Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Frontier Rehabilitation And Extended Care during CMS and state inspections, most recent first.
The facility failed to ensure informed consent was obtained before using a Wander Guard for a resident who was severely cognitively impaired and identified as an elopement risk related to dementia. The care plan included Wander Guard use for safety, but the EHR did not show consent, and the RCM/LPN and DON stated consent from the responsible party should be obtained and documented in the progress notes.
Expired Guardianship Not Maintained: A resident with Alzheimer's disease, non-Alzheimer's dementia, Down Syndrome, and severe cognitive impairment had a court guardianship document in the EHR that expired. The SS Assistant said there was no process to renew expired guardianship papers and confirmed the resident did not have a current guardianship in place, while the SS Director and DON stated a new guardianship should have been obtained after expiration.
MDS assessments were not accurate for two residents with severe cognitive impairment and dementia. One resident’s care plan and elopement risk evaluation documented Wander Guard use, but the MDS did not show it. Another resident was observed with a Wander Guard attached to the wheelchair, and staff confirmed the alarm should have been captured on the MDS but was not.
A resident with major depressive disorder, anxiety disorder, and psychotic disorder had a significant change in condition, became severely cognitively impaired, and started hospice care, but the EHR did not show a new PASRR Level I screening was requested. Staff said the facility’s practice was to complete a new PASRR after a significant change, especially with hospice, but the referral was not completed per policy.
A resident with impaired mobility and a restorative ROM program did not receive restorative nursing services as scheduled. The resident said he needed a Hoyer lift for transfers and reported he was not getting rehab or restorative therapy. Record review showed the program was only documented a few times, with no refusals, and the restorative aide and DON confirmed the resident had not been seen regularly despite a schedule of three times per week.
Failure to provide ADL care occurred for a resident with dementia whose care plan included diabetic nail care by an LN. Weekly skin audits documented completion, but there was no documentation that nail care was performed, and observations showed the resident’s fingernails and toenails were long. The resident stated the nail care had not been done, and an LPN said diabetic nail care should be completed during the weekly skin assessment.
A resident with severe cognitive impairment and Non-Alzheimer's Dementia was observed with a Wander Guard alarm attached to the wheelchair, but the chart did not show a current physician order for the alarm or shift-by-shift LN checks for placement and function. The care plan included a WANDER ALERT intervention, and both the RN/LPN staff and DON acknowledged that an order should have been present.
Daily nurse staffing postings in the lobby were observed with the resident census left blank and the facility name missing. Staff J said she received census information the next day and did not know the postings were supposed to show the current day's census and facility name, while the Divisional President of Operations confirmed the postings should include the facility title and current census.
A resident with moderate cognitive impairment and a history of falls, who required two-person assistance for transfers, was left unattended during a medical appointment. The resident went to the bathroom alone, fell while attempting to transfer, and sustained a pelvic fracture. The facility failed to ensure care-planned supervision was provided, and the transport form did not indicate the need for caregiver assistance, leading to the incident.
The facility failed to implement bowel management interventions for two residents, did not follow physician orders for a resident with a toe fracture, and neglected care plan interventions for another resident with renal insufficiency. These oversights led to prolonged discomfort and unmet medical needs.
A resident with paraplegia was denied the use of a personal refrigerator, despite facility policy allowing it, leading to grievances about missing personal food items. Staff were unaware of the policy, resulting in a failure to honor the resident's rights.
A resident's EHR was left unsecured on a medication cart computer, exposing personal health information. An LPN admitted to being distracted and failing to lock the screen, while the facility's Administrator was unable to secure the computer when questioned. The protocol required the computer to be locked or closed to protect residents' EHRs.
The facility failed to ensure comfortable noise levels, affecting two residents' quality of life. A resident reported difficulty relaxing due to a slamming door outside her room, confirmed by observations of the door slamming 22 times in 15 minutes. Another resident, new to the facility, also noted excessive noise. The Maintenance Director acknowledged the issue, citing the need to keep doors closed due to a flu outbreak, while the Administrator deferred maintenance concerns to the Maintenance Director.
