Inspection Reports for
Polaris Healthcare & Rehabilitation Center LLC

The visit was complaint-related, triggered by allegations of inadequate nursing staff and delayed call bell responses. The complaint was substantiated as evidenced by interviews and observations confirming delays and insufficient staffing.

The facility was found deficient in several areas including insufficient nursing staff to meet resident needs, delays in call bell responses, inadequate dental services, and failure to maintain accurate and complete resident medical records.

The complaint survey was unannounced and no deficient practices were found, indicating no substantiated complaints.

No deficiencies or deficient practices were identified during the survey.

The complaint involved allegations of misappropriation of resident property/funds for resident R18. The facility failed to recognize and report the allegation within 24 hours and failed to thoroughly investigate the allegation. The resident denied missing funds due to misappropriation or exploitation. The facility also failed to continue investigation after the allegation was denied to the police. The complaint was substantiated as evidenced by the deficiencies cited.

The facility was found not to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of April 3, 2025. Deficiencies were identified related to failure to report alleged violations of abuse and misappropriation of resident property timely, failure to thoroughly investigate allegations, failure to prevent further potential abuse during investigations, and failure to maintain complete and accurate resident medical records.

The survey identified multiple deficiencies related to emergency preparedness training, resident discharge procedures, incident reporting, care planning, pain management, medication administration, and resident rights. Several residents were found to have unmet care needs and the facility failed to follow certain regulatory requirements.

The complaint investigation substantiated multiple deficiencies including medication errors, failure to limit psychotropic drug use, and failures in staff training and resident care. Immediate Jeopardy was identified related to insulin administration errors but was abated by 1/23/25.

The facility was found deficient in multiple areas including failure to deliver ordered medications timely, failure to limit psychotropic PRN orders to 14 days, significant medication errors with insulin administration, incomplete temperature monitoring logs for medication refrigerators, failure to promptly notify physicians of lab results, failure to assist residents in obtaining dental services, failure to ensure food safety and proper dietary orders, lack of mandatory communication, resident rights, infection control, compliance and ethics, and behavioral health training for staff. Immediate Jeopardy was identified and later abated with corrective actions.

The complaint survey was unannounced and no deficiencies were found, indicating no substantiated issues.

No deficient practice was identified during the survey.

The complaint investigation was substantiated based on record review and interviews indicating the facility failed to properly discharge one resident (R2), including inadequate education on insulin administration and dressing changes, and lack of coordination with community social services.

The facility failed to implement an effective discharge planning process for one resident, resulting in inadequate discharge preparation and continuity of care. Additionally, the facility failed to ensure continuity of medically related social services upon discharge for the same resident. Multiple deficiencies were identified related to discharge planning and social service provision.

The survey was complaint-related and no deficient practice was found, indicating no substantiated deficiencies.

No deficient practice was identified during the survey.

The survey identified multiple deficiencies related to resident rights, care planning, safety, medication management, and facility environment. The facility failed to meet several regulatory requirements including dignity and respect for residents, accurate assessments, proper care planning, and maintenance of a safe environment.

The complaint investigation was unannounced and no deficiencies were found, indicating no substantiated issues.

No deficiencies or deficient practices were identified during the survey, which included observation, interviews, and document review.

The survey identified multiple deficiencies related to resident rights, safe environment, notification of changes, privacy/confidentiality, care planning, medication administration, infection control, and other regulatory requirements. The facility failed to ensure proper pre-employment TB screening, respect and dignity for residents, adequate notification of changes, privacy of medical records, and proper care planning and medication management.

The facility failed to provide sufficient nursing staff to meet resident needs, resulting in prolonged call bell response times and unmet care needs for several residents. Additionally, the facility failed to ensure timely dental services for a resident awaiting teeth extraction and dentures.

The complaint investigation found substantiated issues related to staffing shortages causing delayed resident care and failure to provide timely dental services to a resident.

The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in prolonged call bell response times and unmet care needs for multiple residents. Additionally, the facility failed to ensure timely dental services for one resident who requested teeth extractions and dentures.

The facility was found deficient in multiple areas including residents' access to personal funds, failure to notify providers and responsible parties of significant changes in condition, failure to report and investigate allegations of misappropriation of resident property, improper discharge and readmission practices, incomplete and untimely care planning, failure to follow physician orders, inadequate supervision to prevent accidents, failure to maintain continence care, medication errors including missed insulin doses, failure to notify providers of lab results, and failure to provide food and fluids in appropriate forms.

The facility was found deficient in multiple areas including failure to ensure timely access to residents' personal funds, failure to notify responsible parties and providers of significant changes in condition, failure to report and investigate allegations of misappropriation of resident property, failure to comply with discharge and readmission requirements, incomplete and inadequate care plans, failure to follow physician orders including medication administration and dietary orders, inadequate supervision leading to resident falls, failure to maintain accurate and complete medical records, and failure to promptly notify providers of laboratory results. An Immediate Jeopardy was identified related to medication errors involving insulin administration but was abated during the survey period.

