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Polaris Transitional Care

910 Compassion Circle, Anchorage, AK 99504 · For profit - Limited Liability company · 50 certified beds · (907) 212-9200 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 2025Resident-funds citation (F0568)2 immediate-jeopardy citations$109,382 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0568)
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $109,382 in federal fines (most recent 2023-09-01)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (66%) runs well above the national median (45%)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6307 Debarr Rd Ste C · (907) 333-7425 · Call to confirm hours
Pharmacy
5600 Debarr Rd Ste 8 · (907) 274-6001 · Call to confirm hours
Grocery
Carrs0.4 mi
5600 Debarr Rd · (907) 339-0900 · Call to confirm hours
Park
801 Pine St · (907) 343-4355 · Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 5 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 4 to 2 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased18.2%16.7%15.4%worse
Long-stay residents who lose too much weight2.7%5.3%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.4%0.9%better
Long-stay residents with a urinary tract infection1.2%2.5%2.0%better
Long-stay residents with depressive symptoms12.9%6.5%6.5%worse
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury2.4%3.2%3.3%better
Long-stay residents on antianxiety or hypnotic medication24.0%14.7%18.9%worse
Long-stay residents given the seasonal flu vaccine82.4%96.0%95.3%worse
Long-stay residents with pressure ulcers8.9%6.9%4.7%worse
Long-stay residents with worsening bladder/bowel control29.4%20.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table18.2%18.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%0.5%1.4%better than state — see note marked double-dagger below the table
Short-stay residents given the seasonal flu vaccine73.0%85.5%79.4%typical
Short-stay residents rehospitalized after admission12.5%15.0%22.6%better
Short-stay residents with an outpatient ER visit14.6%11.0%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.461.001.67better
Long-stay outpatient ER visits per 1,000 resident days1.561.361.80better

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.

65.0% 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 237 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.0%U.S. median 51.5%
Got home and stayed home
7.8%U.S. median 10.7%
Went back to hospital
60.9%U.S. median 56.6%
Met the expected recovery
1.06U.S. median 0.31
Therapy hours / resident / day
0.49hours / resident / day
Physical therapy
0.29hours / resident / day
Occupational therapy
0.28hours / resident / day
Speech therapy

Met the expected recovery: 60.9% 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 138 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 1.06 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.0%CMS range 56.3–71.151.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF7.8%CMS range 5.5–11.110.7%Oct 2022–Sep 2024no 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 discharge60.9%56.6%Oct 2024–Sep 2025CMS 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 discharge65.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.9%50.0%Oct 2024–Sep 2025CMS 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 identified99.4%98.7%Oct 2024–Sep 2025CMS 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 setting97.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS 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 stay1.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.4%CMS range 3.1–8.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.201.02Oct 2022–Sep 2024CMS 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

2.30
RN hours/ resident / day
0.36
LPN hours/ resident / day
2.31
Aide hours/ resident / day
4.97
Total nurse hours/ resident / day
1.76
RN hoursweekends
66.0%
Total nursing turnover
53.3%
RN turnover

How full it usually is: this home is certified for 50 beds and averages 46.3 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. 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 4.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.30 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below 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 4.20 hrs/resident/day on weekends vs 5.29 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 2.51 to 1.76 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 66% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

9
deficiencies at the latest standard inspection (2025-11-21)
6
at the previous standard inspection (2024-11-01)

Deficiencies are more than at the previous inspection — worsening. 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.

ABCDEFGHIJKL

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.

