Polaris Transitional Care

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 resident (Resident #11) out of 1 resident reviewed for dialysis care, received treatment and care in accordance with physician orders, the comprehensive person-centered care plan, and professional standards of practice. Specifically, the facility failed to:1. remove a post-dialysis dressing within the ordered timeframe;2. assess and accurately document the condition of the resident's dialysis access site; and3. monitor, evaluate, and communicate complications related to the resident's vascular access. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored under proper sanitary conditions in the North Dining Room resident/family refrigerators. This failed practice placed all residents who were able to consume food by mouth (based on a census of 39) at risk for foodborne illness An observation on 11/18/25 at 1:00 PM, of the resident/family refrigerator revealed: - an unlabeled large yellow-lidded plastic food container holding a thick white liquid that had condensation/frost buildup. The container did not contain a date of preparation, resident identifier, or a discard date. The food container was stored directly on top of an unlabeled and undated clamshell container of grapes. An observation on 11/18/25 at 1:10 PM of the resident/family mini-refrigerator, revealed: [...]

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure care and services were provided in accordance with professional standards of practice and the comprehensive person-centered care plans for 3 residents (#12, #18, and #68) out of 43 residents (total census). Specifically, the facility failed to follow standards, care plan interventions, and physician's order directing staff not to obtain blood pressure measurements in the residents' compromised arms. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain informed consent prior to the initiation and use of psychotropic medications for 1 resident (#47) out of 12 sampled residents. Specifically, the facility administered multiple psychotropic medications without documented informed consent from the resident or the resident representative. This failure denied the resident and/or resident representative the right to be informed of the risks, benefits, and alternatives of psychotropic medications and the right to participate in care planning and decision-making. Past Noncompliance: During a recertification, licensure and complaint survey conducted on 11/21/25 past noncompliance was identified at F552. The last standard recertification survey was conducted on 11/1/24. [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure 1 resident (#18), out of 12 sampled residents, was given the opportunity to make choices about aspects of his/her life that were significant to him/her. Specifically, the facility failed to ensure the resident had the opportunity to receive a shower and/or a bath according to his/her preferences. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's advance directive (AD) was obtained and maintained in the medical record and was readily accessible to staff for 1 resident (#47) of 12 sampled residents. Specifically, the facility did not obtain, verify, or properly file the resident's advance directive upon admission, resulting in staff being unaware of the resident's documented treatment preferences. [...]

Inspectors wroteBased on record review and interview, the facility failed to report to the State Survey Agency (SSA) and Adult Protective Services (APS) an allegation of resident neglect no later than 24 hours after the allegation was made as required by 42 Code of Federal Regulation (CFR) S483.12(c)(1), for 1 resident (#69), out of 3 unsampled residents reviewed for compliance with reporting requirements. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the drug regimen for one resident (#41), out of 12 sampled residents, was free from unnecessary medication. Specifically, the facility failed to prevent duplicate drug therapy by continuing a maintenance dose concurrently with a high-dose of prednisone (corticosteroid medication used to reduce inflammation and suppress the immune system) without a documented clinical rationale confirming the benefits of maintaining both doses of the medication. This failed practice placed Resident #41 at risk for potential adverse effects from unnecessary medication administration related to excessive corticosteroid exposure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the electronic health record (EHR) of 1 resident (#3), out of 12 sampled residents, was maintained in a manner to ensure confidentiality from unauthorized access. Specifically, Licensed Nurse (LN) #1 left the medication cart computer screen unlocked and unattended in a hallway. This failed practice had the potential to place the resident's medical record at risk for unauthorized access and use An observation on 11/18/25 at 11:21 AM, revealed the nurse's medication cart for the Iliamna Hall was located in front of the clean utility room of the south hall unattended. Further observation revealed the cart's computer screen was not locked and access to resident records was available. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain its Infection Prevention and Control Program (IPCP). Specifically, the facility failed to:Maintain a system for consistent preventing, identifying, reporting, investigating, and controlling infections, such as occupational bloodborne pathogen (infection spread in the blood) exposures. Maintain a system for recording occupational bloodborne pathogen exposures and documenting the corrective actions taken by the facility. Formalized reporting and communication of infection control issues across departments and committees, including Quality Assurance and Performance Improvement (QAPI) and Human Resources (HR), to monitor trends and implement preventive actions. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure their facility assessment was up to date and accurate. This failed practice had the potential to place all residents (based on a census of 49) at risk of not having the necessary care and resources from an accurate assessment.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a homelike environment was set up and maintained for 1 Resident (#1), out of 2 residents observed, who was admitted to the facility over a month ago. This failed practice denied the resident the right to a personalized homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods were stored and labeled in accordance with professional standards for food safety for all residents (based on a census of 43). Specifically, the facility failed to ensure: 1) foods were labeled and dated; 2) foods were being stored at safe temperatures in the Northside and Southside dining room kitchens and 3) expired foods were discarded. These failed practices had the potential of causing or spreading foodborne illness to all residents, who received food from the affected kitchens.

