Frontier Rehabilitation and Extended Care

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives received information about the risk and benefits and obtain informed consent prior to the use of a Wander Guard (a device that detects when a resident approaches or passes through a monitored exit door, preventing elopement) for 1 of 2 sampled residents (Resident 102) reviewed for Wander Guard use. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with the use of a Wander Guard. Findings Included. Review of the facility's Elopement/Wandering policy, dated February 2025, documented, if monitoring systems are used: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain and/or maintain Advance Directives (AD) and/or Guardianship for 1 of 6 sampled residents (Resident 14) reviewed for AD. This failure placed residents at risk of not having their healthcare preferences honored and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 2 of 2 sampled residents (Residents 102 and 9) reviewed for accidents. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I, a screening tool used to identify mental health needs, was requested upon a significant change of condition for 1 of 5 residents (Resident 12) reviewed for PASRR. This failure placed the residents at risk of unidentified mental health needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services for 1 of 2 sampled residents (Resident 106) reviewed for Rehabilitation and Restorative. This failure placed residents at risk for avoidable decline in function and a diminished quality of life. Findings Included. Resident 106 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 02/03/2026, documented Resident 9 was cognitively intact. In an interview on 04/20/2026 at 12:07 PM, Resident 106 said he was concerned about his hip. Resident 106 said he needed a Hoyer lift (a mechanical device that uses a sling to safely lift and transfer people with limited mobility between surfaces) for transfers. Resident 106 said he was not getting any rehabilitation or restorative services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for dependent residents to include nail care for 1 of 2 residents (Resident 67), reviewed for ADLs. This failure placed residents at risk of not receiving the care and services needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and/or initiate physician orders for use of a Wander Guard alarm (a security system that uses a wearable tag and/or sensor designed to prevent people with cognitive impairments from leaving secure areas to ensure their safety, by triggering alerts to caregivers) for 1 of 2 sampled residents (Resident 9) reviewed for accidents. This failure placed residents at risk of injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing information was accurately posted and/or updated daily with resident census for 5 of 5 observed days posted, and with the facility name for 34 of 34 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of current staffing level and facility information.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bowel management interventions were initiated and/or implemented for 2 of 5 sampled residents (61 & 295), failed to ensure physician orders were initiated and/or implemented for 1 of 4 sampled residents (57), and failed to ensure care plan interventions to elevate feet were implemented for 1 of 7 sampled residents (86) reviewed for quality of care. These failures placed residents at risk for unnecessary discomfort, health complications, and a diminished quality of care and quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were able to use personal possessions in their room, including a personal refrigerator, that did not infringe on the rights of other residents for 1 of 1 sampled residents (17) reviewed for resident rights. This failure placed the resident at a risk of a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' medical information were maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure the electronic health record (EHR) for 1 of 1 sampled resident (36) reviewed for privacy and confidentiality. This failure placed residents at risk for loss of confidential medical information and a diminished quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the facility had comfortable noise levels for 2 of 3 sampled residents (86 & 244) reviewed for safe and comfortable homelike environment. This failure placed residents at risk for excessive noise levels and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal abuse when reported concerns about verbal abuse were not followed up on and preventative interventions were not initiated for 1 of 2 sampled residents (17) reviewed for abuse and/or neglect. This failure placed residents at risk for psychological harm, verbal abuse and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of verbal abuse were investigated to prevent further abuse for 1 of 2 sampled residents (17) reviewed for investigations of abuse. This failure placed residents at risk for abuse and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the recommendations on the Preadmission Screen and Resident Review (PASARR) level II were followed for 1 of 7 sampled residents (35) reviewed for PASARR. This failure placed residents at risk of not receiving necessary mental health services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for 2 of 5 sampled residents (43 & 70) reviewed for care plans. This failure placed residents at risk for not receiving personalized care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure altered consistency liquids were provided and consistent with the resident's care plan (CP) for 1 of 1 sampled residents (74) reviewed for hydration. This failure placed residents at risk for aspiration (accidental inhalation of food or liquid into the airways), dehydration, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medically related social services (SS) were provided to attain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 sampled residents (17) reviewed for medically related social services. This failure placed residents at risk for unmet psychosocial care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained to be complete and accurate for 2 of 5 sampled residents (43 & 70) reviewed for resident records. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff properly donned (putting on) and doffed (removing) personal protective equipment (PPE) for 1 of 1 sampled licensed nurse (Staff O, Licensed Practical Nurse) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure essential equipment was in safe operating condition when batteries died while transferring residents on 2 of 4 mechanical lifts reviewed for physical environment. This failure placed residents at risk of being injured and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for oxygen use for 1 of 2 sampled residents (39) reviewed for comprehensive care plans. This failure placed residents at risk for having unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing hours were accurately posted and updated daily for 14 of 42 shifts reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.