22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · J2023-10-17 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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 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). 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, which constituted an immediate jeopardy at CFR 483.45(a) Pharmacy Services. This situation was brought to the attention of the facility's administration on [DATE] at 4:45…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-10-17 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 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. This situation was brought to the attention of the facility's administration on [DATE] at 4:45 PM, at which time the facility was notified of identified immediate jeopardy. The facility submitted an acceptable…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    Based 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.These failed practices had the potential to result in clinically significant complications, including bleeding, infection, or vascular access compromise, and did not meet accepted standards of practice for post-dialysis care Resident #11Record review on 3/25-26/26 revealed Resident #11 was admitted to the facility with diagnoses that included dependence on renal dialysis (medical treatment that performs the function of the kidneys when they are no longer able to adequately filter waste products and excess fluid…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-11-21 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 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: - an undated and unlabeled white Styrofoam takeout container containing leftover food (rice with visible yellow residue/sauce). The container had no resident name, no date of preparation, and no discard date. The container lid was partially open, exposing the food to the…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-21 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide 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

    Based 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. This deficient practice resulted in the potential for compromised circulation, pain, and lymphedema Resident #12Record review from 11/17-21/25 revealed Resident #12 was admitted to the facility with diagnoses that included fracture of the right acetabulum (a break in the socket of the right hip joint where the head of the femur sits) and dependence on renal dialysis (medical treatment that filters waste, toxins, and excess fluid from the blood when the kidneys can no longer perform these functions effectively).Review of the physician's orders dated 10/14/25, revealed: AV SHUNT [surgical vascular access] OLD…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0552 — isolated
    Ensure 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 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. The state agency verified that the facility took appropriate corrective actions for noncompliance found at F552 with a correction date of 8/20/25 Record review on 11/17-21/25 revealed Resident #47 was admitted to the facility on [DATE]…

    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.

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · D2025-11-21 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. This failed practice had the potential to affect the resident's quality of life and sense of well-being Resident #18Record review on 11/17-21/25 revealed Resident #18 was admitted to the facility with diagnoses that included pulmonary fibrosis (lung-scarring disease), end-stage renal disease (kidneys permanently failed - dialyses required), dependence on renal dialysis (Kidney failure requiring dialysis), immunodeficiency associated with other specified major defects (severe immune deficiency), muscle weakness, difficulty walking and need for assistance with personal care.During an interview on 11/18/25 at 9:26 AM, Resident #18 stated he/she would like to take a shower on Tuesdays or Wednesdays and/or…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 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. This failure placed the resident at risk for receiving care or interventions inconsistent with the resident's expressed wishes and compromised the resident's right to request, refuse, and/or discontinue treatment Record review on 11/17-21/25 revealed Resident #47 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (injury to the brain caused by a complete lack of oxygen, leading to the death of brain cells and potentially severe, long-lasting neurological impairments), bipolar disorder (mental health condition characterized by