Average — CMS composite of the measures below.
A standard survey is most likely before around February 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 Polaris Transitional Care during CMS and state inspections, most recent first.
A resident with ESRD and dependence on hemodialysis did not receive post-dialysis care according to physician orders, the care plan, and facility policy. The post-dialysis pressure dressing on the AV fistula was not documented as removed within the ordered timeframe, despite dialysis center instructions specifying timely removal. Although an LN later reported that the access site was bleeding and a dressing change was performed, the TAR documented the site as clear and nursing notes did not reflect any dressing change. Required shift assessments of the fistula site for bleeding, redness, and tenderness were not accurately documented, and there was no evidence that the physician was notified of the bleeding access site, contrary to facility policy and referenced CDC dialysis safety standards.
Unlabeled and undated food items were found in the resident/family refrigerators, including a container of thick white liquid with frost buildup, grapes stored beneath it, a takeout container of leftover rice with the lid partially open, and another container of thick yellowish liquid. The FSS stated containers should have had a patient identifier, received date, and open date, and confirmed the items posed a contamination risk.
A facility failed to follow physician orders and care plan directions for 3 residents by taking BP in restricted arms. One resident with a dialysis access and another with a history of mastectomy had BP readings documented in arms that were specifically ordered off-limits, and a third resident with a left AVF also had a BP taken in the restricted arm. Signs in the rooms and care instructions directed staff to avoid those sites, yet staff still documented BP measurements there.
A resident with anoxic brain injury, bipolar disorder, and post-stroke hemiplegia received multiple psychotropic meds, including quetiapine, lorazepam, hydroxyzine, and olanzapine, without documented informed consent from the resident or RR before initiation and use. The MAR and LN psychoactive med evaluations showed ongoing administration of these meds while consent was missing or could not be determined, and the Administrator confirmed only lorazepam consents were on file.
A resident with ESRD on dialysis, pulmonary fibrosis, and significant assistance needs stated that showering on preferred days was very important, but staff followed a fixed shower schedule and told the resident no when requests were made outside that schedule. The MDS, care plan, Kardex, and shower records did not document the resident’s shower preference, and CNAs reported residents could not choose shower times because the facility used a set schedule.
A resident with severe cognitive impairment, anoxic brain damage, bipolar disorder, and hemiplegia/hemiparesis had DNR status documented, but the facility did not obtain, verify, or file the AD in the chart or make it readily accessible to staff. The EHR initially showed no AD, and the facility only received a faxed document after surveyor request; that document lacked required signatures and did not match the listed health care agent with the resident representative.
Failure to Report Alleged Neglect: A resident with gait impairment, vertebral fractures, COPD, osteoporosis, legal blindness, and a history of falls had a representative file a grievance alleging multiple neglect concerns, including excessive opioid use with delirium, repeated falls, missed toileting assistance, poor meal assistance, delayed pain meds, and lack of communication. The allegation was not reported to SSA or APS within the required timeframe, and the complaint was not included in the facility’s final documentation.
Unnecessary Concurrent Prednisone Orders: A resident with COPD and recent hip surgery received a 5 mg daily prednisone maintenance dose at the same time as a high-dose prednisone burst and taper, without a documented clinical rationale for keeping both orders active. The consultant pharmacist flagged the duplicate therapy, and the MD stated the maintenance dose was left on the MAR so it would not get lost while the burst/taper was extended for severe COPD.
Unsecured EHR Access on Medication Cart: A nurse left a med cart computer screen unlocked and unattended in a hallway, allowing access to resident records. During med pass for a resident, the nurse viewed the MAR in PCC, minimized the screen without locking it, and left the cart unattended while administering meds. Staff stated the screen should have been locked, and the nurse acknowledged anyone could access the record when it was left open.
