Polaris Extended Care

F-F0400. Interview for Daily Preferences: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important .

Resident #86 further stated because nurses must go to other cottages now to help other residents, he/she has had to wait hours for as needed medications for shortness of breath. This had happened so often that he/she had resorted to calling the nurse supervisors for help when nurses weren't in the cottage.

Resident #92

During an observation and interview on 7/15/24 at 11:49 AM, Resident #92 was in bed and had just finished his/her breakfast of pancakes and peanut butter. The resident said that he/she had waited to be served breakfast since 7:00 AM and had received it about an hour ago. He/she was going to skip lunch because it was so late in the day. The resident pressed his/her call light because he/she wanted nicotine gum. The surveyor left the resident's room.

Continued observation on 7/15/24 at 12:38 PM, 46 min later, this surveyor walked over to the call light monitoring system in the common area and saw that Resident #92's call light had been on for 46 minutes. Further observation revealed Resident #92 called out from his/her room to [NAME] #2 in the kitchen. The cook was busy and stated that someone would be in shortly. This surveyor asked Resident #92 if anyone had been in to help, the resident stated no one had come.

During an interview while continuing the observation on 7/15/24 at 12:39 PM, CNA #11 stated he/she was

the only CNA in the cottage. CNA #11 then went into Resident #92's room and the call light was turned off. Resident #92 waited approximately 51 minutes for staff. At 1:17 PM Resident #92 was observed coming out of his/her room in his/her wheelchair. When asked if he/she received his/her nicotine gum, the resident stated, No and that he/she was headed out to go smoke.

Resident Council Meeting Minute Review

Review of Resident Council meeting minutes, dated 1/17/24, revealed: . Resident shared concerns of the night CNA's leaving the cottage for an extended amount of time and not available to help with their own resident[s]. Resident believes it is a safety concern. Resident shared concerns that his call light is not being answered at nights due to caregivers not being available in the cottages. He feels this is escalating and not being addressed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Review of Resident Council meeting minutes, dated 4/17/24, revealed: . [DON] shared with group that staffing situation for C.N.A's and the ability to fill the 17 open positions which led to the leadership team to be Level of Harm - Actual harm creative and revamp the staffing structure . Staffing will be as follows: 1 C.N.A. per cottage during the day with a 4-person support team responsible for showers and weights, meal assist, transferring/transporting to Residents Affected - Many activities etc. and on call as needed when C.N.A's need assistance in the cottages . Resident asked for clarification on toileting assistance with 1 C.N.A. in each cottage. Residents concern is waiting for assistance at night to get help to the toilet and will that also be a problem during the day? [DON] acknowledged and assured resident the scheduled C.N.A. in the cottage will be available to assist and if need of further support,

they are to contact the support team. If the new staffing structure does not work [DON] will revisit the process .

Review of Resident Council meeting minutes, dated 6/20/24, revealed: [DON] shared with the group the new C.N.A. process that started this week. Process is structured with 1 C.N.A. in the cottage and a 4 person C.N. A. support team each supporting 2 cottages . [Home keepers] and Housekeepers are currently in orientation for more extensive training to assist in the cottages . As this is the first week of the new process we are hoping to see a positive outcome . We will be evaluating the process by asking for feedback from our residents . Residents' concerns as follows: Will we have someone on the weekends helping us get out of bed and help with getting ready for the day including church services on Sundays? Per [Administrator] this concern was part of the reason we created the new process . Yes there will be more caregivers available to assist with getting out of bed. What happened if our C.N.A. calls out? Per [DON] if your C.N.A. calls our one of the support team caregivers will jump in while we start calling for someone to come in. Resident shared

she has not been getting up daily as she should and having to wait to be put back to bed causing her pain on

the weekend. [DON] acknowledged residents' complaint and explained that the weekend was very challenged with caregivers calling out and staffing being extremely short, but nursing leadership did step in and assisted as needed . [Administrator] shared with group the new process which went live on Tuesday. To reiterate the support team of 4 C.N.A.s will be doing the showers and vitals and as needed assists. Any concerns please reach out to [DON] and/or [RN Manager] .

Direct Care Staff Interviews

During an interview on 7/8/24 at 9:27 AM, CNA #10 stated the Aniak cottage did not have a home keeper (cook) that day for the cottage. When the cooks were short staffed, the meals for the cottage were prepared

in another cottage, placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number, and brought over. The CNA and LN would serve the meals.

During an interview on 7/8/24 at 1:20 PM, LN #3 stated the lack of staff was a problem. Whenever a CNA was missing, that was a problem. If the cottage's cook was not working that day, the food came from a different cottage. LN #3 stated the housekeepers are often short staffed too.

During an interview on 7/9/24 at 9:07 AM, [NAME] #2 stated that the Aniak cottage did not have a cook for

the last three days (7/6-8/24), and other cooks in the other cottages would rotate preparing meals for the day. [NAME] #2 stated that meals were served in the disposable Styrofoam clamshell food containers because when a cook was covering another cottage, there was no time to wash dishes for both cottages and complete other duties. If another cottage did not have a cook available for the day, [NAME] #2 would prepare meals for the other cottage first before working on the meals for his/her assigned cottage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 7/10/24 at 4:39 PM, the Dietary Manager stated serving meals from disposable Styrofoam clamshell food containers was not ideal and needed to ask dietary why they were delivering food Level of Harm - Actual harm like that. She stated that it did not happen very often and did not know why the food could not be plated.

Residents Affected - Many During an interview on 7/15/24 at 12:39 PM, CNA #11 stated there were no limits on the frequency a resident can get up out of bed or have a shower but depended on the availability of staff. Most of the time the staff were busy, and it was much harder to give showers outside of the resident's schedule.

During an interview on 7/16/24 at 4:35 PM, LN #8 stated staff shortages had affected the ability to spend time with the residents. LN #8 stated it was a struggle to complete turns every 2 hours and showers. When properly staffed it used to be enjoyable and staff could spend time with residents to put on lotion, however staff are now rushed due to the increased workload that resulted in the staff being less available. LN #8 further stated quality time with residents wasn't possible anymore.

During an interview on 7/17/24 at 3:28 PM, CNA #11 stated the 4 person CNA support teams doesn't work and cottage CNAs end up doing everything on their own. CNA #11 further stated nurses would help, when

they are available, but it wasn't easy for the nurses because they now had to cover other cottages.

Administration

During an interview on 7/17/24 at 8:17 AM, when asked if the concerns with low staffing had impacted the resident's care, the Medical Director stated residents did talk to her about how staff needed help. The Medical Director further stated low staffing was affecting the residents with higher acuity, who required heavier assistance in cares, more than the residents who were more independent.

When asked if she was involved with any leadership meetings that would discuss staffing levels and resident care, the Medical Director stated she was only at the facility every other week and when she was here was only at the facility for three days that week. The Medical Director further stated staffing was not something

she would be involved with and didn't think it was her lane to get involved in, If turning residents isn't getting completed, I would say we need to find avenues to get it done.

During an interview on 7/17/24, the Administrator stated she had the overall responsibility of the campus, and that she set the expectation and goals. When asked what kind of involvement in leadership oversight the Medical Director should have, the Administrator stated the Medical Director was supposed to be involved in quality and infection control, but that she had just started the position in May 2024 and was still learning the role.

When asked how many open nursing positions the facility had, the Administrator stated there were currently 10 CNA positions and 5 nursing positions posted, however there were more that needed to be filled.

When asked if the number of staff currently working, based on the bed capacity of 96, was able to meet the needs of the resident acuity levels, the Administrator stated she felt they were able to meet the needs, but not at the standard we would want to meet them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 When asked if they facility had considered lowering the census numbers, to help ease the staffing strain and better meet the resident's needs, the Administrator stated they would consider lowering the census if the Level of Harm - Actual harm facility could not meet the staffing crisis level for 4 consecutive da [TRUNCATED]

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis. Level of Harm - Minimal harm or potential for actual harm 40259

Residents Affected - Many Based on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, from 6/21/24 to 7/15/24 there was no full-time DON for the facility. This failed practice, of not having a full-time DON to provide oversight of nursing staff, including scheduling, responsibilities, and support, placed all residents (based on a census of 93) at substantial risk for subquality of care.

Findings:

During an interview on 7/10/24 at 3:26 PM, the Administrator stated the DON's last full-time day was 6/21/24 and went to a schedule of coming to the facility Monday through Friday, 4:00 AM to 6:00 AM and then coming back in the afternoon if needed. Also, the DON would work Saturday and Sunday 6:00 AM to 12:00 PM or 2:00 PM depending on need. The Administrator stated a new DON was hired and his/her start date was 7/29/24.

When asked for a timesheet accounting of the exact hours the DON worked weekly, from 6/21/24 to present, through the kronos system (time keeping system that tracked working hours of an employee) of the facility,

the Administrator stated this could not be given as the DON's position was salary-based pay and the DON did not clock in and out as an hourly-based pay employee would.

During an interview on 7/11/24 at 2:26 PM, when asked who was designated the DON of the facility when

she was not physically present during business hours, the DON stated she was the only DON and could be contacted through teams messaging and phone calls anytime.

