatened by the aide's behavior, although he did not report feeling physically harmed. The resident expressed that he felt safe at the facility after the aide's removal and did not require psychological counseling. The facility's policy on abuse and neglect clearly states that residents have the right to be free from abuse, including verbal threats. The incident was reported to the facility on June 24, 2024, and the facility conducted an investigation, which included interviews with the resident and his roommate. The resident's care plan was updated to reflect the recent trauma related to the incident. The facility's policy on abuse and neglect was reviewed, and staff were in-serviced on the matter. Observations and interviews conducted after the incident indicated that other residents felt safe and had no concerns about abuse or neglect.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a Licensed Vocational Nurse (LVN A) was recorded verbally and physically abusing a resident. The abuse included pouring water on the resident's face, verbally taunting her, kneeing her, and sitting on her arm. These actions were captured in five video clips that were sent to the facility's corporate office, prompting an investigation. The resident involved was an elderly female with a history of depression, stroke, dementia, and kidney disease requiring dialysis. Her quarterly MDS assessment indicated moderate difficulty with hearing and vision, and moderately impaired cognition. Despite these impairments, the resident did not exhibit physical or verbal behavioral symptoms directed towards others. The resident's care plan included interventions for pressure injury risk, fluid deficit, and discomfort/pain due to impaired mobility and recent hospitalization. The abuse was reported to the facility's administration on the same day the videos were received. The administration immediately began suspension and termination procedures for LVN A. The facility also conducted skin assessments for all residents and in-serviced all employees on abuse prevention, use of photography/social media, and HIPAA privacy laws. Despite these actions, the initial failure to protect the resident from abuse represents a significant deficiency in the facility's duty to ensure a safe environment for its residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near College Station
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accel At College Station | 1.3 mi | ★★★★★ | 8 | 1 |
| Five Points Nursing & Rehabilitation Of College St | 1.7 mi | ★★★★★ | 10 | 3 |
| Legacy Nursing And Rehabilitation | 5.9 mi | ★★★★★ | 5 | 0 |
| Crestview Retirement Community | 6.3 mi | ★★★★★ | 0 | 0 |
| St. Joseph Manor | 6.4 mi | ★★★★★ | 10 | 0 |
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