The facility failed to maintain its IPCP when a CNA had a blood-to-eye exposure during a finger stick and the event was not consistently documented, investigated, or communicated. The CNA wore a mask and gloves but no eye protection, the IP was notified late, the exposure log lacked details of the education and follow-up, and later documentation conflicted about whether medical treatment occurred. The IP did not send the incident to QAPI, the MD was not notified, and the administrator confirmed the breakdown in communication across IP, HR, administration, and QAPI.
The facility's assessment contained inaccurate information regarding bed capacity and physical layout, with documentation stating a higher licensed capacity and a different building structure than what was confirmed by state licensing records and staff interview.
A resident with significant medical needs was admitted to the facility and, despite having personal belongings available, their room remained unpersonalized for over a month, with items left in boxes and minimal personal effects displayed. Staff did not contact the family or representative to assist with unpacking or personalizing the room, contrary to facility policy, resulting in the resident being denied a homelike environment.
The facility failed to ensure proper food storage and labeling, with expired and unlabeled food items found in the main kitchen and dining room kitchens. Missing temperature logs for refrigerators and freezers were also noted. The Dietary Manager acknowledged the lapses, which could potentially lead to foodborne illness among residents.
A facility failed to obtain informed consent before changing the medication regimen for a resident with schizophrenia and anxiety. The resident's Hydroxyzine dosage was increased from twice to three times daily, and Aripiprazole was increased from 25mg to 30mg daily without informing the resident's representative. Interviews confirmed the lack of communication, violating the facility's policy on psychotropic medications.
A facility failed to provide quarterly financial statements to a resident's designated financial representative, despite the resident having a POA for financial obligations. The statements were incorrectly sent to the resident's home address, and the Business Officer was unaware of the POA. This oversight was confirmed through interviews and document reviews, highlighting a failure to adhere to the facility's policy on managing resident funds.
A resident reported being catheterized without consent while in a ceiling lift sling, but the facility failed to investigate and resolve the grievance. Documentation showed no evidence of a thorough investigation or communication of the outcome to the resident. Interviews with staff revealed that the grievance process was not properly followed, with incomplete documentation and follow-up.
A resident lost their dentures, impacting their ability to chew and requiring a dietary adjustment. Despite this, the facility failed to update the resident's care plan to reflect their current dental status, as acknowledged by the DON. The care plan remained outdated, not addressing the resident's edentulous condition and dietary needs.
A facility failed to label medications and supplies used for wound care, risking the use of expired products on a resident. During wound care, two LNs used an opened tube of Triamcinolone Acetonide Ointment and two bottles of Vashe wound cleansing solution, none of which were labeled with the date opened or the initials of the person who opened them. This was against the facility's protocol, which requires such labeling to ensure medications are not expired.
The facility failed to ensure accurate medication transcription, leading to a resident receiving incorrect doses of Lovenox in addition to Heparin, resulting in an anemic crisis and death. Another resident experienced a delay in receiving their prescribed medication due to the same error.
The facility failed to ensure residents were free from significant medication errors, leading to the concurrent administration of two anticoagulants to a resident, resulting in severe health complications and eventual death. The error occurred due to incorrect transcription of a physician's handwritten order and failure to follow the 24-hour chart check protocol.
Failure to Follow Post-Dialysis Orders and Document AV Fistula Complications
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related treatment and care in accordance with physician orders, the resident’s care plan, and facility policy for one resident dependent on hemodialysis with ESRD and PVD. Physician orders and the MAR directed that the post-dialysis pressure dressing on the resident’s AV fistula be removed after a specified number of hours, and dialysis communication from the dialysis center reiterated that the fistula dressing must be removed within a defined timeframe to prevent clotting or narrowing of the AV graft. Record review showed no documentation that the post-dialysis dressing was removed within the ordered timeframe, and there was no indication on the MAR or in nursing progress notes that a dressing change was performed during the relevant dates. The facility also failed to assess, document, and communicate the condition of the dialysis access site as ordered and per policy. The care plan required daily checks and dressing changes at the access site with documentation and monitoring for signs and symptoms of complications, and the TAR included an order to assess the fistula site every shift for clarity, tenderness, redness, and bleeding. A nurse reported that upon the resident’s return from dialysis, the access site was bleeding and a dressing change was performed, but the TAR documentation for that shift indicated the site was “clear,” and nursing progress notes contained no record of a dressing change. Additionally, despite facility policy requiring monitoring for complications and immediate physician notification for bleeding, the medical record contained no evidence that the physician was notified about the post-dialysis bleeding AV fistula. CDC dialysis safety guidelines cited in the report state that standards of care require reassessment of the access site after dressing removal for bleeding, redness, or swelling, with accurate documentation and timely communication of findings, which was not demonstrated in this case.