During an interview on 7/16/24 at 10:00 AM, the Administrator stated the DON's last day of employment was 7/15/24 and the Quality Director was designated the interim DON until the newly hired DON could take over

the position.

The Quality Director worked full-time at the facility, Monday through Friday.

Review of the facility's job description Director Long Term Care RN [Registered Nurse], revised 9/30/19, revealed: . The Director of Nursing is responsible for the administrative direction and clinical leadership of resident care areas and clinical support. Is responsible for the implementation of clinical services and programs that contribute to safe, effective, and efficient resident-centered care and meet all state and federal Long Term Care Regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40259

Residents Affected - Few Based on record review and interview, the facility failed to accurately maintain, dispense, and have accountability of controlled drugs for 1 unsampled resident (#54) who received dialysis, out of 6 dialysis residents reviewed. Specifically, the facility sent the controlled drug oxycodone (an opioid pain medication) with the resident when he/she went to dialysis, which inhibited the facility's control and accountability for this medication. This failed practice placed the resident at risk for not receiving this medication and increased the risk of possible loss or diversion of the medication.

Findings:

Review of Resident #54's most recent MDS assessment, a quarterly assessment dated [DATE REDACTED], revealed active diagnoses that included end stage renal disease, hypotension of hemodialysis (low blood pressure

during dialysis), chronic pain syndrome, and dementia.

Resident #54 had a physician's order for dialysis, dated 5/29/24. Resident #54 was to be transported to the dialysis center every Tuesday, Thursday, and Saturday and returned to the facility after.

Resident #54 had a dialysis communication binder that accompanied the resident at every visit for communication between the facility and the dialysis center.

Review of Resident #54's dialysis communication binder revealed a handwritten note from the dialysis center, dated 4/13/24, which read, Please do not send controlled substances to dialysis. We do not administer them. We cannot be responsible for administration of pain medication that is a controlled substance. We can administer Tylenol that we have here in the clinic .

Further review of Resident #54's dialysis communication binder revealed:

- A provider's order, dated 3/18/24, that read, . oxycodone 2.5mg [milligrams] PO [by mouth] PRN [as needed] pain. Please send 1 dose to dialysis [with] resident included chain of custody letter .; and

- Two narcotic count sheets, dated 3/30/24 through 4/13/24, which revealed:

1) One oxycodone 2.5mg tablet was documented as being sent to dialysis on 3/30/24. It was documented as not given on the count sheet, however, was not documented as accounted for and returned, when the resident returned to the facility (this section of the form was left blank). No nursing signatures or initials were

on the narcotic count sheet for this date.

Further review of Resident #54's binder Dialysis Communication sheet, dated 3/30/24, revealed that one oxycodone 2.5mg tablet was sent with the resident to dialysis. Further review revealed a handwritten message from the dialysis center: [no] oxy [oxycodone] IR [immediate release] given [at] the dialysis center .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 2) One oxycodone 2.5mg tablet was documented as being sent to dialysis on 4/4/24. It was not documented as given (this section of the form was left blank), and not documented as accounted for and returned, when Level of Harm - Minimal harm or resident returned to the facility (this section of the form was left blank). No nursing signatures or initials were potential for actual harm on the narcotic count sheet for this date.

Residents Affected - Few Further review of Resident #54's binder Dialysis Communication sheet, dated 4/4/24, revealed that one oxycodone 2.5mg tablet was sent with the resident to dialysis. Further review revealed no documentation that the oxycodone was, or was not, administered at the dialysis center.

3) It was documented on the narcotic count sheet that one oxycodone 2.5mg was documented as sent to dialysis on 4/1/24 at 7:00 PM, not given, and returned to the facility. There was no documentation in Resident #54's binder that he/she attended dialysis on 4/1/24. Licensed Nurse (LN) #11 was the only initials

on the control count sheet for this date; and

4) It was documented that oxycodone 2.5mg tablets were also transported to the dialysis center on 4/6/24 (documented as given), 4/9/24 (documented as given), 4/11/24 (documented as not given, and returned), and 4/13/24 (documented as not given and returned).

During an interview on 7/18/24 at 11:30 AM, the Quality Director stated no controlled substances should be allowed to go with residents to dialysis.

Review of the facility's policy Medication for Use Outside of the Facility, last revised 7/2024, revealed it only provided guidance for a limited supply of medication with them [the resident] while on a prescriber approved absence from the facility . The dispensing pharmacy prepares an adequate supply of prescription medication for residents who leave the facility during short periods of time, or are en route to another destination . There was no guidance on medications taken with residents to appointments, to include dialysis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 50031 Residents Affected - Few Based on observation and interview, the facility failed to: 1) discard expired medical supplies in the Nenana cottage; and 2) remove and replace expired medication for 1 resident (#93), out of 12 residents reviewed for medication. These failed practices: 1) placed the residents of the Nenana cottage (based on a census of 11) at risk of receiving expired medical supplies and experiencing potential adverse reactions; and 2) placed resident #93 at risk for not having therapeutic emergent medication during a medical emergency.

Findings:

Nenana Cottage

An observation, during the Nenana cottage tour, on 7/12/24 at 8:20 AM, revealed:

1) Medication supply storage room:

- 1- BD Secondary Set (vented/nonvented), MS3500-15, intravenous (IV) tubing secondary set; manufacture expiration date was 4/21/24.

- 3- BD MaxGuard Extension Set (microbore), ME2020, IV tubing; manufacture expiration date was 12/21/23.

- 2- BD MaxGuard Extension Set (microbore), ME2020, IV tubing; manufacture expiration date was 12/20/23.

- 1- BD MaxGuard Extension Set (microbore), ME2020, IV tubing; manufacture expiration date was 7/12/23.

- 1- Medline Suction Swab tray, package opened.

- 104- Medline Eanser Denture Tablet EFFER, 250709, not in manufacture box, individually package, no expiration date identified on packaging.

2) Nurse office:

- 1- 3M Tegaderm dressing, Antimicrobial Dressing with 2% CHG, packaging found opened.

- 2- Medline PSJH IV Start Kit, DYNDV2337A, packaging found opened, manufacture expiration date was 9/30/24.

- 2- BD SafetyGlide Needle, 23G x 1 1/2, 304387, packaging found opened, manufacture expiration date was 12/31/27.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 - 1- 10-millimeter (ml) syringe, found without packaging.

Level of Harm - Minimal harm or - 4- BD Vacutainer, Buffered Sodium Citrate 3.2 %, Blood Collection Tubes, 3257667, manufacture potential for actual harm expiration date was 6/30/24.

Residents Affected - Few - 1- Preoperative skin preparation, 12101451, manufacture expiration date was 12/23.

- 1- BD MaxGuard Extension Set (microbore), ME2020, IV tubing; manufacture expiration date was 7/1/24.

- 2- BD Insyte Autoguard, IV Catheter, 381412, 24 ga x 0.75-inch, manufacture expiration date was 6/30/24.

- 1- BD Insyte Autoguard, IV Catheter, 381423, 22 ga x 1.00-inch, manufacture expiration date was 6/30/24.

- 2- BD Instyte Autoguard, IV Catheter, 381444, 18 ga x 1.16-inch, manufacture expiration date was 5/31/24.

During an interview on 7/12/24 at 9:10 AM, Licensed Nurse (LN) #2 informed of medical supplies found

during observation of medical supply storage room and nursing office. LN #2 stated the facility usually finds expired products when stocking, not sure how this happens when they are supposed to be stocked newest in back. LN #2 took expired medical supplies.

Resident #93

An observation on 7/16/24 at 2:18 PM, revealed Resident #93's medical closet in his/her room contained a bottle of Nitroglycerin 0.4mg tablets. Further observation revealed this bottle of medication expired on 5/2024. There were no other bottles of Nitroglycerin tablets in the resident's medical closet.

During an interview on 7/16/24 at 2:18 PM, Licensed Nurse (LN) #8 confirmed the Nitroglycerin was expired and removed it from the resident's room.

Review of facilities policy Medication Storage, last revised 5/2024, revealed: . Improperly labeled, deteriorated, and expired items are quarantined from general inventory.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 47929

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure sufficient dietary support staff were available to safely and effectively carry out the functions of the food and nutrition services in 1 cottage (Aniak), out of 8 cottages sampled. This failed practice placed all residents in the Aniak cottage (based on a census of 12), who received meals from the kitchen, at risk to be served meals that did not meet their needs and cause a less than optimal dining experience.

Findings:

Random observations on 7/8/24 in the Aniak cottage, revealed there was no Home Keeper (cook) working in

the kitchen.

During an interview on 7/8/24 at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated there was no cook assigned to the Aniak Cottage that day.

During an observation and interview on 7/8/24 at 12:04 PM, Resident #34 was sitting in his/her room, at his/her bedside table with a disposable Styrofoam clamshell food container containing the resident's lunch. Resident #34 stated that the food was cold, but it was no use to call someone to warm it up as it might be forgotten in the microwave, or the staff would take a long time to come get it to heat it up. The resident stated that he/she might as well eat it cold than bother the staff.