alternating periods…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. This failed practice placed Resident #69 at risk for ongoing neglect, unaddressed care concerns, and further exposure to mistreatment and/or mental anguish Record review on 11/17-21/25, revealed Resident #69 was admitted to the facility with diagnoses that included unspecified abnormalities of gait and mobility (gait and mobility impairment), wedge compression fracture of lumbar vertebra (vertebral collapse fracture), COPD (chronic obstructive pulmonary disease) and osteoporosis (bone-thinning disease). Resident #69 was also legally blind and had documented past medical history of frequent falls.Record review of the facility's Resident Concern & Feedback [Grievance] Form, dated 6/15/25, revealed…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 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. Record review on 11/17-21/25, revealed Resident #41 was admitted to the facility with diagnoses that included aftercare following joint replacement surgery and dislocation of the internal right hip prosthesis (artificial components of a right hip replacement move out of their normal position, causing loss of joint alignment, pain, 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard 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 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.During an interview on 11/18/25 at 11:21 AM, the Business Office Manager (BOM) stated the computer should not have been left open and accessible. The BOM located an LN (unidentified) and requested them to lock the computer.An observation on 11/19/25 at…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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.These failed practices had the potential for ineffective Infection Control Program and increased the potential risk for development and transmission of disease and/or infection in all residents (based on a census of 43) and staff. Review of the facility document titled Infection Control Tracking Spreadsheet, (undated, modified 11/20/25), revealed the following…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · F2025-07-29 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings:Record review on 7/29/25 of the facility's Polaris Transitional Care Facility Assessment, dated 2025, revealed: 1. Facility Capacity and Census: - Capacity: Our facility is licensed to provide care for 96 residents. The actual maximum number of residents allowable may be less at times to accommodate for safety resident care needs. Review of the facility's State of Alaska license, effective 3/1/25 through 3/1/26, revealed it was licensed for 50 beds. The facility assessment was not accurate. During an interview on 7/29/25 at 2:14 PM, the Director of Community Liaison stated the bed capacity for PTC was 50 beds. 2. Facility Resources Needed: Day to Day and During Emergencies: - Facility Description: Our facility is a 116,460 square foot nursing facility consisting of 8 cottages, 8…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY .Based 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. Findings:During an interview on 7/28/25 at 4:06 PM, the Office of Public Advocacy (OPA) Guardian for Resident #1 stated she had been his/her Guardian since last year and she had visited Resident #1 at his/her prior facility (PEC - Polaris Extended Care) before he/she moved to Polaris Transitional Care (PTC) on 6/3/25. The OPA Guardian stated that when Resident #1 was at PEC, his/her room was beautifully set up with family pictures on the wall and personal belongings throughout his/her room. The OPA Guardian further stated she visited Resident #1 at PTC on 7/25/25 and his/her room was night and day compared to when he/she was at PEC. The OPA Guardian stated Resident #1 had been at PTC for over a…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-11-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    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 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. Findings: Main Kitchen: An observation, during the initial main kitchen tour, on 10/28/24 at 8:35 AM, revealed: 1) Dry Storage/Pantry area: - Two 7lbs cans of expired Monarch Pork & Beans cans labeled with Rec [Received], dated 8/23/23 and UB [Used By], dated 8/23/24; 2) Walk-In Cooler: - Six 11-ounce container of expired Premier Protein Chocolate Shakes with a manufacture expiration date of 10/2/24; - One plastic bag of green and red whole apples without Rec or UB dates labeled; - One large clear glass jar 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-01 · tag F0552 — isolated
    Ensure 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