Unlabeled and Undated Food Stored in Resident/Family Refrigerators
Penalty
Summary
Food was not stored under proper sanitary conditions in the North Dining Room resident/family refrigerators. During observation, a large yellow-lidded plastic container holding a thick white liquid was found in the resident/family refrigerator with condensation/frost buildup, and it was unlabeled with no date of preparation, resident identifier, or discard date. The container was stored directly on top of an unlabeled and undated clamshell container of grapes. In the resident/family mini-refrigerator, an undated and unlabeled white Styrofoam takeout container with leftover rice and visible yellow residue/sauce was observed with the lid partially open, exposing the food to the refrigerator environment. An unlabeled and undated plastic soup-type container with a thick yellowish liquid or food product was also found with no indication of when it was placed in the refrigerator or when it should be discarded. The Food Service Supervisor stated that every container in the resident/family refrigerators should have been labeled with a patient identifier, received date, and open date, and confirmed the items presented a risk for contamination. The facility policy required foods brought by family or visitors to be stored and served in accordance with food safety professional standards and labeled with the resident name, location, and date.
Blood Pressure Taken in Restricted Arms Despite Orders
Penalty
Summary
The facility failed to follow physician orders, care plan interventions, and professional standards of practice for 3 residents by obtaining blood pressure measurements in compromised arms. Resident #12 had diagnoses including a right acetabular fracture and dependence on renal dialysis, and the physician ordered no needle sticks or blood pressure measurements in the right arm old AV shunt site, with blood pressure to be taken only in the left lower leg. The care plan also directed no blood pressure in either upper extremity and blood draws only to the left upper extremity. Despite these directions, blood pressure readings were documented on the left arm on multiple occasions and on the right arm on multiple occasions. The resident stated that leg blood pressures sometimes read falsely low and that staff had taken blood pressure on the left wrist. A sign above the bed stated that blood pressure could only be taken to the left lower extremity and blood draws only to the left upper extremity. Resident #18 had diagnoses including pulmonary fibrosis, end-stage renal disease, dependence on renal dialysis, immunodeficiency, muscle weakness, difficulty walking, and need for assistance with personal care. The physician ordered the left AVF/dialysis site, and the Kardex directed staff not to draw blood or take blood pressure in the left arm with graft. A sign in the room also stated no blood pressure or blood draws to the left upper arm. Even so, one blood pressure reading was documented in the left arm. Resident #68 had diagnoses including heart failure, insomnia, and pain, and the physician ordered no blood pressures, labs, or IVs in the right upper extremity due to a history of right mastectomy. A sign in the room stated no blood pressure, IV, or labs on the right arm, yet blood pressure readings were documented in the right arm on multiple occasions. During interview, an LPN stated the resident had no restrictions and that either arm could be used.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent before initiating and continuing multiple psychotropic medications for one resident. The resident was admitted with diagnoses including anoxic brain damage, bipolar disorder, and hemiplegia/hemiparesis following a cerebral infarction affecting the left non-dominant side. The record showed orders for quetiapine, lorazepam, and hydroxyzine, all used for behavioral or anxiety-related symptoms, but the facility did not have documented informed consent from the resident or the resident representative before these medications were started or used. Review of the psychotropic consent forms showed consent only for certain lorazepam and hydroxyzine orders, and later consent for lorazepam 2 mg three times daily and quetiapine 150 mg in the evening. However, prior to August 2025, the facility could not produce informed consents for quetiapine, hydroxyzine, or olanzapine, even though these medications had already been administered. The medication administration record showed repeated administration of hydroxyzine, quetiapine, and multiple olanzapine orders over several months without documented consent. The licensed nurse psychoactive medication evaluations also reflected psychotropic use without confirmed informed consent, including entries indicating consent was obtained as "No" or "Unable to Determine." During interview, the Administrator stated that the psychotropic consents for lorazepam were the only consents on file prior to August 2025. The report also noted the facility's policy required informed consent prior to initiation of new psychoactive medications or dosage increases.
