Inspection Reports for Polaris Rehabilitation and Care Center

The inspection was conducted as part of the annual survey of Polaris Rehabilitation and Care Center to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility operations.

The facility was found deficient in multiple areas including the use of unnecessary psychotropic medications, failure to complete significant change assessments, improper care of residents with feeding tubes, lack of CNA abuse registry verification, incomplete pharmacist monthly medication reviews, improper labeling of medications, unsanitary food handling practices, and inadequate infection prevention techniques during dining.

The survey was conducted as a complaint investigation prompted by complaint intake #2695371.

No deficiencies were identified pertaining to the complaint investigation.

Complaint intake #2695371 was investigated and found to have no deficiencies.

The survey was conducted as a complaint investigation prompted by complaint intakes 2652282 and 2651381 regarding an incident of physical abuse between residents.

The facility failed to protect residents from physical abuse by another resident, resulting in actual harm to two residents. Corrective actions were implemented prior to the survey and compliance was met on 2025-10-23.

The complaint investigation was substantiated. Resident #1 was physically assaulted by resident #2, resulting in injuries requiring hospital evaluation. Resident #1 later passed away due to complications. Resident #2 exhibited aggressive behavior and was placed in a separate room with interventions implemented.

A revisit survey was conducted on 11/13/25 through 11/14/25 to verify correction of all previous deficiencies cited on 8/7/25.

The facility failed to ensure residents were free of significant medication errors, specifically for one resident (#6) who experienced missed doses of colchicine due to medication unavailability and lack of physician notification. The facility implemented corrective actions including education, audits, and new tracking procedures to prevent recurrence.

The inspection was conducted due to a complaint investigation regarding failure to protect residents from physical abuse by another resident.

The facility failed to protect residents from physical abuse by another resident, resulting in actual harm to two residents. Corrective measures were implemented prior to the survey and compliance was met on 2025-10-23.

The complaint involved an incident on 2025-10-17 where resident #1 was physically assaulted by resident #2, resulting in injuries requiring hospital evaluation. Resident #1 later passed away due to complications. The facility implemented corrective actions including separation of residents, staff education, and audits. Law enforcement was notified and determined no immediate threat remained.

A complaint survey was conducted from 10/21/2025 to 10/24/2025 prompted by multiple complaint intakes regarding resident care and facility practices.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to provide timely notification of changes in condition, inadequate assistance with activities of daily living such as bathing and incontinence care, insufficient nursing staff to meet resident needs, failure to prevent pressure ulcers, and failure to ensure residents did not receive unnecessary medications.

The survey was complaint-driven based on multiple complaint intakes. Substantiation status is not explicitly stated but deficiencies were found related to the complaints.

The inspection was a routine survey of Polaris Rehabilitation and Care Center to assess compliance with regulatory requirements related to resident care, dignity, safety, and staffing.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to notify family of significant changes, inadequate bathing and pressure ulcer care, insufficient incontinence care, inadequate staffing levels, and failure to prevent unnecessary medication use. Several residents experienced harm or potential harm due to these deficiencies.

The survey was conducted due to complaint intakes 2636066 and 2636607.

No deficiencies were identified pertaining to the complaint investigation based on the survey team's findings.

Complaint intakes 2636066 and 2636607 prompted the survey; no deficiencies were found related to the complaints.

The inspection was conducted as a complaint investigation prompted by complaints #2602955 and #2603036 regarding resident care and staffing issues.

The facility failed to provide routine bathing for multiple residents and did not maintain sufficient nursing staff to meet resident care needs. Staffing shortages led to delayed call light responses and inadequate personal care. The facility also failed to properly post total nursing staff hours per shift.

The investigation was initiated due to complaints about inadequate bathing, delayed call light responses, and insufficient staffing. Resident interviews and grievance reviews confirmed these issues. The complaint was substantiated by findings of missed baths and staffing shortages.

The inspection was conducted to assess compliance with regulatory requirements related to resident care, staffing, and facility operations during the annual survey of Polaris Rehabilitation and Care Center.