A resident with paraplegia and chronic pain reported verbal abuse by a staff member, including profanity and condescending comments. Despite the resident's request for the staff member not to provide care, the staff member continued to be assigned to the resident, causing psychological harm. The facility failed to document the incident or properly investigate the grievance, relying instead on the staff member's account, leading to ongoing distress for the resident.
A resident reported verbal abuse by an LPN, but the facility failed to investigate the allegation. Despite the resident's immediate report to social services and the resident care manager, no formal investigation was conducted, and the incident was not documented. The staff did not follow the facility's abuse prevention policy, leading to a deficiency that placed residents at risk.
A facility failed to implement Level II PASARR recommendations for a resident with severe cognitive impairment, who required mental health interventions for new behaviors. The recommendations were not fully integrated into the care plan, leaving the resident without necessary support for agitation and aggression. Observations revealed the resident lacked activities and functional headphones, while staff could not locate the behavior intervention recommendations in the electronic health record.
The facility failed to develop comprehensive care plans for two residents, one with PTSD and another with dementia, as required. Both residents were alert and oriented, yet their conditions were not addressed in their care plans. A Resident Care Manager and the Director of Nursing confirmed the absence of these care plans in the electronic health records.
A facility failed to provide altered consistency liquids as per a resident's care plan, risking aspiration and dehydration. The resident, with a history of stroke, required nectar thick liquids, but thin liquids were found in their room. Staff interviews revealed communication lapses regarding dietary orders, with some staff unaware of the resident's needs. The DON confirmed that liquids inconsistent with medical orders should not be at the bedside.
A resident with paraplegia reported being verbally abused by staff and expressed multiple concerns about care, which were not adequately addressed by social services. The social services staff failed to document or implement care plan interventions, and the Social Services Director noted the lack of advocacy and interdisciplinary approach, leading to unmet psychosocial care needs.
The facility failed to maintain complete and accurate medical records for two residents, leading to potential risks for unmet care needs. One resident's PASARR Level I was outdated and lacked a Level II evaluation, while another resident required a Level II evaluation for SMI, which was not found in their EHR. Staff was unable to locate the necessary documentation, indicating a deficiency in record-keeping.
A licensed nurse failed to properly don and doff PPE while providing care to a resident under contact precautions. The nurse, identified as Staff O, was observed in the resident's room without the required PPE, despite a sign indicating contact precautions. The nurse acknowledged the expectation to wear PPE, and the facility administrator confirmed this requirement.
The facility failed to maintain mechanical lifts in safe operating condition, leading to battery failures during resident transfers and tangled wheels. A resident reported being left suspended when the lift battery died, and staff struggled with maneuvering due to hair in the wheels. The Maintenance Supervisor cited user error in charging batteries, and there was no maintenance log for battery checks.
The facility failed to develop a comprehensive care plan for a resident's oxygen use, despite a physician's order and observations of the resident using oxygen. Staff confirmed that the care plan should have included this information but did not.
The facility failed to ensure nursing hours were accurately posted and updated daily for 14 of 42 shifts reviewed. Discrepancies between posted and actual staff schedules were observed, with the Staff Coordinator unaware that updates were required throughout the day. The DON expected accurate and updated postings, but this was not done, risking misinformation for residents and visitors.
Failure to Obtain Consent for Wander Guard Use
Penalty
Summary
The facility failed to ensure that Resident 102 and/or the resident’s representative were fully informed about the risk and benefits of using a Wander Guard and that informed consent was obtained before the device was used. Resident 102 was admitted to the facility and was documented on the quarterly MDS as severely cognitively impaired. The resident’s elopement risk evaluation identified the resident as at risk for elopement related to dementia, and the care plan included the intervention that the resident uses a Wander Guard for safety. Review of Resident 102’s EHR progress notes did not show a consent for the Wander Guard. The facility’s Elopement/Wandering policy stated that when monitoring systems are used, the center notifies the resident or responsible party of the results of the evaluation. In interviews, the RCM/LPN and the DON stated that the facility would complete an elopement evaluation, obtain an order, obtain consent from the responsible party, and document the conversation in the progress notes, but no such documentation was found for Resident 102.
