The resident, identified as R46 in inspection records, had been prescribed insulin since November 2024 at Polaris Healthcare and Rehabilitation Center. Federal inspectors found no evidence the facility had created a care plan for her diabetes until January 16, 2025 — the same day administrators were confronted about the missing documentation.
The Director of Nursing confirmed the finding and produced a care plan dated that day, according to the inspection report completed January 28.
R46 was one of eight residents found lacking proper care plans during the federal review. The violations affected nearly a quarter of the 37 residents whose records were examined.
Another resident, R57, had been prescribed anti-anxiety and anti-depressant medications since August 2024. Quarterly assessments in September and December documented the ongoing medication use. Yet inspectors found no care plan addressing the resident's anxiety, depression, or psychiatric medications until administrators created one during the inspection.
The most complex case involved R91, a ventilator-dependent resident with a tracheostomy who was admitted in November 2024. Despite the life-sustaining respiratory equipment, the facility failed to create any care plan addressing her breathing needs.
"R91 did not have a care plan for her respiratory status," the Director of Nursing confirmed to inspectors.
R89's situation highlighted how inadequate planning could create safety risks. The resident was admitted in May 2024 following a stroke that left her paraplegic and completely dependent on staff for all care. Her fall prevention plan instructed staff to keep her call bell within reach and apply non-slip footwear.
The plan made no sense for someone who couldn't walk or use a call bell.
"R89's care plan was not appropriate for R89's status," the Director of Nursing acknowledged when confronted.
Three residents with dementia diagnoses lacked care plans addressing their cognitive impairment. R3 had been living at the facility since September 2023 with severe cognitive impairment from non-Alzheimer's dementia. R27 was admitted in October 2024 with vascular dementia. R4, admitted in December 2024, had no care plan for occasional bowel incontinence documented in her assessment.
The inspection revealed additional communication breakdowns that left families uninformed about their relatives' medical crises.
R64's family member told inspectors she learned about her mother's pneumonia diagnosis only by accident. The resident had developed symptoms on January 10, including lethargy, elevated heart rate, and confusion. Staff ordered blood work, IV fluids, and eventually a chest X-ray that revealed pneumonia.
The family member received one phone call at 10 PM on January 10 about dehydration and IV orders. She heard nothing about the subsequent lab results showing elevated white blood cells, the chest X-ray, pneumonia diagnosis, or antibiotic treatment.
"FM3 stated she had not received an update on R46's condition since 10:00 PM on 1/10/25," inspectors documented. The resident's condition had changed significantly, including a switch to thickened liquids, but the family remained unaware.
Nursing staff confirmed the communication failures. Progress notes lacked evidence that anyone notified the family about changes to the treatment plan or informed the attending physician about abnormal lab results.
The facility also struggled with basic customer service. When R64's family filed a grievance about missing pajama pants that staff had thrown away, administrators took a week to mark it resolved. The resident had been upset about the incident and told her family member the staff person "was not nice to her."
The Director of Nursing confirmed he provided education to the staff member about customer service but made no offer to replace the clothing or provide reimbursement. Only when inspectors interviewed administrators during the survey did the nursing home administrator call the family to request a receipt for reimbursement.
One resident's grooming needs went unaddressed for days. R63, who had dementia and severe cognitive impairment, was observed with approximately half an inch of gray and black facial hair on her chin during multiple inspection visits between January 13 and 17.
Staff explained that R63 was "combative with care" and wouldn't allow anyone near her face for shaving. But the facility had created no care plan to address her refusal of personal grooming or bathing assistance.
"R63 did not have a care plan for refusals of shaving and bathing," a licensed practical nurse confirmed to inspectors.
The inspection findings were reviewed with the nursing home administrator, Director of Nursing, and corporate clinical support staff on January 24. The facility was cited for failing to develop comprehensive care plans, properly communicate with families and physicians, and resolve resident grievances promptly.
For R64's family, the communication breakdown meant days of worry about symptoms they didn't understand, while critical medical decisions were made without their knowledge. For residents like R91, the missing respiratory care plan represented a fundamental failure to address life-sustaining needs that required constant monitoring and specialized intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Polaris Healthcare and Rehabilitation Center from 2025-01-28 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Polaris Healthcare and Rehabilitation Center
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