Polaris Extended Care

In the surveyor’s words

From the most serious findings on record at Polaris Extended Care, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Dec 29, 2021

  Based on observation, interview, and record review the facility administration failed to ensure effective and efficient use of resources to provide for resident safety and to ensure the highest practicable physical, mental, and psychosocial well-being of all residents, based on a census of 94. The facility administration failed to maintain the facility in substantial compliance with regulatory requirements which resulted in substandard quality of care in which residents experienced actual physical harm including development of Stage II, III, and IV pressure ulcers and psychosocial harm to residents affected by prolonged isolation and inadequate care to meet physical, social, and emotional needs due to staffing shortages and facility directed room-based care (RBC) (residents cannot leave… […]

• Immediate jeopardy, widespreadF837Dec 29, 2021

  Based on interview and record review the facility failed to maintain a Governing Body (GB) that ensured it was accountable for the Quality Assurance and Process Improvement (QAPI) program that: 1) consistently identified areas for performance improvement; 2) developed and implemented appropriate Performance Improvement Plans (PIPs) for identified deficiencies; 3) evaluated results; and 4) monitored and measured outcomes. This failed practice, to ensure accountability of QAPI oversight, resulted in: 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC) (residents cannot leave room… […]

• Immediate jeopardy, widespreadF865Dec 29, 2021

  Based on record review and interview the facility failed to maintain a Quality Assurance and Process Improvement (QAPI) committee that developed and implemented appropriate plans of action to correct quality deficiencies they identified or should have identified. Without sufficiently identifying or adequately addressing and communicating about areas of deficient practice, systematic correction could not be achieved and maintained throughout the facility. This failed practice, to achieve or maintain corrective action, resulted in: 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC)… […]

• Immediate jeopardy, widespreadF867Dec 29, 2021

  Based on interview and record review the facility failed to maintain a Quality Assurance and Process Improvement (QAPI) program that: 1) consistently identified areas for performance improvement; 2) developed and implemented appropriate Performance Improvement Plans (PIPs) for identified deficiencies; 3) evaluated results; and 4) monitored and measured outcomes. This failed practice, to achieve or maintain corrective action, resulted in 1) physical harm to residents who developed stage II, III, and IV pressure ulcers and 2) a potential for psychosocial harm to residents affected by isolation and inadequate care to meet physical, social, and emotional needs, due to staffing shortages, during room-based care (RBC) (residents cannot leave room and the resident receives care, treatment, and… […]

• Immediate jeopardy, patternF686Dec 29, 2021

  Based on interview, record review, and observation, the facility failed to ensure that residents received the necessary care and services to prevent the development of new pressure ulcers in 4 residents (#s 7, 12, 42, and 43), out of 28 sampled residents. Failure to accurately and consistently assess and monitor for wounds, provide appropriate interventions, and revise interventions on a timely basis resulted in physical harm to residents who developed deep tissue injuries and stage II, III, and IV pressure ulcers, with 2 resident developing medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . This situation was brought to the attention of the facility's administration on 12/17/21 at 4:30 PM, at which time the facility was notified of identified physical harm and immediate jeopardy. […]