Expired Guardianship Not Maintained
Penalty
Summary
The facility failed to obtain and/or maintain Advance Directives and/or guardianship for one sampled resident. Resident 14 was admitted to the facility and had diagnoses of Alzheimer's disease, Non-Alzheimer's Dementia, and Down Syndrome, and was documented as severely cognitively impaired on the Quarterly Minimum Data Set dated [DATE]. Review of the resident's EHR showed a Letter of Guardianship/Conservatorship from the Superior Court of [NAME], County of Cowlitz, dated [DATE]. Further review showed the Letter of Guardianship/Conservatorship expired on [DATE]. In interview, the SS Assistant stated there was no process to get renewed guardianship papers after they expired and said Resident 14 did not have a current guardianship in place. The Community Relations/SS Director stated that after the guardianship expired, a new guardianship should have been obtained. The DON/RN also stated the resident had a long-term guardianship in place prior to admission and that a new guardianship should have been pursued after it expired.
MDS Did Not Accurately Reflect Wander Guard Use
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was completed accurately to reflect the health status and care needs of two residents reviewed for accidents. For Resident 102, the quarterly MDS dated 02/23/2026 indicated severe cognitive impairment, and the resident’s elopement risk evaluation also dated 02/23/2026 identified risk for elopement related to dementia. The care plan dated 03/09/2026 documented impaired cognitive function or thought processes, short-term memory loss related to metabolic encephalopathy and dementia, and included the intervention that the resident uses a Wander Guard for safety. However, the MDS did not indicate whether a Wander/elopement alarm was used. For Resident 9, the quarterly MDS documented severe cognitive impairment, Non-Alzheimer’s Dementia, and that the resident did not use a wander/elopement alarm. The elopement risk care plan documented a Wander Guard alert on the resident’s wheelchair, and during observation on 04/22/2026 the resident was seen in the dining room in a wheelchair with a Wander Guard alarm attached to the right underside of the wheelchair frame. Staff later confirmed the resident had a Wander Guard alarm and stated its use should have been captured on the MDS, but it was not.
PASRR Screening Not Requested After Significant Change
Penalty
Summary
The facility failed to ensure a new PASRR Level I screening was requested when Resident 12 had a significant change of condition. Resident 12 was admitted with diagnoses including major depressive disorder, anxiety disorder, and psychotic disorder. The Quarterly MDS dated 02/23/2026 showed the resident was severely cognitively impaired and exhibiting signs of physical and mental decline. The resident’s Level I PASRR dated 01/04/2018 documented that a Level II PASRR was not required. Record review showed Resident 12 was assessed for change of condition and started hospice care on 09/20/2024, but the EHR did not show documentation that a new Level I PASRR was completed after that significant change. Staff F stated the facility’s practice was to complete a new PASRR after a significant change, especially when the resident went on hospice. Staff K stated Resident 12 had a significant change assessment completed in 2024 due to a payor change and hospice services. Staff B stated it was the facility’s practice to send new PASRR referrals following a significant change in condition, and that Resident 12’s new PASRR referral was not completed per facility policy.
Failure to Provide Scheduled Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services for Resident 106, who was admitted to the facility and whose quarterly MDS dated 02/03/2026 documented that he was cognitively intact. During an interview on 04/20/2026, Resident 106 said he was concerned about his hip, needed a Hoyer lift for transfers, and was not receiving any rehabilitation or restorative services. During an observation and interview on 04/22/2026, he was seen sitting up in bed eating lunch and again stated that he still had not received restorative therapy and believed he should have been receiving it. Record review showed Resident 106’s impaired mobility care plan included a goal to prevent evidence of lower-extremity contracture through a ROM program and an intervention for active assist ROM to the left knee, 20 repetitions for 2 sets. The EHR POC response history showed the restorative program was provided on 03/27/2026, 03/29/2026, and 04/04/2026, with 24 days since the last program was provided. The record did not show any refusals of the restorative program. Staff H stated all long-term care residents were on restorative unless they refused and, after reviewing the record, said Resident 106 had not recently received restorative services. Staff I stated residents on restorative were supposed to be seen three times per week and said she had not seen Resident 106 that week; after reviewing the record, she said the last restorative service was on 04/04/2026 and there were no refusals. Staff B stated the restorative schedule was three times per week, but Resident 106 was out of the facility frequently and they did not work with him on a regular basis.