During an interview on 7/8/24 at 3:44 PM, Resident #78 showed this surveyor a picture of a meal that was served to him/her on 7/6/24. The picture contained potatoes and carrots that had small traces of pot roast on

the food (Resident #78 was a vegetarian) and was served in a disposable Styrofoam clamshell food container. The resident stated this was very upsetting.

During an interview on 7/9/24 at 9:07 AM, [NAME] #2 stated the cottage did not have a cook working in the cottage for the past 3 days. The cottage had not been stocked during the absence. During the initial inspection of the kitchen and food storage areas, multiple food items in the main kitchen and pantry refrigerators were found to be missing open dates, produce was found to have indented brown spots with mold, and frozen chicken was thawing in the pantry's refrigerator with no thaw-by dates indicated. [NAME] #2 stated the cooks from the other cottages were supposed to cover the duties in the cottage in addition to theirs when a cook is absent.

During an interview with the Resident Council on 7/12/24 at 11:01 AM, Resident #44 stated that he/she was not always happy with the food situation in the cottage. The resident stated there always seemed to be cooks missing. Several of the other residents who attended the meeting agreed with Resident #44.

Review of the Aniak cottage's FREEZER TEMPERATURE LOG on 7/9/24 at 9:04 AM, for the month of July, revealed no temperature checks were performed on 7/7/24. The bottom of the log stated, CHECK TEMPERATURE AT LEAST DAILY, CLEAN ONCE A WEEK AND AS NEEDED.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Review of the Aniak cottage's REFRIDGERATOR/WALK-IN TEMPERATURE LOG on 7/9/24 at 9:04 AM, for

the month of July, revealed no temperature checks were performed on 7/7/24. Level of Harm - Minimal harm or potential for actual harm The bottom of the log stated, CHECK TEMPERATURE AT LEAST DAILY, CLEAN ONCE A WEEK AND AS NEEDED. There were no initials for the first week of July indicating that the weekly refrigerator cleaning had Residents Affected - Few not occurred.

During an interview on 7/12/24 at 9:33 AM, the Manager of Food Services (MFS) stated the cooks assigned to a cottage are responsible for stocking, labeling, cleaning, and cooking the meals. When one cook calls out

the entire day's routine implodes. Other cooks from other cottages were supposed to cover the duties in the cottage that did not have a cook. It was also expected of the cooks to help with resident cares in addition to their normal kitchen duties.

Review of Providence Extended Care: The Cottages A handbook for residents and their families. Revised 7/24 revealed: Our vision is to provide excellent care in a place that truly is a home to those who live here . Just like mealtime at home, mealtime in the Cottage is a cherished time .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47929 potential for actual harm Based on interview, observation, and record review, the facility failed to ensure food and drinks were Residents Affected - Few prepared at a safe and appetizing temperature for 1 resident (#34) in the Aniak cottage (out of 12 residents

in the cottage), and all residents who received meals prepared in the Deska cottage (based on a census of 11), out of 8 sampled cottages. Failure of the food to be at a palatable temperature had the potential to lower consumption and place the residents at risk for decreased nutritional intake and/or weight loss.

Findings:

Aniak Cottage:

During an interview on 7/8/24 at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated that the cottage did not have a home keeper (cook) that day for the cottage. When the cooks are short staffed, the meals for the cottage were prepared in another cottage, placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number, and brought over. The CNA and licensed nurse (LN) would serve the meals.

During an observation on 7/8/24 at 11:59 AM, an open cart, containing disposable Styrofoam clamshell food containers, was brought into the cottage by [NAME] #1. [NAME] #1 placed all containers on the kitchen counter. At 12:02 PM [NAME] #1 left the cottage. The CNA and LN began serving the meals in the disposable Styrofoam clamshell food containers.

During an observation and interview on 7/8/24 at 12:04 PM, Resident #34 was sitting in his/her room, at his/her bedside table with a disposable Styrofoam clamshell food container containing the resident's lunch. Resident #34 stated that the food was cold, but it was no use to call someone to warm it up as it might be forgotten in the microwave, or the staff would take a long time to come get it to heat it up. The resident stated that he/she might as well eat it cold than bother the staff.

During an interview on 7/9/24 at 9:07 AM, [NAME] #2 stated that the cottage did not have a cook for the last three days, and other cooks in the other cottages would rotate preparing meals for the day. [NAME] #2 stated when a cook is covering another cottage, there was no time to wash dishes for both cottages and complete other duties. If another cottage did not have a cook available for the day, [NAME] #2 would prepare meals for the other cottage first before working on the meals for his/her assigned cottage, and food temperatures are taken prior to serving.

Deska Cottage:

Review of the recorded menus for 7/8/24 revealed the menu for breakfast included: oatmeal, cheese omelet, blueberries, milk, juice. The menu for lunch included: half meatloaf sandwich, tomato soup, milk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 An observation on 7/8/24 at 9:15 AM, revealed one disposable cup of milk and a disposable cup of coffee sitting on a tray, two pieces of toast sitting in the toaster, and several pieces of cheese in a measuring cup Level of Harm - Minimal harm or left unattended on the kitchen counter area of the cottage until 10:07 AM, 47 minutes later, when [NAME] #9 potential for actual harm delivered these items to a resident, with no prior temperature checks.

Residents Affected - Few An observation on 7/8/24 at 11:00 AM, revealed [NAME] #9 prepared oatmeal for a resident requesting a late breakfast and served it without checking the temperature.

An observation on 7/8/24 at 11:06 AM, revealed [NAME] #9 poured canned tomato soup into a pot and heated it up on an electric range stove, at a heat of level 2. At 11:32 AM, [NAME] #9 checked the temperature while the soup was still simmering, it was 159.8 degrees F (Fahrenheit). The soup continued to simmer on a level 2 for another 44 minutes, after which the cook then began placing the soup into bowls and assembling the residents' meal trays. Soup was served without further temperature checks. The last bowl of soup served was at 12:24 PM, 52 minutes after the previous temperature check mentioned above.

Review of the HOMEKEEPERS ASSIGNMENT CHECKLIST, dated 7/8/24 revealed the soup temperature was logged at 166 degrees F.

During an interview on 7/10/24 at 4:39 PM, the Dietary Manager stated food temperatures should be check prior to serving meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43792

Residents Affected - Few 47929

Based on observation, interview, and record review, the facility failed to ensure: 1) food was stored under proper sanitary conditions and stored at safe temperatures for the Aniak and Yukon cottages, out of 4 cottages observed, and 2) staff wore hairnets consistently when in the kitchen for the Matanuska and Kenai cottages, out of 4 cottages observed. This failed practice placed all residents who received food from the affected kitchens, based on a census of 46, at risk for foodborne illness and communicable disease.

Findings:

1) Food Storage

Aniak Kitchen and Storage area:

An observation on [DATE REDACTED] at 9:17 AM, revealed the following food and beverages issues on the initial inspection of the kitchen and food storage areas:

Main Kitchen and Refrigerator:

- 1 pack - 14 oz Kirkland Black Forest Ham, open package, no open date;

- 1 partial container - Glenview Farms Whipped Butter Blend Margarine, no open date.

- 1 - uncovered oatmeal in a disposable Styrofoam bowl;

- 1 bottle - Kirkland Organic Raw & Unfiltered Honey, no open date;

- 3 partial bags - Denali [NAME] Bread, no open date;

- 1 partial bag - Cinnamin Raisin Bread, no open date;

- 1 Regal Cinema soda cup with a resident number written on it, no use by date.

Pantry Refrigerator:

- yellow squash with small circular indented brown and mold spots

- 2 bags of Frozen Tyson Boneless Skinless Chicken Thighs thawing in clear containers, no thaw by date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Review of the Aniak cottage pantry's FREEZER TEMPERATURE LOG on [DATE REDACTED] at 9:04 AM, for the month of [DATE REDACTED], revealed no temperature checks were performed on [DATE REDACTED]. The bottom of the log stated, Level of Harm - Minimal harm or CHECK TEMPERATURE AT LEAST DAILY, CLEAN ONCE A WEEK AND AS NEEDED. potential for actual harm

Review of the Aniak cottage pantry's REFRIDGERATOR/WALK-IN TEMPERATURE LOG on [DATE REDACTED] at 9:04 Residents Affected - Few AM, for the month of [DATE REDACTED], revealed no temperature checks were performed on [DATE REDACTED].

The bottom of the pantry's refrigerator log stated, . CLEAN ONCE A WEEK AND AS NEEDED. There were no initials from ,d+[DATE REDACTED]-,d+[DATE REDACTED] in the column titled, Cleaning Initials indicating the refrigerator cleaning had not occurred.

During an interview on [DATE REDACTED] at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated there was no Homekeeper (Cook) assigned to the Aniak Cottage that day, and the cooks were responsible for labeling, stocking, and preparing food for the cottage.

