Frontier Rehabilitation and Extended Care

In the surveyor’s words

From the most serious findings on record at Frontier Rehabilitation and Extended Care, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 14, 2025

  Based on interview and record review, the facility failed to ensure adequate care planned supervision was provided, for an out of the facility appointment, to prevent accidents for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards and supervision to prevent accidents. Resident 1; who was assessed with moderate cognitive impairment, poor safety awareness and required maximum assistance with transfer and mobility; experienced harm when left unattended at an out of the facility medical appointment and fell while attempting a toilet transfer/stand from a seated position in the bathroom, required transfer to the hospital and experienced a pelvic bone fracture. This failure placed residents at risk for falls with injury, pain and a diminished quality of life. […]

• Actual harm, isolatedF600Feb 7, 2025

  Based 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. Resident 17 experienced harm when a staff member verbally abused him with profanity and condescending comments; and when the resident's request, to not have the staff member provide care, was disregarded which continued to upset the resident. […]

• No harm, potential for more than minimal, patternF684Feb 7, 2025

  Based 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. Finding included . […]

• No harm, potential for more than minimal, patternF644Mar 28, 2022

  Based on interview and record review, the facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) screening was requested after residents were diagnosed with a mental disorder for three of six sampled residents (6, 43 & 27) reviewed for PASARR. This failure placed residents at risk for unmet behavioral health care needs and a diminished quality of life. Findings included . 1) Resident 6 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 01/05/2022, documented the resident was severely cognitively impaired. Resident 6's Level I PASSAR, dated 10/30/2020, documented the resident had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF688Mar 28, 2022

  Based on interview and record review, the facility failed to provide services to prevent further loss of range of motion (ROM) for three of four sampled residents (28, 25 & 53) reviewed for range of motion and mobility. This failure placed residents at risk for decline in ROM and a diminished quality of life. Findings included . 1) Resident 28's quarterly Minimum Data Set (MDS), an assessment tool, dated 02/05/2022, showed the resident received zero days of nursing restorative services in the previous seven days. Resident 28's significant change MDS, dated [DATE], showed the resident received zero days of restorative services in the previous seven days. Resident 28's annual MDS, dated [DATE], showed the resident received zero days of restorative services in the previous seven days. […]