Failure to Provide Ordered Nail Care
Penalty
Summary
Failure to provide ADL care occurred for a dependent resident with dementia and a care plan that included diabetic nail care by an LN. The resident’s care plan, Kardex, and weekly skin audits documented the need for diabetic nail care, but the treatment records for multiple weekly skin audits did not document that nail care had been performed. During an observation and interview, the resident’s fingernails were noted to be about 1/8 inch long, and the resident stated a preference for short nails. The resident also stated that the facility had been told his toenails needed to be clipped. On a later observation and interview, the resident again said his nail care had not been done and showed long fingernails. When staff were asked to assess the toenails, an LPN/RCM observed the toenails to be about 1/4 inch long. Staff stated that diabetic nail care should be completed during the weekly skin assessment.
Missing Physician Order for Wander Guard Alarm
Penalty
Summary
The facility failed to obtain and/or initiate physician orders for the use of a Wander Guard alarm for one resident reviewed for accidents. The facility policy titled, Elopement/Wandering, updated February 2025, stated that if monitoring systems are used, the center obtains a physician's order for the device prior to application and the LN obtains an order to complete an evaluation for placement and function every shift, with documentation on the MAR or TAR. The resident was admitted to the facility and was documented on the Quarterly MDS as severely cognitively impaired with Non-Alzheimer's Dementia. The resident's elopement risk care plan included a WANDER ALERT intervention stating the alarm would be on the resident's wheelchair. During observation, the resident was seen in a wheelchair in the dining room with a Wander Guard alarm attached to the right underside of the wheelchair frame. However, review of the resident's active physician orders did not show an order for the Wander Guard alarm or for shift-by-shift evaluation of placement and function, and the April 2026 MAR and TAR did not show documentation of those evaluations. Staff stated the resident had a Wander Guard alarm and acknowledged that a current physician order should have been in place.
Daily Nurse Staffing Postings Missing Census and Facility Name
Penalty
Summary
The facility failed to ensure the Daily Nursing Staffing Information postings were accurately posted and updated each day with the resident census and the facility name. During observations on 04/20/2026, 04/21/2026, 04/22/2026, and 04/23/2026, two staffing postings were seen in the entrance lobby each day, but the resident census was blank and the facility name was not included on the postings. Record review of the postings dated 03/21/2026 through 04/18/2026 also showed no facility name on the postings. During interview, Staff J, Receptionist/Staffing, stated she did not receive the census information until the next day and would add the previous day's census to the posting the following day. Staff J said she did not know the daily nurse staff postings were supposed to have the current day's census and the facility name on them. Staff C, Divisional President of Operations, observed the postings with the resident census blank and no facility name and stated he expected the facility title to be on the nurse staff postings and the daily census to be posted for the current day.
Failure to Provide Required Supervision During Out-of-Facility Appointment Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, poor safety awareness, and a history of falls was not provided with the care-planned level of supervision during an out-of-facility medical appointment. The resident, who required two-person maximal assistance for toilet transfers and sitting to standing, was left unattended in the clinic lobby after her appointment while waiting for facility transportation. The facility's transportation driver, whose role was limited to driving, checked the resident in and left her in the lobby without a staff assistant, despite the resident's care plan indicating the need for such supervision. Clinic staff were not informed that the resident required assistance, and after the appointment, the resident was left alone in the waiting area. The resident subsequently went to the bathroom unaccompanied, locked the door, and fell while attempting to transfer herself from a seated position. She was found on the floor by clinic staff after they heard her calling for help. The incident resulted in a pelvic fracture, confirmed by a CT scan, and required transfer to the hospital for evaluation and treatment. Interviews with facility staff revealed that the process for determining which residents required staff assistance for out-of-facility appointments was not consistently followed. The transport form for the appointment was not properly completed to indicate the need for caregiver assistance, and the staff member responsible did not identify themselves on the form, preventing follow-up. Both facility and clinic staff confirmed that the resident was not safe to transfer or sit to stand without assistance, and that she had a history of attempting self-transfers. The lack of adequate supervision and failure to follow the resident's care plan directly led to the accident and injury.