During an interview on [DATE REDACTED] at 9:07 AM, [NAME] #2 stated the cottage did not have a cook working in the cottage for the past 3 days. The cottage had not been stocked and routine duties did not occur during the absence.

Yukon Cottage Kitchen and Storage area

An observation on [DATE REDACTED] at 1:15 PM revealed the following food and beverages issues on the initial inspection of the kitchen and food storage areas:

Kitchen Refrigerator:

- 1 - Gallon container of Glenview Farms 2 % milk - unopened and full - expiration date was [DATE REDACTED].

- 1- Gallon container of Glenview Farms 2% milk- opened, no open date, ,d+[DATE REDACTED] full-expiration date was [DATE REDACTED]

- Storage area Refrigerator:

- 1-Gallon container of Glenview Farms 2 % milk - unopened and full - expiration date was [DATE REDACTED].

During an interview on [DATE REDACTED] at 1:17 PM, Licensed Nurse (LN) #3 stated there were expired milks in the refrigerators. LN #3 also stated the cleaning schedule had not been completed, and the cook was not here today.

During an additional interview on [DATE REDACTED] at 1:30 PM, LN #3 stated he/she could not find the refrigerator and panty refrigerator temperature logs.

2) Hairnets

Matanuska Cottage

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 An observation on [DATE REDACTED] at 10:13 AM, revealed Licensed Nurse (LN) #15 entered the kitchen without a hairnet and retrieved cold water from the refrigerator, then exited the kitchen. Level of Harm - Minimal harm or potential for actual harm An observation on [DATE REDACTED] at 9:12 AM, revealed [NAME] #3, who was working another cottage, entered the cottage from the back door and walked directly into the kitchen. [NAME] #3 was not wearing a mask or a Residents Affected - Few hairnet, he/she did not wash his/her hands prior to entering the kitchen. [NAME] #3 was observed to open

the refrigerator while rubbing the nares of his/her nose with the opposite hand. [NAME] #3 noticed this surveyor, exited the kitchen and donned a mask. [NAME] #3 re-entered the kitchen, without washing his/her hands and re-opened the refrigerator.

An observation on [DATE REDACTED] at 9:42 AM, revealed LN #16 entered the kitchen without a hairnet on after washing his/her hands. LN #16 took scrambled eggs from the food warmer and prepared some toast. LN #16 was observered to initially start to eat this meal while standing at the kitchen counter, then moved into the nurse's station to finish.

Kenai Cottage

An observation on [DATE REDACTED] at 9:30 AM, revealed Certified Nursing Assistant (CNA) #10 in the kitchen without

a hair net. When CNA #10 noticed this surveyor, he/she exited the kitchen and donned a hairnet, then returned into the kitchen.

During an interview on [DATE REDACTED] at 9:33 AM, the Manager of Food Services (MFS) stated every food item should have an open date and a use by date. Food items that are thawing in the refrigerators should have a blue tape labeled with the thaw by date. The thaw by date is three days from the date it was pulled from the freezer. Hairnets should be worn by anyone who goes into the kitchen. The temperature logs should be filled out every day. In the morning, the cooks are expected to check the fridge and freezer temperatures. When one cook calls out the entire day's routine implodes. It is expected of the cooks to help with resident cares in addition to their normal kitchen duties.

Review of the facility's dietary protocol LABELING FOR REVEIVING AND STORAGE OF FOOD ITEMS dated ,d+[DATE REDACTED], revealed: Items left in their original containers will have an opened date .The date will say 'Open Date . use by date' . Items repackaged or processed within the department will be labeled with a use by date for 3 days later . Personal items for residents must be labeled and dated with a use by date of three days .

Review of the facility's dietary protocol REFRIDGERATOR/FREEZER CLEANING IN COTTAGES dated , d+[DATE REDACTED] revealed: Dietary responsible for weekly cleaning and sanitizing of Refrigerators.

Review of the facility's dietary protocol FOOD HANDLING REQUIREMENTS revised ,d+[DATE REDACTED] revealed: Hairnets and/or caps are required while in the kitchen area.

Review of The Food Code, U.S. Public Health Service 2022, accessed from https://www.fda. gov/media/164194/download?attachment, revealed: ,d+[DATE REDACTED] Hair Restraints. (A) FOOD EMPLOYEES shall wear hair restraints .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Actual harm 40259

Residents Affected - Many Based on interview, observation, 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. This placed all residents (based on a census of 93) at risk for physical and/or psychosocial harm.

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 III, IV, and unstageable pressure ulcers and deep tissue injuries. These failed practices caused actual harm due to the of deterioration of pressure ulcers. In addition, failure to ensure adequate staffing to provide for residents' physical, social, and emotional needs caused psychosocial harm.

The facility administration was aware of the concerns but failed to identify or implement effective corrective measures.

Findings:

Review of the facility campus revealed eight separate cottage buildings, with 12 resident bedrooms in each cottage, for a total of 96 resident beds. Facility administrative and support staff (e.g. pharmacist, laundry, therapies) were located at the commons building. The facility's total census at the time of this survey was 93 residents.

During an interview on 7/10/24 at 3:26 PM, the Administrator stated the Director of Nursing's (DON's) last full-time day was 6/21/24 and went to a schedule of coming to the facility Monday through Friday, 4:00 AM to 6:00 AM and then coming back in the afternoon if needed. Also, the DON would work Saturday and Sunday 6:00 AM to 12:00 PM if needed. The Administrator stated a new DON was hired and his/her start date was 7/29/24. See

F-F0500. Interview for Daily Preferences: How important is it to you to do things with groups of people? Very important. How important is it to you to do your favorite activities? Very important .

Resident #39

During an interview on 7/8/24 at 10:58 AM, Resident #39 stated that his/her biggest complaint with the facility was the lack of staffing due to a new system which was one CNA per cottage. There were times when there was no cook, no nurse, or CNA. Resident #39 stated that the lack of staffing consequence was that he/she did not always get his/her shower. Resident #39 stated, when questioned about the lack of showers, stated,

This is unacceptable. Resident #39 had concerns that his/her exercises were not always completed. Resident #39 stated, If we lack staff, the replacement has to come from a different cottage. The lack of CNAs has always a problem. The doctors are gone too. The [administrative leadership] are aware of this. We can't take care of ourselves. One CNA with 12 people is a lot.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Review of Resident #39's Baseline Care Plan, printed on 7/17/24, revealed: Special Precautions . Assist me with ROM exercises to all extremities, 3-5 rep, BID [twice a day] with care as tolerated . I bathe with the help Level of Harm - Actual harm of 1-2 people doing 100% of the care, using the Carendo shower chair. Transfer me with the ceiling lift and blue sling. No Male CNAs during shower. Nails to be trimmed by PCN. Bath/shower: Tuesday (day); Friday Residents Affected - Many (day).

During an interview on 7/9/24 at 9:01 AM, Resident #39 stated he/she was not being able to choose more showers when she/he wished. Showers were scheduled two days a week. Resident #39 stated, I often miss showers due to there not being enough staff here.

Review of Resident #39's MDS annual assessment, dated 3/14/24, revealed: . Section

F-F400. Interview for Daily Preferences . how important is

it to you to choose between a tub bath, shower, bed bath, or sponge bath? [response] Very important.

During an interview on 7/15/24 at 12:39 PM, Certified Nursing Assistant (CNA) #11 stated there were no limits on the frequency a resident could shower or when a resident was able to get up, but mainly depended

on the availability of staff. Most of the time the staff were busy, and it was much harder to give showers outside of the resident's schedule.

Resident #39

Record review on 7/8-12/24 and 7/15-19/24 revealed Resident #39 was admitted to the facility with diagnoses that included Quadriplegia (paralysis of all four limbs) and other chronic osteomyelitis (bone infection caused by bacteria or fungus).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0561 During an interview on 7/9/24 at 9:01 AM, Resident #39 stated he/she was not able to choose more showers when she/he wished. Showers were scheduled two days a week. Resident #39 stated, I often miss showers Level of Harm - Minimal harm or due to there not being enough staff here. potential for actual harm

Review of Resident #39's medical record failed to reveal the resident was given showers twice weekly. The Residents Affected - Some baseline care plan revealed the resident was to receive showers twice a week on Tuesdays and Fridays

during the day. The showers or bed baths were not given twice a week in the weeks of 6/25-29/24 (resident refused on 6/25/24 since a male CNA was only available to give a shower); 6/30/24-7/6/24; and 7/7-13/24 with only one shower a week documented. A lack of Tuesday showers was noted on the dates of 7/2/24 and 7/9/24.

During an observation on 7/12/24 at 10:10 AM, CNA #2 was observed to give Resident #39 a shower by using a ceiling lift device and a shower chair.

During an interview on 7/17/24 at 3:31 PM, Licensed Nurse (LN) #1 stated the resident does not always get showered due to the need for a two-person assist and that sometimes there was a lack of staff at the facility. Resident #39 should have showers two times a week. LN #1 stated, [Resident #39] is particular, and sometimes there is no one here to give a shower. [He/she] does refuse a male caregiver.

