Frontier Rehabilitation and Extended Care
1500 3rd Avenue, Longview, WA 98632 · For profit - Individual · 140 certified beds · (360) 423-8800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.6% | 14.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.8% | 5.5% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 1.0% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.4% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.8% | 17.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.1% | 2.6% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.7% | 17.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 3.1% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 84.8% | 93.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 4.5% | 4.3% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 20.2% | 22.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.9% | 15.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 57.6% | 82.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 21.6% | 19.9% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 24.1% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.87 | 1.33 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 6.14 | 1.52 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
66.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 163 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 42.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 80 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 34% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 66.7%CMS range 55.6–75.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.0–13.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 42.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 20.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 36.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 92.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 96.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.8% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.8%CMS range 5.5–14.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 140 beds and averages 100.5 residents a day — about 72% occupied, or roughly 40 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.21 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.76 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.71 hrs/resident/day on weekends vs 4.41 on weekdays — 16% thinner on weekends. RN hours go from 0.51 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · D2026-04-23 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. If it is determined that the resident is at risk for elopement and the center has a resident monitoring system installed, the following protocol is followed: a. The center notifies the resident or resident's responsible party of the results of the evaluation.Resident 102 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-23 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included. Resident 14 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated [DATE], documented Resident 14 had a diagnosis of Alzheimer's disease (a progressive disease that causes dementia, a decline in cognitive function), Non-Alzheimer's Dementia, Down Syndrome (a genetic condition that affects brain and body development leading to intellectual disabilities), and was severely cognitively impaired. Review of Resident 14's Electronic Health Record (EHR) showed Resident 14 had a Letter of Guardianship / Conservatorship from the Superior Court of [NAME], County of Cowlitz, dated [DATE]. Further review of Resident 14's EHR showed The Letter of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-23 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included . Resident 102 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS - an assessment tool), dated 02/23/2026, indicated Resident 102 was severely cognitively impaired. Record review of Resident 102's Elopement Risk Evaluation, dated 02/23/2026, indicated Resident 102 was at risk for elopement related to (r/t) dementia (a decline in cognitive function severe enough to impair daily life, caused by progressive brain damage). Record review of Resident 102's care plan, dated 03/09/2026, indicated the problem, Resident 102 has impaired cognitive function or impaired thought processes,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-23 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included . Record Review of the facility's policy, titled, PASRR Process Policy and Procedure, revised January 2025, documented, .4. If there is a significant change of condition that affects their diagnosed need for a PASRR II, staff refer for a NEW PASRR level II. Resident 12 was admitted to the facility on [DATE], with multiple diagnoses to include major depressive disorder (mood disorder characterized by persistent depressed mood), anxiety disorder (disorder characterized by excessive fear and worry), and psychotic disorder (severe mental illness causing to lose touch with reality). The Quarterly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-23 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. In an observation and interview on 04/22/2026 at 12:56 PM, Resident 106 was observed sitting up in bed eating lunch. Resident 106 said he still had not received any restorative therapy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-23 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included . Resident 67 was admitted on [DATE]. Record review of Resident 67's care plan, dated 04/08/2026, documented the problem for Resident 67 was an ADL [activities of daily living - basic self-care task to include nail care] self-care performance deficit r/t [related to] Dementia [a decline in cognitive function-memory, thinking, and behavior-severe enough to impair daily life, caused by progressive brain damage]. The care plan intervention - Diabetic Nail care by LN [licensed nurse]. Record review of Resident 67's Kardex (a centralized record of resident's care plan), dated 04/08/2026, indicated Diabetic Nail care by LN. Record review of Resident 67's Treatment Administration Record's, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included. Record Review of the facility's policy titled, Elopement/Wandering, updated February 2025, documented, . If monitoring systems are used: . b. The center obtains a physician's order for the use of the device prior to application. c. The LN [Licensed Nurse] also obtains an order to complete an evaluation for placement and function every shift. Documentation to occur on the MAR [Medication Administration Record] or TAR [Treatment Administration Record] . Resident 9 was admitted to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-23 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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.Findings included. In an observation on 04/20/2026 at 10:14 AM, two Daily Nursing Staffing Information postings, dated 04/19/2026 and 04/20/2026, were observed posted on the wall in the entrance lobby of the facility. There was no title and/or label observed on the wall near the postings with the facility name. Further review of both postings showed the resident census was blank and the facility name was not on the postings. In an observation on 04/21/2026 at 8:10 AM, two Daily Nursing Staffing Information postings, dated 04/20/2026 and 04/21/2026, were observed posted on the wall in the entrance lobby of the facility. Further review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-07 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . 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 . <Bowel Management> The facility's policy entitled, Bowel Protocol, updated 03/2018, documented, If a resident does not have a bowel movement for three days, the nurse administers the physician ordered bowel program . in the event the center has no specific bowel program the nurse administers medication as ordered as followed: --Administer milk of magnesia per physician order on day four. --If milk of magnesia offers no…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . Facility policy entitled Resident personal refrigerators and food brought in by family and visitors, updated August 2020, documented, under procedure 6 Residents or responsible party may provide their own UL [Underwriters Laboratories, an organization that tests and certifies products to ensure public safety] approved personal refrigerator for use in their room, provided the room can accommodate the refrigerator's electrical load and physical space. Designated refrigerators are available in the Center for storage of resident foods. Resident 17 was admitted to the facility on [DATE] with diagnoses including paraplegia. The quarterly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2025-02-07 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Finding included . On 02/06/2025 at 9:11 AM, while walking past the Oceanside medication cart, Resident 36's EHR, the resident's personal health information, was observed being displayed on the medication cart computer. There were no facility staff around. At 9:12 AM, Staff O, Licensed Practical Nurse, was observed walking out of the nurse's station office and towards the resident hallway. At 9:13 AM, Staff A, Administrator, was observed walking past the medication cart. As Staff A walked by, Staff A was asked what the process was for protecting the EHRs of residents. Staff A walked back to the medication cart and attempted to lock the computer but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings included . 1) On 02/03/2025 at 9:46 AM, Resident 86 said it was hard to relax or sleep because of the constant slamming door just outside of her room. Resident 86 said this caused her the inability to relax and sleep because it jolted her awake. On 02/04/2025 at 10:45 AM, the double doors that closed off the countryside corridor were observed to slam shut loudly. For the following 15 minutes, the doors opened and closed 22 times. At 12:55 PM, Staff J, Maintenance Director stated, Yes, the doors do slam, and they are loud. It's because they are solid and heavy. Staff J said the doors must be closed due to the flu outbreak. Staff J said the doors had to slam in order to latch closed. 2) On 02/06/2025 at 12:09 PM, Resident 244 said there was a lot of noise in the hall that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . 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. This failure placed residents at risk for psychological harm, verbal abuse and a diminished quality of life. Findings included . The facility policy entitled Prevention of All Types of Abuse, Neglect, Mistreatment, Involuntary Seclusion, Exploitation, and Misappropriation of Resident Property, revised October 2022, noted, Center supervisors and staff [as appropriate] correct and intervene in reported or identified situations in which abuse, neglect, or misappropriation of property is more likely to occur by analyzing the following [items that would make residents more vulnerable to abuse] . d. the supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . The facility policy entitled Prevention of All Types of Abuse, Neglect, Mistreatment, Involuntary Seclusion, Exploitation, and Misappropriation of Resident Property, revised October 2022, noted, Center supervisors and staff [as appropriate] correct and intervene in reported or identified situations in which abuse, neglect, or misappropriation of property is more likely to occur by analyzing the following [items that would make residents more vulnerable to abuse] . d. the supervision of staff to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while giving care, etc. Resident 17 was admitted to the facility on [DATE] with diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-07 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . Resident 35 was admitted to the facility on [DATE]. The annual Minimum Data Set assessment, dated 01/09/2025, showed Resident 35 was severely cognitively impaired. Resident 35 triggered a significant change PASARR to be completed on 12/12/2024 for new/changed behaviors. This PASARR indicated Resident 35 now required a Level II PASARR assessment by a licensed mental health professional or mental health agency for individual services. The Level II PASARR recommendations were received on 01/02/2025 by the facility for implementation. Resident 35's medical record showed the recommendations were not fully implemented by the facility to assist…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-02-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . 1) Resident 43 was admitted to the facility on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD). The Annual Minimum Data Set (MDS) assessment, dated 11/20/2024, showed Resident 43 was alert and oriented. Review of Resident 43's electronic health record (EHR) did not show PTSD was not addressed in the comprehensive care plan. On 02/06/2025 at 1:33 PM, when asked if Resident 43 had a care plan for PTSD with measurable goals and interventions, Staff I, Resident Care Manager and Licensed Practical Nurse, after reviewing the care plan, stated, It doesn't look like he has a care plan for that. 2) Resident 70 was admitted to the facility on [DATE] with diagnoses including Unspecified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . Resident 74 was admitted to the facility on [DATE]. The 5-day Minimum Data Set assessment, dated 01/15/2025, documented the resident was alert and oriented and had a stroke history. Resident 74's diet order, dated 01/30/2025, documented, nectar thick liquid consistency. On 02/04/2025 at 9:12 AM, Resident 74's room was observed to have a water pitcher containing thin liquid water. Resident 74 said some of the staff who pass water did not know she was on thickened liquids. The resident's care plan, printed and posted in Resident 74's room closet, documented, FLUID CONSISTENCY: mildly thick. At 9:40 AM, Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . Resident 17 was admitted to the facility on [DATE] with a diagnoses including paraplegia. The Quarterly Minimum Data Set assessment, dated 01/23/2025, indicated Resident 17 was alert and oriented. Review of the care plan, entitled Risk for psychosocial well-being r/t (related/to) [being in the facility for] long-term care, revised 01/10/2025, documented [Resident 17] is a younger resident . [Resident 17] should speak with SS to assist him in setting realistic goals. On 02/03/2025 at 2:10 PM, Resident 17 said he was cussed out by a staff member in August 2024. Resident 17 said he had talked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . 1) Resident 43 was admitted to the facility on [DATE] with diagnoses including Depression and Post Traumatic Stress Disorder (PTSD). The Annual Minimum Data Set (MDS) assessment, dated 11/20/2024, showed Resident 43 was alert and oriented. Review of Resident 43's PASARR Level I, dated 11/13/2020, documented Resident 43 showed indicators for mood disorders, but section IV of the Level I PASARR did not indicate service needs. Review of Resident 43's electronic health records (EHR) did not show a corrected PASARR Level I, dated 11/13/2020, and did not show a Level II PASARR determination or evaluation. On 02/05/2025 at 2:28 PM, when asked if Resident 43's Level I PASARR was accurate, Staff H, Social Services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings included . The Center for Disease Control and Prevention's (CDC) Contact Precautions sign, undated, indicated, Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: .Put on gown before room entry. Discard gown before room exit. On 02/07/2025 at 12:45 PM, Staff O was observed in Resident 46's room. Staff O had Resident 46's right arm in her gloved hands. Outside of Resident 46's room, next to the right side of the door, was a sign that read Contact Precaution. After Staff O exited the room, Staff O said she was attempting to find Resident 46's vein. Staff O said she was supposed to wear PPE anytime they provided…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-07 · tag F0908 — failed to keep essential equipment working — isolatedKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . On [DATE] at 2:07 PM, Resident 17 said the battery on the mechanical lift had died numerous times during transfers. Resident 17 said he was left suspended in the mechanical lift between the bed and chair while staff left the room or called others to swap out the battery. Resident 17 said the nursing staff also struggled with maneuvering the mechanical lifts due to hair tangled in the wheels of the mechanical lifts. Resident 17 said he felt there was a concern for safety due to both issues. On [DATE] at 10:13 AM, the mechanical lift in the Country Side short hall was observed sitting in the hallway with hair tangled in the rear wheels. On [DATE] at 11:50 AM, Resident 17 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-19 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based 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. Findings included . Resident 39 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 03/05/2024, showed the resident was cognitively intact. On 04/15/24, at 2:45 PM, Resident 39 was observed sitting in a chair with his oxygen mask on and concentrator turned on. Resident 39 was unable to provide information regarding his oxygen use. Review of Resident 39's electronic health record did not show the use of oxygen was addressed in the resident's comprehensive care plan. Resident 39's physician orders, dated 11/09/2023, documented, oxygen 1-4 L (liters) keep oxygen above 90% as needed. No additional documentation for the use of oxygen was provided. On 04/19/2024 at 8:54 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Ccited before2024-04-19 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings included . Review of the nursing home daily staff postings showed they had not been updated for 14 shifts, dated 04/01/2024 through 04/14/2024, to accurately reflect the number of nurses and/or nursing assistants working per shift. For 04/01/2024-- The posting showed .5 registered nurse (RN) for the day (6:00 AM - 2:30 PM) shift. The actual day shift schedule showed zero RNs worked. For 04/04/2024-- The posting showed 14 nursing assistants (NA) for the day shift. The actual day shift schedule showed 12.5 NAs worked. The posting showed 9.5 NAs for the evening (2:00 PM - 10:00 PM) shift. The actual evening shift schedule showed 9 NAs worked. The posting showed 7 NAs for the Noc (10:00 PM - 6:00 AM) shift. The actual schedule showed 6 NAs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to EVERGREEN HEALTHCARE GROUP — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.5 | +1.5 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 4 of 5 | 3.3 | +0.7 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 43 homes this chain runs (chain average 2.5★, per CMS)
Showing 40 of 43; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| FRONTIER SNF OPERATIONS LLC | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/23/2025 |
| PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS (WA) LLC | Organization | DIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| CH PACIFIC NORTHWEST HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| COUVE FINANCIAL SERVICES LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/23/2025 |
| PACIFIC NORTHWEST SNF OPERATIONS HOLDINGS LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 08/31/2023 |
| WITZCORP GLOBAL LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/31/2023 |
| BAYHON, MARISSA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| ODENTHAL, JASON | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| COUVE HEALTHCARE CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/14/2025 |
| PACIFIC NORTHWEST OPCO MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/14/2025 |
| WASHINGTON SNF CONSULTING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/14/2025 |
| BATES, DENISE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| CHHEDA, NEEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| SCHNEIDERMAN, MARC | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| SPIELMAN, SHIMON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/31/2023 |
| YENOWITZ, YITZCHOK | Individual | OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNF | since 05/27/2025 |
| HERZKA, YISROEL | Individual | ADP OF THE SNF | since 08/31/2023 |
CMS files one row per role, so the 36 rows in the source record cover these 17 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $224K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in WA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Washington Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 505276. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.