Failure to Implement Bowel Management, Physician Orders, and Care Plan Interventions
Penalty
Summary
The facility failed to implement bowel management interventions for two residents, leading to prolonged periods without bowel movements. Resident 61 did not have a bowel movement for over four and a half days on two separate occasions, yet the facility did not initiate the bowel protocol as required by their policy. Similarly, Resident 295 went seven days without a bowel movement, and although Milk of Magnesia was administered, it was ineffective, and no further interventions were documented. Staff acknowledged that the bowel protocol should have been followed, but it was not implemented as per the physician's orders. In another instance, the facility did not ensure that physician orders were followed for Resident 57, who had a fracture in her left great toe. Despite a physician's order for a hard sole open-toe post-operative shoe, the order was not documented in the resident's electronic health record, and the shoe was never provided. The resident expressed concern about not receiving the shoe and was observed without it, indicating a failure to follow through with the physician's directive. Additionally, the facility did not implement care plan interventions for Resident 86, who was supposed to have her feet elevated to prevent swelling due to renal insufficiency. Observations showed the resident sitting with her feet on the floor, contrary to the care plan. Staff admitted that the intervention was not included in the care directives for nursing assistants, resulting in the resident experiencing discomfort and swelling.
Failure to Allow Personal Refrigerator for Resident
Penalty
Summary
The facility failed to honor a resident's right to use personal possessions, specifically a personal refrigerator, which did not infringe on the rights of other residents. The facility's policy, updated in August 2020, allowed residents to provide their own UL-approved personal refrigerator if the room could accommodate it. However, Resident 17, who was alert and oriented with a diagnosis of paraplegia, was denied this request by both social services and administration. This denial occurred despite the resident's grievances about missing personal food items from the shared refrigerator. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy regarding personal refrigerators. Staff G, a Resident Care Manager and RN, incorrectly stated that regulations did not allow personal refrigerators. Staff A, the Administrator, was unsure of the policy and suggested an ice chest instead. Staff C from Social Services was unaware of the policy and acknowledged that if the policy allowed personal refrigerators, there was no reason to deny the request. This oversight placed Resident 17 at risk of a diminished quality of life due to the inability to secure personal food items.
Failure to Secure Resident EHR on Medication Cart
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' medical information when a resident's electronic health record (EHR) was left unsecured on a medication cart computer. On the morning of February 6, 2025, Resident 36's personal health information was observed being displayed on the computer screen of the medication cart without any facility staff present. Shortly after, a Licensed Practical Nurse (LPN), identified as Staff O, was seen leaving the nurse's station and heading towards the resident hallway. The facility's Administrator, Staff A, walked past the medication cart and was questioned about the process for securing EHRs. Staff A attempted to lock the computer but was unsuccessful and subsequently retrieved Staff O from the hallway. Staff O admitted to usually locking the screen but stated she was distracted at the time. The medication cart computer was supposed to be locked or closed to protect residents' EHRs, as per facility protocol.
Excessive Noise from Slamming Doors Affects Residents' Quality of Life
Penalty
Summary
The facility failed to maintain comfortable noise levels, impacting two residents' quality of life. Resident 86 reported difficulty relaxing or sleeping due to a constantly slamming door outside her room, which repeatedly jolted her awake. Observations confirmed that the double doors in the countryside corridor slammed shut loudly, opening and closing 22 times in 15 minutes. Staff J, the Maintenance Director, acknowledged the noise, attributing it to the doors being solid and heavy, and stated they needed to remain closed due to a flu outbreak. Resident 244, who had been at the facility for only one day, also reported excessive noise in the hallway resembling a door slamming. Staff A, the Administrator, deferred maintenance concerns to Staff J, indicating a lack of immediate action to address the noise issue.