Resident’s Shower Preference Not Honored
Penalty
Summary
The facility failed to ensure a resident was given the opportunity to make choices about a shower or bath that was important to him/her. Resident #18 was admitted with pulmonary fibrosis, end-stage renal disease requiring dialysis, severe immune deficiency, muscle weakness, difficulty walking, and a need for assistance with personal care. During interview, the resident stated a preference to shower on Tuesdays or Wednesdays and/or weekends, and said staff sometimes told him/her no because it was not on the schedule. The resident also stated that because of dialysis days, he/she was supposed to be resting on the days staff wanted the shower completed. The resident’s MDS dated 10/30/25 showed substantial/maximal assistance was needed for bathing and that choosing between a tub bath, shower, bed bath, or sponge bath was marked as very important. The MDS nurse stated shower preferences should have been obtained at admission and included in the care plan, but for this resident the preference was not documented. Review of the care plan and Kardex showed dialysis on Monday, Wednesday, and Friday and that the resident preferred to rest after returning from dialysis, but no shower preference or schedule was included. Staff interviews showed the facility followed a set shower schedule rather than resident choice. CNAs stated residents were assigned showers on fixed days and times, with Resident #18 assigned nighttime showers, and that residents could not choose shower times outside the assigned schedule because of staffing and workload. The DON stated shower preferences should have been obtained by the admitting nurse and added to the shower schedule and care plan, but no documented preference was found in the admission assessment, care plan, Kardex, or shower schedules. The TAR showed two showers and multiple refusals, with refusals occurring on dialysis days, and the resident’s room had no signage of shower preference.
Advance Directive Not Obtained or Filed for Resident
Penalty
Summary
The facility failed to ensure that Resident #47’s advance directive was obtained, verified, and maintained in the medical record and readily accessible to staff. Resident #47 was admitted with diagnoses including anoxic brain damage, bipolar disorder, and hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The quarterly MDS dated 11/10/25 indicated the resident was not screened with the Brief Interview for Mental Status because the resident rarely or never understood, and the staff-assessed cognitive score was 3, indicating severe impairment and that the resident never or rarely made decisions regarding tasks of daily life. Review of the EHR on 11/18/25 showed the resident’s code status was documented as DNR, but no advance directive was present in the Misc section. The Contacts section listed the resident as the care conference person/legal representative/self, and another individual was listed as an emergency contact and resident representative. The facility did not have a copy of the resident’s advance directive until after the surveyor requested it on 11/19/25. Admission notes showed staff contacted Alaska Native Medical Center and were told there was no advance directive or POLST on file there, then contacted Alaska Regional Hospital and were told an advance directive was on file and would be faxed to the facility. Staff also attempted to contact the resident representative and power of attorney to arrange signing of admission and advance directive acknowledgment forms. The faxed advance health care directive did not match the name of the listed health care agent with the resident representative, and it lacked a signature, date, witness signature, and notary signature. The Administrator stated the facility did not have a copy of the advance directive prior to 11/19/25, and the Assistant Administrator stated the facility provided written information about advance directives upon admission but could not access the original admission agreement.
