Resident #83 at Polaris Extended Care told federal inspectors that on July 14, 2024, at 6:00 PM, he felt short of breath while sitting in his wheelchair and used his call light for assistance. Nobody came for three and a half hours, so he began yelling for help.
Licensed Nurse #6 finally arrived and placed oxygen on the resident. When Resident #83 asked when he would be transferred to bed, the nurse "got really out of control screaming," according to the resident's account to inspectors.
"[LN #6] got behind me and hit me like a hammer on top of my head. It hurt really bad," Resident #83 stated. When he asked why the nurse was hitting him, the nurse continued screaming and then left, abandoning him in his wheelchair.
Another resident, #32, heard the commotion and came to check. "I heard people fussing and raising hell. Yelling voices loud enough to disturb and upset me," Resident #32 told inspectors. By the time he arrived at Resident #83's room, the nurse had left. Resident #83 told him: "[LN #6] hit me on my head."
Resident #32 later expressed fear about speaking up. "I don't want [LN #6] to know I am talking because I am afraid [LN #6] may poison me."
The resident who was struck has quadriplegia and requires staff to perform 100% of transfer efforts using an overhead lift. His care plan notes he is weak and instructs staff to notify nurses when he is short of breath.
Supervisor Long Term Care Nurse #1 was notified of the incident at 6:50 PM and completed an initial report at 7:25 PM. But Licensed Nurse #6 remained on duty in the cottage until 7:30 PM, working for 40 minutes after supervisors knew about the abuse allegation.
The next day, July 15, Resident #83 had a headache and dizziness. His head remained tender to the touch. "I don't want to see [LN #6] again, I am afraid, like a killer they won't stop. [He/She] will do this again. I can't control [him/her], [LN #6] is very strong, powerful," the resident told inspectors.
Despite the facility's policy requiring immediate removal of alleged perpetrators during investigations, Licensed Nurse #6 was scheduled for and worked a full 12.5-hour shift on July 15 in a different cottage.
Supervisor #1 acknowledged knowing the facility policy but said shift change was occurring and the nurse was leaving soon anyway. The supervisor claimed the Director of Nursing planned to have the Operations Director intercept the nurse the next morning to prevent them from working.
The Quality Director later revealed a "miscommunication" - the Operations Director was on vacation July 15. She confirmed Licensed Nurse #6 should have been placed on administrative leave immediately upon receiving the abuse report.
In a separate incident, the facility failed to protect another resident from an aide who had thrown a nightshirt in the resident's face with enough force to strike their open eyes.
Resident #86 reported that Certified Nursing Assistant #2 became frustrated while helping clean up after an incontinence accident. When the resident requested a fresh nightshirt, the aide "retrieved a fresh nightshirt from Resident #86's dresser and threw it in Resident #86's face" with force, causing it to strike the resident's open eyes.
The facility investigated and concluded that "everyone was having a bad day." The corrective action plan stated the aide would be moved to another cottage with no interaction between the aide and Resident #86.
But weeks later, the aide returned to work in Resident #86's cottage due to staffing shortages. The resident tearfully told inspectors he felt so unsafe he didn't leave his room the entire day.
Beyond the abuse investigation failures, residents described a facility where basic dignity had eroded due to chronic understaffing.
Resident #39, who has quadriplegia and chronic bone infection, told inspectors: "I often miss showers due to there not being enough staff here." The resident was scheduled for showers twice weekly on Tuesdays and Fridays but frequently missed them. Records showed the resident received only one shower per week during multiple weeks in June and July.
Licensed Nurse #1 confirmed the resident doesn't always get showered due to needing two-person assistance "and sometimes there was a lack of staff at the facility." The nurse added: "[Resident #39] is particular, and sometimes there is no one here to give a shower. [He/she] does refuse a male caregiver."
The facility's resident rights paperwork promises residents can "receive services that meet your individual needs and preferences and choose healthcare, activities and schedules that are consistent with these."
When cooks called out sick, residents received meals in disposable styrofoam containers that felt "like eating take out," according to Resident #34. The resident said the food was often cold, but calling staff to reheat it was pointless because "it might be forgotten in the microwave, or the staff would take a long time to come get it and heat it up."
Cook #2 explained that when covering multiple cottages, there was no time to wash dishes for both locations. If another cottage lacked a cook, that cottage's meals took priority over his assigned cottage.
The facility's handbook promises "excellent care in a place that truly is a home" where "mealtime in the Cottage is a cherished time."
Resident #26 requested no male caregivers for changing and showering, stating it bothered both the resident and spouse. But a male aide told the resident: "If your husband doesn't know it will be ok." The resident replied: "But it bothers me."
Licensed Nurse #7 acknowledged the cultural preference but said: "I have talked to his/her [spouse] many times and explained we do not always have a [female] CNA."
The facility also failed to properly post survey results for residents to review. Digital displays showing survey locations were broken in three of eight cottages, with signs reading "Digital Display Down for Repairs Please see posting in the book." Staff didn't know which book the signs referenced.
During a resident council meeting, residents said they had never known state survey results existed or where to find them. One blind resident expressed concern about bedbound residents having no access to the information.
Multiple residents described feeling hopeless and helpless about staffing conditions. They expressed "apathy, humiliation, frustration, and feelings of helplessness about the current staffing situation and how it has affected their livelihood at the facility," according to inspectors.
Resident #83 still experiences headaches and dizziness from being struck. He remains afraid of the nurse who hit him, describing them as "very strong, powerful" and worrying they "will do this again."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Polaris Extended Care from 2024-07-19 including all violations, facility responses, and corrective action plans.