Failure to Address Verbal Abuse Concerns
Penalty
Summary
The facility failed to protect Resident 17 from verbal abuse, as reported concerns about such abuse were not adequately followed up on, and preventative interventions were not initiated. Resident 17, who was cognitively intact and had diagnoses including paraplegia, pressure wounds, and chronic pain, reported being verbally abused by a staff member, Staff E, in August 2024. The resident claimed that Staff E used profanity and condescending comments, which caused him distress. Despite Resident 17's request for Staff E not to provide care, the staff member continued to be assigned to him on multiple occasions, exacerbating the resident's psychological harm. The facility's policy on abuse prevention required supervisors and staff to intervene in situations where abuse was likely to occur. However, the incident involving Resident 17 was not documented in the facility's August 2024 Accident/Incident Log or Grievance Log. When Resident 17 reported the verbal abuse to Staff C, Social Worker, and Staff G, Resident Care Manager and RN, no effective action was taken to address the resident's concerns. Staff G admitted to not interviewing Resident 17 and instead relied on Staff E's account of the incident. This lack of proper investigation and response to the resident's grievance contributed to the ongoing issue. Furthermore, the facility's Director of Nursing Services, Staff B, and the Administrator, Staff A, were not fully informed or did not recall the details of the incident. Staff B assumed that Staff G had handled the situation, while Staff A could not remember if he had followed up with Resident 17. This lack of communication and failure to adhere to the facility's abuse prevention policy resulted in Resident 17 experiencing continued distress and a diminished quality of life due to the unresolved issue with Staff E.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to investigate allegations of verbal abuse involving a resident, identified as Resident 17, who was cognitively intact and had diagnoses including paraplegia, multiple pressure wounds, and chronic pain. The incident occurred when Resident 17 reported being verbally abused by a Licensed Practical Nurse (LPN), referred to as Staff E. The resident claimed that Staff E used derogatory language and made condescending comments after a disagreement about the delivery of pain medication. Despite the resident's immediate report to social services and the resident care manager, no formal investigation was conducted, and the incident was not documented in the facility's logs. The facility's policy on abuse prevention requires supervisors and staff to intervene in situations where abuse is likely to occur. However, in this case, the staff failed to follow the protocol. Staff G, the Resident Care Manager, did not interview Resident 17 or notify the Director of Nursing Services (DNS) and the Administrator (ADM) as required. Instead, Staff G relied on the account provided by Staff E, who was involved in the incident. The DNS, Staff B, was unaware of the details and assumed that Staff G had handled the situation. This lack of communication and failure to follow procedures resulted in the incident not being addressed appropriately. Furthermore, the facility's training on abuse reporting was not effectively implemented. Staff members, including the Staff Development Coordinator and Nursing Assistant, were aware of the reporting procedures, but the process was not followed in this case. The Administrator, Staff A, was informed of the incident through a text message from Resident 17 but did not recall taking any action. This series of inactions and miscommunications led to the deficiency, placing residents at risk for abuse and a diminished quality of life.
Failure to Implement PASARR Recommendations for Resident
Penalty
Summary
The facility failed to implement the recommendations from a Level II Preadmission Screen and Resident Review (PASARR) for a resident who was severely cognitively impaired. The resident, identified as Resident 35, was admitted to the facility and later triggered a significant change PASARR due to new or changed behaviors, necessitating a Level II assessment. The recommendations from this assessment, received by the facility on January 2, 2025, were not fully implemented to assist staff with interventions and strategies to manage the resident's symptoms of agitation and aggression. During observations, Resident 35 was found sitting on the side of the bed, expressing a lack of activities and interest in listening to music, but unable to do so due to non-functional headphones. Staff H, a Social Services Assistant, acknowledged the process of updating PASARR forms and forwarding them for interventions but was unable to locate the completed recommendations for behavior interventions in the resident's electronic health record. This oversight placed the resident at risk of not receiving necessary mental health services and a diminished quality of life.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, which resulted in a deficiency. Resident 43, who was admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD), did not have PTSD addressed in their comprehensive care plan, despite being alert and oriented as per the Annual Minimum Data Set (MDS) assessment. Staff I, a Resident Care Manager and Licensed Practical Nurse, confirmed the absence of a care plan for PTSD upon review of the electronic health record (EHR). Similarly, Resident 70, admitted with a diagnosis of Unspecified Dementia, also did not have dementia addressed in their comprehensive care plan. The Annual MDS documented that Resident 70 was alert and oriented. Staff I confirmed the lack of a care plan for dementia in the EHR. The Director of Nursing Services, Staff B, acknowledged that it was expected for residents with such diagnoses to have care plans addressing their individual needs.