Review of the facility's Your Rights. Our Responsibilities resident rights paperwork in the admission packet, effective date 4/1/21, revealed: As a Resident, you have the Right: . To receive services that meet your individual needs and preferences and choose healthcare, activities and schedules that are consistent with

these .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Level of Harm - Potential for 47929 minimal harm Based on observations, interviews, and record review, the facility failed to: 1) clearly post the location of Residents Affected - Some available state survey reports in 3 out 8 cottages due to digital displays being down for repairs; and 2) ensure state survey reports were readily accessible to all residents and resident representatives. This failed practice denied residents, resident representatives, and their families of knowing recent facility surveys were available for review and where they were located.

Findings:

Aniak, Deshka, and Matanuska Cottages

During random observations on 7/8-12/24 revealed large flat screen televisions, that were not turned on, hanging on the wall by the kitchens of the Aniak, Deshka, and Matanuska cottages. Each TV had a sign taped to it that said, Digital Display Down for Repairs Please see posting in the book.

During an interview on 7/8/24 at 9:27 AM, when asked about which book the sign taped to the TV was referring to, Certified Nurse Assistant (CNA) #10 did not know. When asked if he/she knew where the state survey results were, CNA #10 did not know.

Further observations revealed a countertop by the entry way that contained a wooden grievance box, several unlabeled white three ring binders, a white three ring binder labeled Special Orders, a closed black horizontal three ring binder on a black stand, and various other objects. Once opened, the black horizontal three ring binder revealed a page that contained the following: GOOD THINGS TO KNOW. At Providence Extended Care, our most recent survey results are available for review in the Den.

During an interview with the Resident Council on 7/12/24 at 11:47 AM, when asked if the residents knew where the state survey results were, Resident's #59 and #60 stated he/she had never known the state survey results existed. When asked if they knew what book the signs that were taped to the TV's by the kitchens were referring to, or if there was a sign posted in their cottages that directed them to the location of

the state survey results, everyone stated that they did not know. Resident #45 stated that he/she had found

the state survey results in the extra room with the computer in it (which was the den). Some of the residents replied that they did not use the facility's computer and were not sure where this room was. Resident #60 stated he/she was blind and had his/her own tablet set up to use and expressed concerns about those residents who were bed bound not having access to those results.

During an interview on 7/15/24 at 11:43 AM, Resident #34 stated he/she did not know that the state survey results were located or available to read. The resident further stated he/she never noticed any signs posted

in his/her cottage indicating the state survey results' location.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0577 An observation on 7/15/24 at 12:42 PM, revealed that the digital display in the Kenai Cottage was active and working appropriately. Further observation revealed the digital display indicated the most recent survey Level of Harm - Potential for results were located in the dining rooms, and not the den as three-ring binders indicated in other cottages. minimal harm Further observation revealed the most recent survey results were in the den of the Kenai Cottage.

Residents Affected - Some During an interview on 7/17/24 at 3:14 PM, the Senior Manager of Support Services (SMSS) stated that the cottages large TV's by the kitchens are frequently not working. These TV's would normally have facility postings broadcasted to them. The content of the broadcasts was made by the facility, but the feed was controlled by a third party, and they have had issues with the feed. When asked if he knew which book the signs taped to the TV's were referring to, he did not know.

Review of Your Rights. Our Responsibilities. resident rights paperwork in the admission packet, effective date 4/1/21, revealed: As a Resident, you have the Right: . To examine results of facility surveys. Results from the past three years are available upon request .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 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. Level of Harm - Minimal harm or potential for actual harm 43792

Residents Affected - Some 47929

Based on interview, observation, and record review, the facility failed to provide a homelike dining experience for all residents who received cooked meals in the Aniak cottage (based on a census of 12). This failed practice had the potential to cause a sense of being institutionalized, resulting in diminished self-worth and a reduced sense of well-being.

Findings:

During an interview on 7/8/24 at 9:27 AM, Certified Nurse Assistant (CNA) #10 stated that the cottage did not have a home keeper (cook) that day for the cottage. When the cooks were short staffed, the meals for the cottage were prepared in another cottage, placed in separate disposable Styrofoam clamshell food containers labeled with the resident's room number, and brought over. The CNA and licensed nurse (LN) would serve the meals.

During an observation on 7/8/24 at 11:59 AM, an open cart, containing disposable Styrofoam clamshell food containers, was brought into the cottage by [NAME] #1. [NAME] #1 placed all containers on the kitchen counter. At 12:02 PM [NAME] #1 left the cottage. The CNA and LN began serving the meals in the disposable Styrofoam clamshell food containers.

During an observation and interview on 7/8/24 at 12:04 PM, Resident #34 was sitting in his/her room, at his/her bedside table with a disposable Styrofoam clamshell food container containing the resident's lunch. Resident #34 stated that the food was cold, but it was no use to call someone to warm it up as it might be forgotten in the microwave, or the staff would take a long time to come get it and heat it up. The resident stated that he/she might as well eat it cold than bother the staff. Resident #34 stated he/she had been eating out of Styrofoam containers all weekend as well as that day. His/her meals were served this way when a cook would call out. When this happened, their meals would be prepared in another cottage and brought over. He/she stated the meals felt like he/she was eating take out and would rather eat off real dishes.

During an interview on 7/8/24 at 3:44 PM, Resident #78 showed this surveyor a picture of a meal that was served to him/her on 7/6/24. The picture contained potatoes and carrots that had small traces of pot roast on

the food (Resident #78 was a vegetarian) and was served in a disposable Styrofoam clamshell food container. The resident stated this was very upsetting.

During an interview on 7/9/24 at 9:07 AM, [NAME] #2 stated that the cottage did not have a cook for the last three days (7/6-8/24), and other cooks in the other cottages would rotate preparing meals for the day. [NAME] #2 stated that meals were served in the disposable Styrofoam clamshell food containers because when a cook was covering another cottage, there was no time to wash dishes for both cottages and complete other duties. If another cottage did not have a cook available for the day, [NAME] #2 would prepare meals for the other cottage first before working on the meals for his/her assigned cottage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 During an interview on 7/10/24 at 4:39 PM, the Dietary Manager stated serving meals from disposable Styrofoam clamshell food containers was not ideal and needed to ask dietary why they were delivering food Level of Harm - Minimal harm or like that. She stated that it did not happen very often and did not know why the food could not be plated. potential for actual harm

Review of the facility's Providence Extended Care: The Cottages A handbook for residents and their families, Residents Affected - Some revised 7/2024, revealed: Our vision is to provide excellent care in a place that truly is a home to those who live here . Just like mealtime at home, mealtime in the Cottage is a cherished time .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations.

Level of Harm - Actual harm 40259

Residents Affected - Few Based on interview and record review, the facility failed to protect residents in response to allegations of abuse. Specifically, the facility failed to:

1) ensure an alleged perpetrator, Licensed Nurse (LN) #6, was immediately removed from resident care, to prevent further potential abuse, while an active abuse investigation was in progress for 1 sampled resident (#83), out of 1 active abuse investigation reviewed; and

2) ensure an alleged perpetrator, Certified Nurse Assistant (CNA) #2, was kept from 1 unsampled resident (#86), out of 1 past abuse investigation reviewed, after an investigation of abuse was completed.

These failed practices caused psychosocial harm to Residents #'s 83 and 86; and placed all residents of the Susitna Cottage (based on a census of 12), and all residents of the Deshka Cottage (based on a census of 11) at risk for further potential abuse.

Findings:

Resident #83

During an interview on 7/17/24 at 9:10 AM, Resident #83, who was a resident of the Susitna Cottage, stated that on 7/14/24 at 6:00 PM he/she was sitting in his/her wheelchair and felt short of breath. He/she wanted

the fan on, and also felt the need for oxygen. Resident #83 stated he/she used his/her call light to call for assistance. Resident #83 stated he/she waited 3 1/2 hours, and since no one came, he/she began to yell for help. Resident #83 stated LN #6 arrived and placed oxygen on him/her. Resident #83 asked LN #6, .when will I get transferred to the bed . Resident #83 stated LN #6 got really out of control screaming. [LN #6] got behind me and hit me like a hammer on top of my head. It hurt really bad. Resident #83 further stated he/she asked LN #6, 'Why are you hitting me?' and [LN #6] was screaming loud. [LN #6] left and left me in my chair.

Resident #83 further stated that Resident #32 arrived at Resident #83's room to check on him/her. Resident #83 further stated he/she reported the incident to CNA #9 and then Supervisor Long Term Care Nurse (SRN) #1 arrived in the resident's room on 7/14/24. Resident #83 stated he/she provided his/her report of the incident to SRN #1. Resident #83 further stated that after SRN #1 left, LN #6 remained in the cottage and completed his/her shift on 7/14/24.

Resident #83 stated that the next day, 7/15/24, he/she had a headache and was dizzy. Resident #83 stated his/her head was still tender to the touch. Resident #83 stated, 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 During an interview on 7/17/24 at 10:30 AM, Resident #32 stated he/she, . heard people fussing and raising hell. Yelling voices loud enough to disturb and upset me. By the time I got to [Resident #83's] room, [LN #6] Level of Harm - Actual harm took off.I asked [Resident #83] what was going on? [Resident #83] stated '[LN #6] hit me on my head.' Resident #32 further stated . I don't want [LN #6] to know I am talking because I am afraid [LN #6] may Residents Affected - Few poison me.