Failure to Report Alleged Neglect
Penalty
Summary
The facility failed to report an allegation of resident neglect to the State Survey Agency and Adult Protective Services within 24 hours after the allegation was made for one resident. The resident had diagnoses including unspecified abnormalities of gait and mobility, a wedge compression fracture of the lumbar vertebra, COPD, osteoporosis, legal blindness, and a documented history of frequent falls. The allegation was raised in a grievance submitted by the resident’s representative, who described multiple incidents he/she believed constituted neglect. The grievance stated that the resident received high doses of narcotic pain medication early in the admission despite cautions from two prior facilities about a history of opioid-induced delirium, and that this led to significant delirium and confusion that interfered with therapy participation. The representative also alleged repeated preventable falls, including a fall after kyphoplasty when toileting requests were not addressed, resulting in a new acute L4 compression fracture. Additional concerns included failure to notify family of falls and the new fracture, lack of escort or pre-medication for imaging appointments, meal trays being left at the bedside without assistance for a legally blind resident, delays in pain medication, repeated loss of laundry, refusal to release medical records to a receiving facility, exposure to an aggressive co-resident, and minimal communication from providers and nursing staff. Record review found no documentation that these neglect allegations were reported to the SSA or APS. During interview, the Quality Director stated that the resident representative’s complaint had not been included in the documentation or final report and that there had been no formal APS reporting system at the time. The facility policy required alleged neglect to be reported immediately, and no later than 24 hours when the event did not involve abuse or serious bodily injury.
Unnecessary Concurrent Prednisone Orders
Penalty
Summary
The facility failed to ensure one resident’s drug regimen was free from unnecessary drugs when prednisone maintenance therapy was continued at the same time as a high-dose prednisone burst and taper without a documented clinical rationale for maintaining both doses. Resident #41 was admitted with diagnoses including aftercare following joint replacement surgery, dislocation of the internal right hip prosthesis, and COPD. A physician progress note dated 10/17/25 documented that the resident had been coughing since admission, had shortness of breath, had prior COPD exacerbations, and had sputum production, with a plan for a steroid burst and taper. The consultant pharmacist’s October 2025 medication regimen review identified two prednisone orders for the resident: a 5 mg daily maintenance dose for COPD and a 15-day taper using 20 mg tablets. The pharmacist asked the facility to confirm whether the 5 mg dose was intended to start after the taper or should be discontinued. A handwritten note signed by the physician stated that the 5 mg dose was maintenance and was kept so it would not get lost, and that the burst and taper were extended due to severe COPD. Review of the MAR showed the resident received the 5 mg daily prednisone dose along with the burst-and-taper prednisone orders from 10/18/25 through 11/6/25, totaling 19 days, with daily prednisone exposure ranging from 15 mg to 65 mg. During interview, the pharmacist stated that when a steroid burst and taper is prescribed, the maintenance dose is typically discontinued during that period and that the order should have been clarified. The Medical Director stated he left the 5 mg dose on the MAR so it would not get lost and said the resident consented to keeping it, and he was unsure whether he received a notification from the verifying pharmacist when the orders were entered.
Unsecured EHR Access on Medication Cart
Penalty
Summary
The facility failed to ensure the electronic health record of one resident was maintained in a manner that protected confidentiality from unauthorized access. On 11/18/25 at 11:21 AM, observation showed the nurse's medication cart for Iliamna Hall was unattended in front of the clean utility room on the south hall, and the cart computer screen was not locked, leaving resident records accessible. During the same observation, the Business Office Manager stated the computer should not have been left open and accessible and located a nurse to lock it. On 11/19/25 at 9:03 AM, LN #1 was observed preparing medications for Resident #3 and checking the MAR in Point Click Care. After preparing the medication, LN #1 minimized PCC without locking the screen, then went to the resident's room and administered the medications while the medication cart was left unattended in the hallway. During interview, LN #1 stated that anyone could access the resident's medical record when the screen was not locked and said he/she had been trained on how to lock the computer, but forgot to do so. The DSD stated staff were trained in HIPAA and should keep the screen off or log off and make sure the computer was locked, and the facility's HIPAA policy stated PHI must be safeguarded from unauthorized access and that computers are logged off when not in use.