Failure to Provide Altered Consistency Liquids as Per Care Plan
Penalty
Summary
The facility failed to provide altered consistency liquids as per the care plan for a resident, placing them at risk for aspiration, dehydration, and decreased quality of life. Resident 74, who was alert and oriented with a history of stroke, had a diet order for nectar thick liquid consistency. However, during an observation, a water pitcher containing thin liquid was found in the resident's room. The resident confirmed that some staff were unaware of her thickened liquid requirement. The care plan, which was posted in the resident's room, documented the need for mildly thick liquids. Staff interviews revealed inconsistencies in communication and adherence to the resident's dietary orders. Staff E, an LPN, acknowledged the presence of thin water as a mistake and mentioned that CNAs received diet order information during morning reports and from care plans. Staff F, a CNA, stated that thickened liquids were usually provided by the kitchen and given to nurses, and she was aware of the resident's thickened liquid orders from shift reports. Staff G, a Residential Care Manager and LPN, confirmed that thickened liquid orders were documented on care plans and meal tickets, and noted a recent change in the resident's diet order. The Director of Nursing Services emphasized that residents should not have liquids at the bedside that are inconsistent with medical orders.
Failure to Provide Adequate Social Services for Resident
Penalty
Summary
The facility failed to provide adequate medically related social services to Resident 17, who was admitted with a diagnosis of paraplegia and was alert and oriented. The care plan for Resident 17, revised in January 2025, indicated a need for social services to assist in setting realistic goals due to being a younger resident in long-term care. However, Resident 17 reported being verbally abused by a staff member in August 2024 and expressed multiple concerns about staff treatment, training, and personal challenges to Staff C, the social services staff. Despite these reports, Staff C acknowledged not formally addressing the concerns between nursing staff and Resident 17, nor consulting with the Social Services Director to mitigate these issues. Staff C admitted to not following Resident 17 closely enough and failing to document or implement care plan interventions to assist staff in providing care. The Social Services Director, Staff D, stated that she would expect a social worker to advocate for the resident, troubleshoot concerns, and ensure an interdisciplinary approach to address Resident 17's issues. Staff D also emphasized the importance of providing emotional support and identifying coping strategies, which were not adequately addressed in the care plan. This lack of action placed Resident 17 at risk for unmet psychosocial care needs and a diminished quality of life.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, which placed them at risk for unmet care needs and a diminished quality of life. Resident 43, who was admitted with diagnoses including Depression and PTSD, had an Annual MDS assessment indicating they were alert and oriented. However, their PASARR Level I, dated 11/13/2020, showed indicators for mood disorders but did not indicate service needs. The electronic health records (EHR) for Resident 43 did not contain a corrected PASARR Level I or a Level II PASARR determination or evaluation. Staff H, a Social Services Assistant, acknowledged the need for a new PASARR but was unable to locate a corrected Level I PASARR in the EHR. Similarly, Resident 70, admitted with diagnoses including Major Depressive Disorder and Psychotic Disorder with Delusions, had an Annual MDS documenting alertness and orientation. Their Level I PASARR, dated 10/19/2023, indicated a Level II evaluation was required for serious mental illness (SMI). However, a Level II PASARR evaluation was not found in Resident 70's EHR. Staff H was unable to locate a Level II PASARR in the EHR for Resident 70, further highlighting the facility's failure to maintain accurate and complete medical records.