Review of Resident #83's base line care plan, undated, revealed: . transfers . I need staff to do 100% of the effort using the overhead lift .

Review of Resident #83's care plan, dated 6/11/24, revealed: . I am weak . tell my nurse when I am short of breath .

Review of the facility's initial report, completed by SRN #1 on 7/14/24, revealed it was documented that SRN #1 was made aware of the incident at 6:50 PM, and the report was completed at 7:25 PM.

Review of the LN #6's hours worked on 7/14/24, from the facility's kronos system (time keeping system that tracked working hours of an employee), revealed LN #6 remained on the clock and worked on the Susitna Cottage until 7:30 PM. LN #6 was allowed to work for 40 minutes after SRN #1 was made aware of the allegation of abuse.

During an interview on 7/17/24 at 9:50 AM, SRN #1 stated on the evening of 7/14/24, he/she was informed by CNA #9 that Resident #83 wanted to talk to him/her right away. SRN #1 stated he/she went to the resident's room and Resident #83 reported the allegation of abuse. SRN #1 stated he/she completed the initial report and contacted the Administrator and Director of Nursing (DON) about the incident on 7/14/24 at 7:00 PM.

When asked if he/she was aware of the facility's policy to remove staff from the facility, for resident safety, when a report of alleged abuse was given until the investigation was completed, SRN #1 stated he/she was aware of this policy however stated shift change was occurring and LN #6 stayed because he/she was leaving soon. SRN #1 stated he/she did report this incident to the nightshift nursing supervisor prior to him/her leaving for the night.

When asked if LN #6 was taken off the schedule until the investigation was over, SRN #1 stated the DON had told him/her, when he/she made contact about the incident, that the Operations Director would intercept LN #6 in the morning to prevent him/her from working on 7/15/24.

Review of the facility's staff schedule for 7/15/24, the day after this incident, revealed LN #6 was scheduled to work a full shift on the Deshka Cottage.

Review of the LN #6's hours worked on 7/15/24, from the facility's kronos system, revealed LN #6 worked a full shift (7:00 AM to 7:30 PM) on the Deshka Cottage.

During an interview on 7/18/24 at 11:15 AM, the Quality Director stated she was only informed of the allegation of abuse concerning LN #6 later in the day on 7/15/24, and LN #6 continued to work through 7/15/24. When told of the DON's plan to have the Operations Director to intercept LN #6 in the morning, the Quality Director stated there was a miscommunication, and that the Operations Director was on vacation on 7/15/24. The Quality Manager stated that LN #6 should have been placed on administrative leave as soon as

the report of allegation was received, and the investigation was completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Resident #86

Level of Harm - Actual harm During an interview on 7/12/24 at 1:09 PM, Resident #86 stated he/she was involved in an incident with CNA #2 where Resident #86 requested assistance after having a urine incontinence accident which resulted in the Residents Affected - Few need for his/her bedding and clothing be changed. Resident #86 stated CNA #2 came into the room frustrated over the situation. At one point, Resident #86 requested another nightshirt. Resident #86 stated CNA #2 retrieved a fresh nightshirt from Resident #86's dresser and threw it in Resident #86's face. Resident #86 stated it was thrown with force, which caused the nightshirt to strike Resident #86's open eyes. Resident #86 further stated that he/she did report the incident and the facility did investigate. The result of the investigation concluded that everyone was having a bad day and it was decided that CNA #2 would not work

in Resident #86's Cottage anymore, which Resident #86 was satisfied with and felt the incident was addressed and concluded.

Resident #86 stated that a couple of weeks later, CNA #2 returned to the cottage to work, despite the agreement that CNA #2 would no longer work in his/her cottage. As Resident #86 began to cry during the interview, he/she stated he/she felt fearful and reported the incident to a supervisor, although could not remember who it was. Resident #86 stated the supervisor stated CNA #2 had to work the cottage due to staffing shortages. Resident #86 tearfully stated he/she felt so unsafe, he/she didn't leave his/her room the entire day.

Review of the facility's investigation of this incident revealed the date of incident was 2/25/24, and the final investigation concluded on 2/28/24. Further review revealed a corrective action plan of [CNA #2] is being moved to another cottage and there is to be no interaction between [CNA #2] and the resident [Resident #86].

Review of the CNA #2's hours worked from the facility's kronos system, dated 2/25/24 to 4/30/24, revealed CNA #2 worked a full day in Resident #86's cottage on 3/3/24.

During an interview on 7/18/24 at 11:15 AM, the Quality Director stated she could not speak to this incident,

the investigation, or the outcome as the Director of Nursing (DON) handled this incident.

The DON was not available to interview.

Review of the facility's policy SNF [Skilled Nursing Facility]/AL [Assisted Living] Abuse Prohibition and Prevention, last revised 1/2024, revealed: . Protection: Resident will be protected from physical and psychological harm during and after the investigation. Protection measures include, but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation . increased supervision of the alleged victim and other residents at risk; room or staffing changes, if necessary, to protect

the resident(s) from the accused; protect from retaliation .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40259

Residents Affected - Some 47929

Based on record review and interview, the facility failed to ensure the comprehensive care plan: 1) included

the listing of potential serious side effects of medications used, to ensure monitoring was established for resident safety, for 1 resident (#13), out of 20 sampled residents; and 2) included smoking interventions, for resident and cottage safety, for 1 resident (#92), out of 20 sampled residents. These failed practices had the potential to: 1) place the resident #13 at risk for a delay in identifying serious side effects that could affect the resident's health and wellbeing; and 2) place the Aniak Cottage (based on a census of 11) at risk for potential smoke and fire exposure.

Findings:

Resident #13

Record review on 7/8-12/24 and 7/15-19/24 revealed Resident #13 was admitted to the facility with diagnoses that included hemiplegia and hemiparesis (weakness or paralysis of one side of the body) following a cerebral infarction affecting left non-dominant side and acute kidney failure.

Review of Resident #13's care plan revealed an identified need/preference, dated 6/17/24, of I may experience side effects from my medications because I am on the following medications: narcotics, antihypertensive, beta-blocker, anticonvulsants, antispasmodic, antidepressants, anticoagulant and PRN [as needed] antihistamine.

Further review revealed an approach, dated 6/17/24, of I need my nurses to give me my medications and evaluate effectiveness and adverse effects of medication. I need my aides to notify my nurse if I have dizziness, drowsiness, confusion, blurred vision, weakness, or change/decline in mental status or signs of bleeding/bruising.

Review of Resident #13's Medication Administration Record (MAR), dated 7/1/24 to 7/17/24, revealed the following medications that had potential side effects that were not listed in the care plan:

1) Buspirone (an anti-anxiety, or anxiolytic medication) 2.5mg by mouth twice a day given for anxiety.

Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed Buspirone included side effects of abdominal distress, dry mouth, headaches, or insomnia.

A serious adverse reaction for this medication could be serotonin syndrome (a serious drug reaction caused by medications that build up high levels of serotonin in the body: symptoms include fast heartbeat, hallucinations, loss of coordination, twitching muscles, severe dizziness, severe nausea/vomiting, unexplained fever, agitation/restlessness).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 2) Apixaban (Eliquis - an anticoagulant medication) 5mg by mouth twice a day for atrial fibrillation.

Level of Harm - Minimal harm or Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed Apixaban came with a black potential for actual harm box warning (a Food and Drug Administration [FDA] requirement for medications with serious safety risks or rate but dangerous side effects) which stated, premature discontinuation [of the medication] increased risked Residents Affected - Some of thrombotic events [blood clots].

Review of Resident # 13's MARs, revealed he/she has had a history of refusing medications, including Apixaban:

- June 1 through 24, 2024 MAR: Resident refused Apixaban 20 out of the 48 times offered.

- July 5 through 16, 2024 MAR: Resident refused Apixaban 4 out of the 23 times offered.

3) Leflunomide (a medication to treat rheumatoid arthritis) 20mg by mouth every morning. This medication was identified as hazardous and required appropriate handling precautions in the MAR, however no instructions for this were visible on the MAR.

Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed Leflunomide came with a black box warning which stated, Risk of severe liver injury, monitor liver function tests [LFTs - lab work].

Other side effects listed were erythematous rashes (red, inflamed, bumpy skin rash), diarrhea, headaches, and alopecia (hair loss).

4) Levetiracetam (Keppra - an anticonvulsant medication) 250mg by mouth twice a day for seizures.

Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed side effects of behavior abnormalities, psychiatric reactions, dyspepsia (persistent or recurrent pain of the upper abdomen), and headache.

5) Metoprolol Succinate ER (Extended Release) (a beta-blocker medication, used to treat chest pain, heart failure, and high blood pressure) 12.5mg by mouth daily in the morning for atrial fibrillation.

Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed serious side effects of laryngospasm and bronchospasm (airway spasms that could affect breathing). Other side effects listed were cardiac arrhythmias, gastric pain, and paresthesia (tingling or prickling sensations).

6) Megestrol acetate (a hormone medication used to treat breast cancer, endometrial cancer, and weight loss) 400mg by mouth daily in the morning. This medication was identified as hazardous and required appropriate handling precautions in the MAR, however no instructions for this were visible on the MAR.

Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed Megestrol acetate came with a black box warning which stated, . risk of thromboembolic events [blood clots], stop drug at sx [signs or symptoms] of thrombosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Other side effects lists were edema, fluid retention, photosensitivity (sensitivity to ultraviolet rays from sun or other light source), and rash. Level of Harm - Minimal harm or potential for actual harm 7) Duloxetine (an antidepressant medication) 30mg by mouth daily at night.

Residents Affected - Some Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed Duloxetine came with a black box warning which stated, monitor for increased depression (agitation, irritability, increased suicidality), especially at start of treatment or dose change .

A serious allergic reaction listed was hepatotoxicity (damage to liver). Other side effects listed were serotonin syndrome, sweating, and urinary hesitancy (unable to void).

8) Methadone (medication used for relief of severe pain) HCl 5mg by mouth twice a day for pain.

Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed Methadone came with a black box warning which stated, . carefully determine all drugs patient [is] taking, respiratory depression and death have occurred .

Other serious side effects listed were apnea, cardiac arrest, circulatory depression, prolonged QT (hearth rhythm), respiratory arrest, respiratory depression, and shock.

9) Oxycodone (an opioid narcotic pain medication) concentrate 5mg, or 0.25mL (milliliter), by mouth as needed three times a day for pain.

Review of [NAME] 2024 Pocket Drug Guide for Nurses, dated 2024, revealed Oxycodone came with a black box warning which stated, Risk of addiction/abuse/misuse that can lead to overdose/death . other CNS [central nervous system] depressants may result in increased drug effect, potentially fatal respiratory depression, coma, death .

During an interview on 7/16/24 at 3:08 PM, the MDS Nurse #1 stated he/she did not look at black box warnings when choosing which side effects were listed in the care plan. The MDS Nurse #1 stated in the electronic MAR, that the nurses work out of, there were drop down options to list side effects for medications, however these side effects were not listed in the care plans for residents. When asked how he/she was ensuring important side effects for each medication were listed in the care plan, the MDS Nurse #1 stated, that's a good question.

Resident #92

Record review on 7/8-12/24 and 7/15-19/24 revealed Resident #92 was admitted to the facility with diagnoses that included cerebral infarction (a stroke where clusters of brain cell die due to insufficient blood flow), hemiplegia (loss of strength or paralysis on one side of the body) and hemiparesis (mild to moderate muscular weakness on one side of the body), a history of traumatic brain injury, and nicotine dependence.

During an interview on 7/8/24 at 3:23 PM, Resident #92 stated he/she smoked cigarettes. The resident confirmed that the cigarettes and lighter are locked in a drawer in his/her room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Review of the Resident Assessment Instrument 3.0 Minimum Data Set (MDS, a federally required nursing assessment for long term care residents) admission assessment dated [DATE REDACTED] revealed: Section J .Current Level of Harm - Minimal harm or Tobacco Use . Yes [was checked] . potential for actual harm

Review of the Baseline Care Plan/RDCP,, undated and printed on 7/10/24 at 2:04 PM, did not document Residents Affected - Some Resident #92's smoking.

Review of Resident #92's Care Plan, undated and printed on 7/10/24 at 2:05 PM, did not document Resident #92's smoking.

During an interview on 7/17/24 at 9:06 AM, MDS Nurse #1 stated that smoking was something that should be care planned for. When he/she reviewed Resident #92's care plan he/she was unable to locate it.

Review of the facility's policy SNF [skilled nursing facility] Baseline Care Plans, revised 2/2022, revealed:

The baseline care plan will be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders; physician orders . In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals or physical, mental or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary .

Review of the facility's policy Interdisciplinary Care Plan and Team Conference for Long Term Care Residents, revised 8/2023, revealed: . complete a full assessment of the resident and record problem areas and plan of treatment . any changes should be recorded on the new care plan . the assessment shall identify resident needs and problems . Identify an action plan including the care and services that must be provided to meet resident goals .

Review of the facility's policy Smoke Free Environment, revised 12/2022, revealed: . Should a resident and/or a visitor wish to smoke they must be off of the [facility] campus. Resident will have a Smoking Safety Evaluation completed upon admission or when they identify as wanting to smoke, annually and with an identified change of condition. Resident should sign the LOA [leave of absence] book when they leave to facility to smoke. Residents will use a smoking blanket/apron if indicated. Residents should have a reflective flag or equipment on their wheelchair to increase visibility.

Further review revealed no indication that smoking should be a part of the resident's care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0675 Honor each resident's preferences, choices, values and beliefs.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40259

Residents Affected - Some .

Based on record review, interview, and observation, the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Specifically, the facility's failed to create and sustain an environment that humanizes and individualizes each resident's quality of life and ensuring that the care and services provided were person-centered, and honored and supported each resident's preferences, choices, and values. This failed practice resulted in psychosocial harm for 10 residents (#s 26, 34, 39, 47, 56, 61, 77, 78, 86, and 92).

In addition, these failed practices placed the remaining 83 residents at risk for living and receiving care in a less that optimal environment.

Findings:

Resident Quality of Life

During random interviews and observations, 7/8-10/24 and 7/15-18/24, revealed multiple residents expressed feelings of hopelessness, had sad-toned verbal expressions, tearfulness, and shared they experienced apathy, humiliation, frustration, and feelings of helplessness about the current staffing situation and how it has affected their livelihood at the facility.

Resident #26

During an interview on 7/8/24 at 4:01 PM, Resident #26 stated he/she had requested . no male caregivers for changing and showering. Resident #26 stated males providing hygiene to him/her bothered his/her spouse as well. Resident #26 further stated CNA #3 told him/her, . If your husband doesn't know it will be ok. Resident #26 stated . But it bothers me.

During an interview on 7/15/24 at 11:10 AM, CNA #6 stated Resident #26 refused CNA #6 to provide personal cares because Resident # 26's spouse does not like it. CNA #6 stated a male CNA on nights showered resident.

During an interview on 7/15/24 at 3:20 PM, LN #7 stated Resident #26 did not want male caregivers providing personal/pericare [cleaning of the genitalia and buttock area]. LN #7 stated, .It is more his/her [spouse] and his/her culture. I have talked to his/her [spouse] many times and explained we do not always have a [female] CNA .

Review of the facility-provided ADL assistance documentation from resident's medical records, received 7/16-17/24, revealed Resident #26: I BATHE with 1 helper providing all of the effort. I use the shower chair. I prefer showers .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0675 Resident #34

Level of Harm - Actual harm During an observation and interview on 7/8/24 at 12:04 PM, Resident #34 was sitting in his/her room, at his/her bedside table with a disposable Styrofoam clamshell food container containing the resident's lunch. Residents Affected - Some Resident #34 stated that the food was cold, but it was no use to call someone to warm it up as it might be forgotten in the microwave, or the staff would take a long time to come get it to heat it up. The resident stated that he/she might as well eat it cold than bother the staff. Resident #34 stated he/she had been eating out of Styrofoam containers all weekend as well as that day. His/her meals were served this way when a cook would not come into work. When this happened, their meals would be prepared in another cottage and brought over. He/she stated the meals felt like he/she was eating take out and would rather eat off real dishes.

During an interview on 7/8/24 at 1:50 PM, Resident #34 stated that he/she was at the mercy of the staff. He/she stated that he/she would like to shower every night before bed, but he/she was told the facility policy was to shower twice a week. The resident stated that his/her shower days were Wednesdays and Saturdays.

The resident expressed concerns that he/she would not be able to get a shower if he/she had a bad episode of bowel incontinence.

Review of Resident #34's MDS (Minimum Data Set - A federally required nursing assessment) annual assessment dated [DATE REDACTED], revealed: . Section

F-F675 for additional information regarding quality of life.

Review of the facility's policy SNF [skilled nursing facility]/AL [assisted living] Abuse Prohibition and Prevention, revised 1/2024, revealed: . The purpose of this policy is to set forth the . policy regarding the prohibition and prevention of resident . neglect . Definitions . Neglect . means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43792 potential for actual harm 50031 Residents Affected - Some Based on record review, interview, and observation, the facility failed to: 1) ensure personal protective equipment (PPE) was worn during wound care for 1 resident (#48), out of 9 wound care records reviewed; and 2) ensure proper hand hygiene was performed and completed during wound care treatments for 1 resident (#82), out of 4 wound care treatments observed. This failed practice created potential risk for infection in the wounds, decreased wound healing, and resident well-being.