Infection Control Program Failed to Track and Communicate Bloodborne Exposure
Penalty
Summary
The facility failed to maintain its Infection Prevention and Control Program by not consistently preventing, identifying, reporting, investigating, and controlling infections, including occupational bloodborne pathogen exposures. The record review identified an occupational exposure in which a CNA performing a blood sugar finger stick had blood splash into the right eye after pricking a resident’s finger with a lancet and squeezing for blood. The CNA was wearing a mask and gloves but no eye protection, rinsed the eye with saline, and notified the charge nurse the same day, but the Infection Preventionist was not notified until two days later. The facility’s tracking documentation for the exposure was incomplete. The spreadsheet showed that an employee injury report and bloodborne pathogen education were marked as completed, but no details of the education were documented, no follow-up treatment was recorded after the CNA declined initial medical evaluation, and the employee’s phone number was not recorded. The Employee Statement of Accident later showed the employee sought medical treatment on an undisclosed date, which was inconsistent with the earlier documentation stating that no follow-up treatment had been given. During interviews, the Infection Preventionist stated the only documentation available was the employee self-report form, the supervisor’s accident/exposure form, and the IP tracking spreadsheet. The IP stated the source resident’s chart was reviewed for HIV or hepatitis history, but source labs were not routinely obtained unless there was a specific concern. The IP also stated the incident was not forwarded to QAPI and was only verbally reported to the administrator, while the administrator stated communication was primarily verbal and confirmed the exposure was not documented in QAPI minutes for August or September 2025. The Medical Director stated he was not aware of the exposure, had not been notified, and had not reviewed the source resident or ordered related labs.
Inaccurate Facility Assessment Documentation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was up to date and accurate, as required. Record review revealed discrepancies in the reported bed capacity and facility description. The facility assessment stated a licensed capacity of 96 residents, while the State of Alaska license indicated the facility was licensed for 50 beds. During an interview, the Director of Community Liaison confirmed the correct bed capacity was 50 beds, highlighting the inaccuracy in the assessment documentation. Additionally, the facility assessment described the physical layout as consisting of 8 cottages, 8 courtyards, and a common building, whereas the initial licensing application described the facility as a single building with two wings, each containing specific hallway and room arrangements. These inconsistencies demonstrate that the facility assessment did not accurately reflect the facility's current resources and structure, as required for both day-to-day operations and emergency preparedness.
Failure to Provide Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a homelike environment was established and maintained for a resident who had been admitted over a month prior. Despite the resident's history of having a personalized room at a previous facility, observations revealed that the resident's personal belongings remained packed in boxes, with minimal personal items displayed in the room. The only visible personal effects were a few pictures on a corkboard, which was obscured behind a television and not easily visible from the resident's bed. The room otherwise lacked any personal touches or homelike features. Interviews with facility staff indicated that it was the responsibility of the assigned CNA to inventory and put away personal items upon admission, and that family members were typically contacted to assist with unpacking. However, there was no documentation that staff had reached out to the family or the resident's representative for assistance, nor was there any record of resistance from the resident or representative regarding the personalization of the room. The facility's policy required social services to contact family or responsible parties to help personalize the resident's environment, but this was not done, resulting in the resident being denied a homelike environment.
Improper Food Storage and Labeling in Facility Kitchens
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper labeling and storage of food items in the main kitchen and dining room kitchens. During an inspection, it was observed that several food items in the dry storage, walk-in cooler, and walk-in freezer were either expired or lacked proper labeling with received, open, or use-by dates. Specifically, expired cans of Monarch Pork & Beans, Premier Protein Chocolate Shakes, and various other food items were found in the main kitchen. Additionally, the Northside and Southside dining room kitchens had missing temperature logs for their refrigerators and freezers, and several food items were found without open date labels. The Dietary Manager confirmed that all containers should have been labeled with received, open, and use-by dates, and that expired food should be discarded. The facility's policy on labeling and storage of food items was not followed, as evidenced by the presence of expired and unlabeled food items. This failure to comply with food safety standards had the potential to cause or spread foodborne illness to all residents receiving food from the affected kitchens.