The facility was found deficient in multiple areas including failure to honor resident care preferences, incomplete advance directive discussions, inadequate notification of changes in condition, unresolved resident grievances, improper discharge procedures, lack of bed hold notifications, incomplete care plans, unlicensed staff performing assessments, inadequate assistance with activities of daily living, failure to follow physician orders, delayed contracture evaluations, improper medication management including missed insulin doses, inadequate respiratory care, failure to provide dental services, food safety violations, and incomplete staff training in communication, infection control, compliance, and behavioral health.

The facility was found deficient in multiple areas including resident rights, care planning, medication management, infection control, staff training, and food safety. Several residents experienced issues such as failure to honor care preferences, inadequate pain management, missed medication doses, lack of proper care plans, and failure to provide timely notifications and services.

The investigation was complaint-driven, focusing on the discharge process for resident R2. The complaint included concerns about inadequate discharge planning, lack of education on wound care and insulin administration, inappropriate discharge circumstances following a behavioral incident, and failure to notify the community caseworker, resulting in a lapse of medically related social services.

The facility failed to ensure an effective discharge plan for R2, who had multiple medical needs including diabetes, visual impairment, and an open wound. The discharge process lacked proper education and demonstration of self-care abilities, failed to designate a community physician, and did not ensure continuity of medically related social services, resulting in a lapse of care and delayed access to resources after discharge.

The complaint investigation focused on the discharge process for resident R2, who was discharged without adequate discharge planning, education, or coordination with community services. The resident was visually impaired, diabetic, and had an open wound. The facility did not ensure demonstration of self-care abilities or timely notification and coordination with the community caseworker, resulting in a lapse of medically related social services and delayed access to necessary resources.

The facility failed to implement an effective discharge plan for resident R2, who had multiple medical needs including diabetes, visual impairment, and open wounds. The discharge process lacked proper education on self-care, demonstration of abilities, and continuity of medically related social services, resulting in a lapse of care and delayed connection to community resources.

The complaint investigation included allegations of dignity violations, abuse, and accident prevention failures. The resident-to-resident abuse allegation was substantiated as the facility failed to recognize and immediately report it. The fall incident was determined to be past non-compliance with corrective actions completed.

The facility failed to maintain resident dignity by providing care with doors open exposing residents, failed to timely report an allegation of abuse between residents, and failed to provide adequate supervision to prevent accidents resulting in harm to a resident. Some deficiencies were determined to be past non-compliance with corrective actions completed.

The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate notification of changes in resident condition, failure to ensure call bell accessibility, failure to provide required notices, cleanliness issues, failure to timely report abuse, inaccurate assessments, incomplete care plans, failure to prevent pressure ulcers, inadequate respiratory care, failure to promote continence, and improper food storage.

The facility was found deficient in multiple areas including resident dignity, communication of health status changes, call bell accessibility, abuse reporting, care planning, pressure ulcer prevention, continence care, respiratory care, medication regimen review, psychotropic medication monitoring, and food safety.

The complaint investigation involved dignity violations for residents R7, R23, and R57; an abuse allegation involving resident R53 and roommate R17 that was not immediately reported; and an accident involving resident R57 falling from a Hoyer lift due to inadequate supervision. The abuse allegation was substantiated by interviews and documentation.

The facility failed to maintain resident dignity during care, did not immediately report an allegation of abuse, and failed to provide adequate supervision to prevent accidents resulting in harm. Some deficiencies were determined to be past non-compliance with corrective actions completed.

The complaint investigation found substantiated deficiencies related to failure to timely notify the physician of a resident's change in condition and failure to notify the Ombudsman of a resident's hospital transfer.

The facility failed to make timely contact with the physician when a resident (R1) had a new onset of vomiting, resulting in a 6.5 hour delay in treatment. Additionally, the facility failed to notify the Ombudsman when another resident (R4) was transferred to the hospital. The facility lacked a written process for contacting an on-call physician if the provider could not be reached.

The investigation was complaint-driven, focusing on failure to timely notify the physician of a resident's vomiting and failure to notify the Ombudsman of a resident's hospital transfer. The complaints were substantiated with findings of delayed physician contact and lack of Ombudsman notification.

The facility failed to timely notify the physician about a resident's vomiting and change in condition, resulting in a 6.5 hour delay in treatment. Additionally, the facility failed to notify the Ombudsman when a resident was transferred to the hospital.

The facility was found deficient in multiple areas including resident dignity, timely physician consultation, confidentiality of medical records, environmental comfort, grievance procedures, abuse reporting, transfer notifications, baseline and comprehensive care planning, respiratory care, medication management, infection control, dental services, rehabilitation services, and COVID-19 vaccination documentation.

The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate respiratory and medication management, failure to provide timely abuse reporting, incomplete care plans, failure to provide required notifications for hospital transfers, inadequate infection control practices, and failure to ensure residents received routine dental and rehabilitative services.