Findings:

Resident #48

Review on 7/8-12/24 and 7/15-19/24 revealed Resident # 48 was admitted to the facility with diagnoses that included diabetes mellitus, multiple CVA's (cerebrovascular accident - strokes), resulting in severe expressive aphasia (defect or loss of the power of expression by speech, writing, or signs, or of comprehending spoken or written language, due to injury or disease of the brain centers), severe dysphagia (difficulty swallowing), right sided hemiparesis (partial paralysis of one side of the body), and failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol)

Review of Resident #48's Baseline Care Plan/RDCP, on 7/10/24, revealed: Resident/Patient is on Enhanced Barrier Precautions. Use gown & gloves during high-contact activities.

Record review, on 7/11/24 at 11:22 AM, of Resident #48's wound photographs of pressure ulcer on the left heel, dated 4/25/23, revealed Certified Nursing Assistant (CNA) #3's hand holding a wound measurement tape on resident's wound. Further review revealed CNA #3 was not wearing gloves, and CNA #3's artificial nails were touching the wound's edges.

During an interview on 7/17/24 at 11:15 AM, the Wound Care Nurse (WRN) #1 stated any caregiver should use the resident's daily care plan located on back of resident's door for resident care. Resident #48's left heel picture, dated 4/25/23, was presented to WRN#1. WRN #1 stated CNA #3, who assisting in the wound care, should have been wearing gloves.

During an interview on 7/17/24 at 1:45 PM, the Infection Preventionist (IP) was presented with Resident #48's left heel picture, dated 4/25/23. IP stated he/she was severely concerned the employee was not wearing PPE and fingernails were touching the wound.

Review of the facility's Providence Extended Care Sufficient Staffing Education HR Worksheet, dated 7/10/24, revealed CNA #3 completed Infection Control (IC) initial education on 5/9/22 and annual IC education on 7/27/23.

Resident #82

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review on 7/8-12/24 and 7/15-19/24 revealed Resident # 82 was admitted to the facility with diagnoses that included Chronic Respiratory failure with hypercapnia (condition of abnormally elevated carbon dioxide levels Level of Harm - Minimal harm or in the blood) and chronic obstructive pulmonary disease (chronic lung disorders resulting in blocked air flow potential for actual harm in the lungs).

Residents Affected - Some Review of Resident #82's Baseline Care Plan/RDCP, on 7/16/24, revealed: Resident/Patient is on Enhanced Barrier Precautions. Use gown & gloves during high-contact activities.

An observation on 7/12/24 at 11:10 AM, of Resident #82's wound dressing change, revealed WRN #1, with gloved hands removed a dressing from Resident #82's coccyx area. WRN #1, without removing the soiled gloves, proceeded to cleanse the wounds with Vashe, a wound wash, and then assessed and measured the wound, and placed the sterile dressing onto the bedside table, before removing the soiled gloves and washing hands. WRN #1 then applied the skin prep to the surrounding skin, applied Puracol Plus, a wound care treatment, to the wound bed, and applied the foam dressing. WRN #1 did not remove gloves and perform hand hygiene after removing a soiled dressing.

During an interview on 7/12/24 at 11:17 AM, WRN #1 agreed that removing gloves and washing hands after dressing removal was best practice. He/she used [NAME] for wound care practice.

During an interview on 7/16/24 at 11:55 AM, the Infection Preventionist stated that during a wound care dressing change the nurse would remove the soiled dressing and discard appropriately and then remove soiled gloves and discard and then perform hand hygiene and then apply clean gloves before proceeding with dressing change.

Review of Clinical Safety: Hand Hygiene for Healthcare Workers retrieved at https://www.cdc. gov/clean-hands/hcp/clinical-safety/index.html, dated 2/27/24, revealed: Know when to clean your hands .

After contact with blood, body fluids or contaminated surfaces.

Review of the Providence Extended Care: The Cottages, A handbook for residents and their families, revised date July 2024, Infection Prevention is a program to prevent the spread of infection among our residents .

This involves handwashing and wearing personal protective equipment (PPE) when coming in contact with body fluids or contaminated surfaces.

Review of the Centers for Disease Control (CDC) web site accessed 7/22/24 at https://www.cdc. gov/clean-hands/hcp/clinical-safety/index.html , revealed Clinical Safety: Hand Hygiene for Healthcare Workers, . natural nails should not extend past the fingertip.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of 95 025036

F-F676 for additional information regarding Activities of Daily Living (ADLs).

During an interview on 7/17/24, when asked if the number of staff currently working, and based on the bed capacity of 96, was affecting the facility's able to meet the needs of the resident acuity levels, the Administrator stated she felt they were able to meet the needs, but not at the standard we would want to meet them.

When asked how many open nursing positions the facility had, the Administrator there were currently 10 CNA positions and 5 nursing positions posted, however there were more that needed to be filled.

Home Keepers/Housekeepers/Activity Staff

During an interview on 7/10/24 at 3:26 PM, when asked what other measures the facility had attempted to help support the cottages to meet the needs of the residents, the Administrator stated they increased training with home keepers (cooks), housekeepers, and activity staff to help with assisting CNAs when needed in bed mobility and transfers, as well, as assist with dining for residents who required minimal support. These staff were trained in safe patient handling and dining assistance.

During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the DON stated the CNAs had expressed concerns that the home keepers, housekeepers, and activity staff weren't supporting them during the day because they were unsure on what they could or couldn't do.

Random observations on 7/8-10/24 and 7/15-18/24 revealed no home keeper, housekeeper, or activity staff assisted CNAs with bed mobility, transfers, or dining assistance.

See

F-F725 for additional information regarding sufficient staffing.

Quality of Life

During an interview on 7/17/24 at 8:17 AM, when asked if the concerns with low staffing had impacted the resident's care, the Medical Director stated residents talked to her about how staff needed help. The Medical Director further stated low staffing was affecting the residents with higher acuity, who required heavier assistance in cares, more than the residents who were more independent.

Review of the Resident Council Meeting Minutes, dated 1/17/24, 4/17/24, and 6/20/24, the DON noted a decrease in staffing had been occurring. During the 6/20/24 meeting the [Administrator] shared with group

the new process [staffing restructure] which went live on Tuesday [6/23/24].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing levels, the DON stated nurses had expressed concerns on having to pick up residents in a second cottage. Level of Harm - Actual harm The CNAs had expressed concerns that the home keepers, housekeepers, and activity staff weren't supporting them during the day because they were unsure on what they could or couldn't do. Residents Affected - Many

During an interview on 7/16/24 at 4:35 PM, LN #8 stated staff shortages had affected the ability to spend time with the residents. LN #8 stated it was a struggle to complete turns every 2 hours and showers. When properly staff showers used to be enjoyable and staff could spend time with residents to put on lotion, however staff are now rushed due to the increased workload that resulted in the staff being less available. LN #8 further stated quality time with residents wasn't possible anymore.

During random interviews and observations, 7/8-10/24 and 7/15-18/24, revealed multiple residents expressed feelings of hopelessness, had sad-tones verbal expressions, tearfulness, and shared they experienced apathy, humiliation, frustration, and/or feelings of helplessness about the current staffing situation and how it had affected their livelihood at the facility.

See

F-F727 for additional information regarding not having a full-time DON.

During an interview on 7/17/24, the Administrator stated she had the overall responsibility of the campus, and that she set the expectations and goals.

Staffing

During an interview on 7/10/24 at 3:26 PM, when asked to describe the current staffing situation in the cottages, the Administrator stated the facility traditionally would have had one nurse in every cottage, and 16 CNAs (2 CNAs per cottage) scheduled on the dayshift, however since COVID they had not been able to meet that staffing level. The Administrator stated that the facility was currently running at crisis staffing level where there was one nurse for every 18 resident (one nurse per 1 and a half cottages) and one CNA for every 12 residents (one CNA per cottage), and there was a goal of having 4 support CNAs (1 support CNA per two cottages) to provide support and complete showers. This had been a challenge to attain, however, due call outs, and currently had been able to only provide about 3 support CNAs a day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 95 025036 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 025036 B. Wing 07/19/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Extended Care 920 Compassion Circle Anchorage, AK 99504

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 When asked if the facility had received any calls or grievances about the staffing shortages, the Administrator stated there had been grievances from family. Level of Harm - Actual harm

During an interview on 7/11/24 at 1:25 PM, when asked if staff had voiced any concerns about the staffing Residents Affected - Many levels, the DON stated nurses had expressed concerns on having to pick up extra residents in a second cottage.

During an interview on 7/12/24 at 10:29 AM, when asked how the staffing shortage and crisis level staffing had affected resident care, the Lead CNA (LCNA) stated it was a challenge to meet the needs of residents as swiftly as they could have with a full complement of staff, that staff able to give the residents the attention as they used to. The LCNA stated it was hard to meet the needs of the residents, and residents had voiced that their care had been delayed, to include not getting showers, and they didn't like the new staffing schedule. The LCNA further stated that if there weren't enough support CNAs, residents would get bed baths instead of showers because there weren't enough staff to provide showers.

The LCNA further stated that having only one CNA per cottage now meant that residents had to wait longer for their needs to be met and it may have been impacting pressure ulcers because the CNAs were having trouble meeting the turning schedule of every 2 hours. See