    Based 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. Findings: Resident #8 Record review on 10/28/24-11/1/24 revealed Resident #8 was admitted to the facility with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety, agitation, and insomnia. Hydroxyzine (brand name: Vistaril) classified as an antihistamine medication: Review of Psychotropic R[isks] & B[enefits], dated 8/7/24, revealed: Psychotherapeutic Drug Started: 8/7/24 . Hydroxyzine, Diagnosis of resident, Anxiety,…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0568 — isolated
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings: Record review on 10/28/24-11/1/24 revealed Resident #8 was admitted to the facility with diagnoses that included schizophrenia (serious mental illness that affects how a person thinks, feels and behaves). During an interview on 10/29/24 at 11:59 AM, Resident #8's Resident Representative (RR) #1stated that he/she had not received any bank statements from the facility. During an interview on 10/31/24 at 12:20 PM, LN #5 stated Resident #8 had a POA [RR #1] that was declared for financial obligations. LN #5 stated the resident's face sheet should identify who the financial POA was and not the resident. LN #5 stated that the financial POA should be receiving the resident's…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings: During an interview on 10/28/24 at 12:00 PM, Resident #18 stated, I have been upset with cares . I was put into a sling [lift to transport resident to bathroom or transfer to a wheelchair from bed or chair] and given drugs . I was violated. The resident stated recalling waking up on a ceiling lift sling in February 2024 with a pain in the vaginal area and realized he/she was being catheterized without his/her permission or knowledge. Licensed Nurse (LN) #3 was the nurse. Resident #18 stated further, I was not hurt in the catheterization incident. Resident #18 stated his/her complaints were not always investigated and resolved. Review of the Resident Concern and Feedback Communication, dated 4/10/24, revealed the facility failed to show a grievance was fully investigated and the facility failed to document the resident was informed…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings: Record review on 10/28/24 -11/1/24, revealed Resident #3 was admitted to the facility with diagnoses that included fracture of the femur (thigh bone), facial weakness and dysphagia (difficulty swallowing). During an interview on 10/28/24 at 2:30 PM, Resident #3 stated he/she lost his/her dentures in his/her room. Resident #3 stated he/she reported it to the staff. The facility staff including the Director of Nursing (DON) searched for the missing dentures but were not found. Review of the ST [Speech Therapy] NOTES (all), dated 9/17/24, revealed: . [Resident #3] reporting lost dentures Friday afternoon, increased difficulty [and] effectively chewing foods. Nurse supervisor[unknown] downgrading [Resident] to soft and bite size diet textures. Review of the Nutrition Notes, dated 10/9/24,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-01 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    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 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. Findings: An observation, during Resident #17's wound care, on 10/31/24 at 2:45 PM, revealed Licensed Nurse (LN) #2 and LN #1 placed wound care dressing supplies onto a bedside table with a clean field draped over the table. LN #2 placed an opened tube of Triamcinolone Acetonide Ointment with a manufacturer's expiration date of 1/2027 onto this field. This tube had a black handwritten ink letter, B and no other labeled identification of the initials of who opened the tube or date of when the tube had been opened. LN #2 also placed two opened bottles of Vashe wound cleansing solution with the same manufacturer's expiration date of 8/31/25 onto this clean field. These bottles of Vashe wound cleansing solution had no label of when the bottles…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based 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. Findings: Record review from 8/28/23 to 9/1/23 revealed Resident #31 was admitted to the facility with diagnoses that included cerebral infarction (stroke) affecting the resident's right dominant side. During an interview on 8/28/23 at 3:19 PM, Resident # 31 stated he/she had not received a shower on two Sundays, which were his/her shower days. Record review on 8/30/23 at 10:56 AM, of the CNA (Certified Nursing Assistant) shower documentation revealed Resident #31 received: - 8 showers during the month of June, with one shower being done on Sunday (6/11/23), and 1 missed shower the 3rd week of June. No refusals were documented. - 6 showers during the month of July, with one shower…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-01 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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. Findings: Resident #3 Record review on 8/28/23- 9/1/23 revealed Resident #3 was admitted to the facility with a primary diagnosis of cerebral infarction (stroke). Review on 9/1/23 at 2:00 PM, of Resident #3's vaccination status, revealed the resident's Prevnar 20 (pneumococcal conjugate vaccine that protects against 20 strains of pneumococcus) status was unknown during admission. Prevnar 20 and Covid-19 vaccine was offered but the Resident declined. Resident #249 Record review on 8/28/23- 9/1/23 revealed Resident #249 was admitted to the facility with a primary diagnosis of orthopedic aftercare following surgical amputation. Review on 9/1/23 at 2:00 PM, of Resident #249 vaccination status, revealed the resident's Prevnar 13 (pneumococcal conjugate vaccine that protects…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$109,382 in federal fines across 1 penalty.

  • $109,382 — penalty dated 2023-09-01

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 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 →

RatingThis homeChain avg
Overall 3 of 53.2-0.2 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 5 of 54.4+0.6 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; 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 / managerTypeRoleSince
TIEVA, DANIELIndividualMANAGING CONTROL - GOVERNING BODY; ADP OF THE SNFsince 03/01/2025
WILLITS, ADAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 09/12/2024
BURNAM, SOONIndividualCORPORATE OFFICERsince 09/12/2024
CULLIFER, JAREDIndividualCORPORATE OFFICERsince 09/12/2024
HANCOX, NEILIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/11/2025

CMS files one row per role, so the 8 rows in the source record cover these 5 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.

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.

$15.2M
Net patient revenuemost recent cost report
-25.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 40%Medicare 46%Other / private 14%

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

$1,225per resident / day
operating cost
$37,245per month
≈ monthly operating cost
$980per day
avg. revenue, all payers

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 AK

Paying with Medicaid

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 Alaska Medicaid page.

Typical monthly cost in Alaska
$27,831/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)*
$9,882/mo
Assisted living

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. The starred figure is the national median (no state figure published).

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 025018. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, 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.

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