Failure to Obtain Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident, which is a violation of the residents' rights to be informed about their treatment. Specifically, the facility made changes to the medication orders for a resident diagnosed with schizophrenia, anxiety, agitation, and insomnia, without obtaining informed consent from the resident or their representative. The resident was prescribed Hydroxyzine, an antihistamine used for anxiety, and Aripiprazole, an antipsychotic for schizophrenia. The facility increased the frequency of Hydroxyzine administration from twice daily to three times daily and increased the dosage of Aripiprazole from 25mg to 30mg daily without documenting the risks and benefits or obtaining approval from the resident's representative. Interviews with the resident's representative and the nursing supervisor revealed that the facility did not inform the representative about the changes in medication dosage and frequency. The facility's policy on psychotropic medications requires that residents or their representatives be advised of the potential risks and benefits of psychotropic medication therapy. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and communication regarding the changes in the resident's medication regimen.
Failure to Provide Quarterly Financial Statements to Resident's POA
Penalty
Summary
The facility failed to provide quarterly statements for personal fund accounts to the resident's designated financial representative, which is a requirement according to the facility's policy. The resident in question, who has schizophrenia, had a Power of Attorney (POA) assigned for financial obligations. However, the facility was sending the quarterly bank statements to the resident's home address instead of the POA. This oversight was confirmed during interviews with the resident's representative and facility staff, including a Licensed Nurse (LN) and a Business Officer (BO). The Business Officer was unaware of the POA designation and stated that the facility had been sending the statements directly to the resident. A review of the resident's face sheet incorrectly listed the resident as the financially responsible party, despite the existence of a POA document that clearly designated the resident's representative as the agent for banking transactions. This failure to provide accurate and complete accounting of the resident's personal funds to the appropriate representative placed the resident and their representative at risk of not receiving necessary financial information.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance for a resident who reported being catheterized without consent while in a ceiling lift sling. The resident expressed feeling violated and stated that their complaints were not always investigated and resolved. Documentation revealed that the facility did not show evidence of a thorough investigation or inform the resident of the outcome of the grievance process. The incident involved a resident who was somnolent and unable to void, leading to a bladder scan that showed 590 ml of urine. A straight catheterization was ordered, but the resident felt uncomfortable and requested the procedure to stop. Despite this, the resident later reported being catheterized without consent while in a sling, which was not documented as having occurred. The facility's grievance log showed incomplete documentation and follow-up regarding the resident's complaint. Interviews with facility staff, including the DON and DOQ, revealed that the grievance process was not properly followed. The DON admitted to not documenting the follow-up with the ombudsman or the resident, and the DOQ acknowledged that the investigation and resident follow-up were incomplete. The facility's grievance policy requires prompt resolution and written follow-up, which was not adhered to in this case.
Failure to Update Care Plan for Resident's Dental Status
Penalty
Summary
The facility failed to update a comprehensive care plan according to a resident's current dental status, which placed the resident at risk of not receiving appropriate care. The resident, who was admitted with diagnoses including a femur fracture, facial weakness, and dysphagia, reported losing their dentures in their room. Despite the staff, including the Director of Nursing (DON), searching for the dentures, they were not found. The resident expressed difficulty chewing foods and was downgraded to a soft and bite-sized diet texture by the nurse supervisor. The resident also reported being unable to eat the provided meals and requested specific food items that were easier to consume. The care plan, dated prior to the loss of dentures, indicated the need for dentures due to swallowing problems and required staff assistance with denture care. However, the care plan was not updated to reflect the resident's edentulous status and dietary needs following the loss of dentures. The DON acknowledged that the care plan should have been updated to indicate the absence of dentures and confirmed that the comprehensive care plan was not revised according to the resident's current dental status. The facility's policy requires the care plan to be updated every 90 days and as changes occur, which was not adhered to in this case.