Failure to Properly Use PPE Under Contact Precautions
Penalty
Summary
The facility failed to ensure proper donning and doffing of personal protective equipment (PPE) by a licensed nurse, identified as Staff O, during care of a resident under contact precautions. On February 7, 2025, at 12:45 PM, Staff O was observed in the room of Resident 46, holding the resident's right arm with gloved hands. A sign outside the room indicated that contact precautions were in place, requiring the use of PPE. Staff O admitted to not wearing the required PPE while providing care to Resident 46, acknowledging the expectation to do so. The facility administrator, Staff A, confirmed the expectation for staff to follow posted precaution signs.
Mechanical Lift Battery and Maintenance Issues
Penalty
Summary
The facility failed to ensure that essential equipment, specifically mechanical lifts, was in safe operating condition. This deficiency was observed when batteries died during the transfer of residents, leaving them suspended in the air. Resident 17 reported that the battery on the mechanical lift had died numerous times during transfers, causing him to be left hanging between the bed and chair while staff left the room to swap out the battery. Additionally, the mechanical lifts were difficult to maneuver due to hair tangled in the wheels, which further compromised the safety and smoothness of the transfer process. Observations revealed that the mechanical lift in the Country Side short hall had hair tangled in its rear wheels, and during a transfer, Resident 17 was left hanging for two minutes when the battery died. Staff members acknowledged that some batteries held charges longer than others and that the wheels were difficult to turn due to hair and lint. The Housekeeping Supervisor admitted there was no schedule for cleaning the wheels, and the Maintenance Supervisor noted that the battery issue was ongoing due to user error in charging. However, there was no maintenance log for battery checks, as they were done randomly.
Failure to Develop Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for oxygen use for Resident 39, who was admitted on [DATE]. The quarterly Minimum Data Set (MDS) dated 03/05/2024 indicated that the resident was cognitively intact. On 04/15/2024, Resident 39 was observed using an oxygen mask and concentrator but was unable to provide information regarding his oxygen use. A review of the resident's electronic health record revealed that the use of oxygen was not addressed in the comprehensive care plan, despite a physician's order dated 11/09/2023 for oxygen 1-4 L to keep oxygen levels above 90% as needed. Staff D, an RN, confirmed that the oxygen use was not documented in the care plan and stated that it should have been. Staff E, a Resident Care Manager and LPN, also confirmed that oxygen use should be included in the care plan and noted its absence. Staff B, the Director of Nursing Services and RN, acknowledged that the care plan should have been updated to include the oxygen use orders.
Failure to Accurately Post and Update Nursing Hours
Penalty
Summary
The facility failed to ensure nursing hours were accurately posted and updated daily for 14 of 42 shifts reviewed. This discrepancy was observed between the posted nursing staff information and the actual staff schedules from 04/01/2024 to 04/14/2024. For instance, on 04/01/2024, the posting showed 0.5 registered nurses (RNs) for the day shift, but no RNs actually worked. Similarly, on 04/04/2024, the posting indicated 14 nursing assistants (NAs) for the day shift, while only 12.5 NAs worked. These inaccuracies were consistent across multiple dates and shifts, affecting both RNs and NAs, as well as licensed practical nurses (LPNs). The discrepancies were confirmed through interviews and record reviews, revealing that the daily staff postings were not updated throughout the day to reflect actual staffing levels. Staff C, the Staff Coordinator, admitted to posting the daily staff information every morning but did not update it throughout the day when changes occurred. Staff C was unaware that the postings needed to be updated to maintain accuracy. The Director of Nursing Services (DON) expected the postings to be accurate and updated throughout the day. This failure to update the postings placed residents, their representatives, and visitors at risk of not being fully informed about the current staffing levels and census information.
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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.
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Nursing homes near Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Americana Health And Rehabilitation | 0.7 mi | ★★★★★ | 9 | 0 |
| Beacon Hill Rehabilitation | 2.5 mi | ★★★★★ | 9 | 0 |
| Woodland Convalescent Center | 18.3 mi | ★★★★★ | 2 | 0 |
| Saint Helens Post Acute | 19.7 mi | ★★★★★ | 36 | 0 |
| Avalon Care Center - Scappoose | 26.4 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.