Inspectors wroteBased on record review and interview, the facility failed to obtain informed consent prior to administering psychotropic medications (medications in the class of either antipsychotics, antianxiety, or antidepressants that would have affected behavior, mood, thoughts, or perception). Specifically, the facility made changes to the medication orders for one resident (#8) out of 5 sampled residents for unnecessary medications. This failed practice denied the Resident and/or Resident's Representative the right to consent to medications and be informed of the risk and benefits for the medications use.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statements for personal fund accounts to one resident (#8's) Resident's Representative (RR), out of 1 sampled resident whose money was held by the facility. This failed practice placed the Resident and/or his/her RR at risk for not receiving a complete and accurate accounting of his/her personal funds entrusted to the facility.

Inspectors wroteBased on record review and interview, the facility failed to investigate and resolve a grievance for 1 resident (#18), out of 12 sampled residents. This failed practice violated the Resident's right to have a grievance investigated and resolved.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan was updated according to the resident's current dental status for 1 resident (#3), out of 12 sampled residents. This failed practice placed the resident at risk of not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure inappropriately labeled medications and supplies were not used for wound care for one resident (#17) out of 1 resident observed for wound care. This failed practice placed the resident at risk for receiving expired medications and expired wound cleansing solution.

Inspectors wroteBased on record review and interview, the facility failed to implement pharmaceutical services that included procedures to ensure the accurate dispensing and administration of medications for 2 residents (#s 1 and 2), out of 2 sampled residents. Specifically, the facility failed to ensure the pharmaceutical service processes included the receiving and interpretation of prescriber's original hand-written medication orders to confirm the Five Rights (right patient, right medication, right dose, right route, and right time) were accurately followed during the transcription of the orders into the resident's electronic Medication Administration Record (eMAR). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from significant medication errors for 2 resident (#s 1 and 2), out of 2 sampled residents. The facility failed to implement and maintain processes and procedures to ensure accurate transcription of physician orders for medications. The facility administered seven doses of an anticoagulant medication (a blood thinning medication that decreases the blood's ability to clot) without a valid physician order which resulted in concurrent administration of two different anticoagulants. This failed practice resulted in Resident #1 requiring hospitalization for an anemic crisis, did not respond to blood transfusions, and later died, which constituted an immediate jeopardy at CFR 483.45(f)(2) Significant Medication Errors. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the necessary services to maintain good personal hygiene were provided to 1 resident (#31), out of 14 sampled residents. Specifically, the resident was not always provided a shower on scheduled shower days. This failed practice denied the resident from maintaining his/her highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure 2 residents (#3 and #249), out of 5 residents reviewed for immunization, were educated of the risks and benefits of immunizations. This failed practice had the potential to not fully educate the residents on the risk and benefits of the vaccination.