Failure to Label Medications and Supplies for Wound Care
Penalty
Summary
The facility failed to ensure that medications and supplies used for wound care were appropriately labeled, which placed a resident at risk of receiving expired medications and wound cleansing solutions. During an observation of wound care for a resident, two licensed nurses placed wound care dressing supplies on a clean field. Among these supplies was an opened tube of Triamcinolone Acetonide Ointment with a manufacturer's expiration date of January 2027, which was marked only with a handwritten letter 'B' and lacked any indication of who opened it or when it was opened. Additionally, two opened bottles of Vashe wound cleansing solution with a manufacturer's expiration date of August 2025 were used, but they also lacked labels indicating the date they were opened or the initials of the person who opened them. In an interview, one of the licensed nurses admitted that the ointment and wound cleanser were not labeled with the necessary information, such as the initials of the person who opened them and the date they were opened, acknowledging that they should have been properly labeled. The facility's nursing protocol for medication labeling, dated March 2024, requires that medications with defined expiration periods be labeled with open and expiration dates, as well as the initials of the person who opened them. This protocol was not followed, leading to the use of potentially expired medications and wound cleansing solutions on the resident.
Medication Transcription Error Leads to Resident's Death
Penalty
Summary
The facility failed to implement pharmaceutical services that ensured the accurate dispensing and administration of medications for two residents. Specifically, the facility did not have procedures in place to confirm the Five Rights (right patient, right medication, right dose, right route, and right time) during the transcription of prescriber's original hand-written medication orders into the electronic Medication Administration Record (eMAR). This failure led to a medication error where a nurse transcribed an order for Lovenox intended for one resident into another resident's eMAR, resulting in the incorrect administration of the medication. Resident #1, who was already on Heparin therapy, received seven doses of Lovenox due to this transcription error. This error caused a significant drop in the resident's blood values, leading to an anemic crisis. Despite receiving multiple blood transfusions, the resident's condition did not improve, and they eventually passed away. The error was discovered and discontinued after four days, but the damage had already been done. Resident #2 experienced a delay in receiving their prescribed Lovenox due to the transcription error. The facility's process for handling medication orders involved physicians handwriting orders into paper charts, which were then transcribed into the eMAR by nursing supervisors. The pharmacy was alerted electronically but did not receive the original hand-written orders, leading to a lack of verification and control over the accuracy of transcriptions. This systemic failure in the medication order process contributed to the severe outcomes for the residents involved.
Significant Medication Error Due to Incorrect Transcription
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically involving two residents. The error occurred due to the incorrect transcription of a physician's handwritten order for an anticoagulant medication. A Licensed Nurse (LN) mistakenly transcribed an order for Lovenox, intended for one resident, into the electronic medication administration record (eMAR) of another resident who was already receiving Heparin. This resulted in the concurrent administration of two different anticoagulants to the wrong resident over several days, leading to severe health complications and eventual death of the resident due to an anemic crisis and critically low blood values. The resident who received the incorrect medication had a history of chronic kidney disease, liver abscess, and was on long-term anticoagulant therapy. The error was discovered after the resident's blood values showed a significant drop, prompting an emergency evaluation and hospitalization. Despite multiple blood transfusions, the resident's condition did not improve, and they were eventually placed on comfort care and passed away. The facility's process for handling medication orders involved handwritten entries by physicians, which were then transcribed into the eMAR by nursing supervisors. However, the 24-hour chart check process failed to catch the transcription error. The involved nurses admitted to not following the protocol correctly, leading to the oversight. The facility's policies and procedures did not include a step to ensure that all transcribed orders in the eMAR had corresponding written orders in the hard chart, contributing to the error.
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Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anchorage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Polaris Extended Care | 0 mi | ★★★★★ | 6 | 0 |
| Centennial Post Acute | 2.5 mi | ★★★★★ | 49 | 1 |
| Maple Springs Of Wasilla | 29.4 mi | ★★★★★ | 0 | 0 |
| Maple Springs Of Palmer | 34 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.