The facility failed to ensure routine bathing was provided to 5 of 10 sampled residents, and there were significant staffing shortages impacting resident care on two units. The facility also failed to post total nursing staff hours per shift as required. Multiple resident interviews, record reviews, and staff interviews confirmed inadequate bathing and insufficient nursing staff to meet resident needs.

A complaint survey was conducted from 2025-08-05 through 2025-08-07 prompted by multiple complaint intakes and incidents related to resident safety and medication errors.

The facility failed to protect a resident from physical abuse by another resident, resulting in injury and required intervention. Additionally, the facility failed to prevent a significant medication error involving a fentanyl patch, which caused actual harm and hospitalization of a resident.

The survey was complaint-driven based on complaint intakes #2570509, #1901387, #1901386, #1901385 and incidents #1901388, #1901380. The complaint investigation substantiated abuse allegations involving resident-to-resident physical abuse and medication errors causing harm.

The inspection was conducted based on complaints alleging physical abuse by a resident and significant medication errors affecting residents at Polaris Rehabilitation and Care Center.

The facility failed to protect a resident from physical abuse by another resident, resulting in mild injury and requiring intervention including separation and medical treatment. Additionally, the facility failed to prevent a significant medication error involving a fentanyl patch, which caused actual harm and hospitalization of a resident due to opioid overdose.

The complaint investigation involved allegations of physical abuse by resident #5 against resident #4, confirmed by witness and staff interviews, incident reports, and medical assessments. The investigation also included review of medication errors affecting resident #2, resulting in hospitalization for opioid overdose.

The inspection was conducted to investigate complaints related to the facility's failure to communicate changes in residents' healthcare appointments and to assess the infection prevention and control program during a COVID-19 outbreak.

The facility failed to ensure changes in healthcare appointments were communicated to residents or their representatives for 2 of 4 residents reviewed, and failed to maintain documentation of SARS-CoV-2 test results during a COVID-19 outbreak. Multiple staff interviews and record reviews revealed lack of documentation and communication regarding appointment changes and COVID-19 testing.

The complaint investigation revealed that the facility failed to communicate appointment changes to residents or their representatives and failed to document COVID-19 testing results during an outbreak. The investigation included interviews with residents' representatives, staff, and review of medical and appointment records.

The inspection was conducted to investigate complaints regarding the failure to provide ordered tracheostomy care for a resident with a tracheostomy at Polaris Rehabilitation and Care Center.

The facility failed to ensure tracheostomy care was performed as ordered for one resident, including missed dressing changes, cleaning, suctioning, and documentation omissions. Staff competency records were lacking, and resident refusals were noted but not consistently documented.

The complaint investigation found substantiated deficiencies related to failure to provide ordered tracheostomy care, documentation omissions, and lack of staff competency documentation.

The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.

The facility was found deficient in multiple areas including failure to develop baseline and comprehensive care plans addressing residents' immediate and current needs, inadequate documentation and communication regarding dialysis treatments, failure to ensure a safe environment free from accident hazards related to smoking, failure to post daily nurse staffing information timely, and failure to ensure residents received pneumococcal vaccinations according to CDC recommendations.

The inspection was conducted to assess compliance with regulatory requirements related to resident safety, food service, and staff practices at Polaris Rehabilitation and Care Center.

The facility failed to prevent an avoidable resident fall due to staff miscommunication and improper transfer technique, failed to ensure residents were offered meal choices according to their preferences, and failed to ensure staff wore beard restraints during food service. Corrective actions were implemented for the fall incident prior to the survey.

The inspection was conducted to evaluate compliance with resident rights, restraint use, psychotropic medication monitoring, and infection control practices at Polaris Rehabilitation and Care Center.

The facility failed to honor a resident's right to refuse treatment and improperly restrained a resident during medication administration. The facility also failed to ensure appropriate behavior monitoring and interventions for residents on psychotropic medications, and failed to implement proper infection control techniques during wound care.