Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Polaris Transitional Care during CMS and state inspections, most recent first.
A resident with ESRD and dependence on hemodialysis did not receive post-dialysis care according to physician orders, the care plan, and facility policy. The post-dialysis pressure dressing on the AV fistula was not documented as removed within the ordered timeframe, despite dialysis center instructions specifying timely removal. Although an LN later reported that the access site was bleeding and a dressing change was performed, the TAR documented the site as clear and nursing notes did not reflect any dressing change. Required shift assessments of the fistula site for bleeding, redness, and tenderness were not accurately documented, and there was no evidence that the physician was notified of the bleeding access site, contrary to facility policy and referenced CDC dialysis safety standards.
The facility's assessment contained inaccurate information regarding bed capacity and physical layout, with documentation stating a higher licensed capacity and a different building structure than what was confirmed by state licensing records and staff interview.
A resident with significant medical needs was admitted to the facility and, despite having personal belongings available, their room remained unpersonalized for over a month, with items left in boxes and minimal personal effects displayed. Staff did not contact the family or representative to assist with unpacking or personalizing the room, contrary to facility policy, resulting in the resident being denied a homelike environment.
The facility failed to ensure proper food storage and labeling, with expired and unlabeled food items found in the main kitchen and dining room kitchens. Missing temperature logs for refrigerators and freezers were also noted. The Dietary Manager acknowledged the lapses, which could potentially lead to foodborne illness among residents.
A facility failed to obtain informed consent before changing the medication regimen for a resident with schizophrenia and anxiety. The resident's Hydroxyzine dosage was increased from twice to three times daily, and Aripiprazole was increased from 25mg to 30mg daily without informing the resident's representative. Interviews confirmed the lack of communication, violating the facility's policy on psychotropic medications.
A facility failed to provide quarterly financial statements to a resident's designated financial representative, despite the resident having a POA for financial obligations. The statements were incorrectly sent to the resident's home address, and the Business Officer was unaware of the POA. This oversight was confirmed through interviews and document reviews, highlighting a failure to adhere to the facility's policy on managing resident funds.
A resident reported being catheterized without consent while in a ceiling lift sling, but the facility failed to investigate and resolve the grievance. Documentation showed no evidence of a thorough investigation or communication of the outcome to the resident. Interviews with staff revealed that the grievance process was not properly followed, with incomplete documentation and follow-up.
A resident lost their dentures, impacting their ability to chew and requiring a dietary adjustment. Despite this, the facility failed to update the resident's care plan to reflect their current dental status, as acknowledged by the DON. The care plan remained outdated, not addressing the resident's edentulous condition and dietary needs.
A facility failed to label medications and supplies used for wound care, risking the use of expired products on a resident. During wound care, two LNs used an opened tube of Triamcinolone Acetonide Ointment and two bottles of Vashe wound cleansing solution, none of which were labeled with the date opened or the initials of the person who opened them. This was against the facility's protocol, which requires such labeling to ensure medications are not expired.
The facility failed to ensure accurate medication transcription, leading to a resident receiving incorrect doses of Lovenox in addition to Heparin, resulting in an anemic crisis and death. Another resident experienced a delay in receiving their prescribed medication due to the same error.
The facility failed to ensure residents were free from significant medication errors, leading to the concurrent administration of two anticoagulants to a resident, resulting in severe health complications and eventual death. The error occurred due to incorrect transcription of a physician's handwritten order and failure to follow the 24-hour chart check protocol.
Failure to Follow Post-Dialysis Orders and Document AV Fistula Complications
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis-related treatment and care in accordance with physician orders, the resident’s care plan, and facility policy for one resident dependent on hemodialysis with ESRD and PVD. Physician orders and the MAR directed that the post-dialysis pressure dressing on the resident’s AV fistula be removed after a specified number of hours, and dialysis communication from the dialysis center reiterated that the fistula dressing must be removed within a defined timeframe to prevent clotting or narrowing of the AV graft. Record review showed no documentation that the post-dialysis dressing was removed within the ordered timeframe, and there was no indication on the MAR or in nursing progress notes that a dressing change was performed during the relevant dates. The facility also failed to assess, document, and communicate the condition of the dialysis access site as ordered and per policy. The care plan required daily checks and dressing changes at the access site with documentation and monitoring for signs and symptoms of complications, and the TAR included an order to assess the fistula site every shift for clarity, tenderness, redness, and bleeding. A nurse reported that upon the resident’s return from dialysis, the access site was bleeding and a dressing change was performed, but the TAR documentation for that shift indicated the site was “clear,” and nursing progress notes contained no record of a dressing change. Additionally, despite facility policy requiring monitoring for complications and immediate physician notification for bleeding, the medical record contained no evidence that the physician was notified about the post-dialysis bleeding AV fistula. CDC dialysis safety guidelines cited in the report state that standards of care require reassessment of the access site after dressing removal for bleeding, redness, or swelling, with accurate documentation and timely communication of findings, which was not demonstrated in this case.
Inaccurate Facility Assessment Documentation
Penalty
Summary
The facility failed to ensure that its facility-wide assessment was up to date and accurate, as required. Record review revealed discrepancies in the reported bed capacity and facility description. The facility assessment stated a licensed capacity of 96 residents, while the State of Alaska license indicated the facility was licensed for 50 beds. During an interview, the Director of Community Liaison confirmed the correct bed capacity was 50 beds, highlighting the inaccuracy in the assessment documentation. Additionally, the facility assessment described the physical layout as consisting of 8 cottages, 8 courtyards, and a common building, whereas the initial licensing application described the facility as a single building with two wings, each containing specific hallway and room arrangements. These inconsistencies demonstrate that the facility assessment did not accurately reflect the facility's current resources and structure, as required for both day-to-day operations and emergency preparedness.
Failure to Provide Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a homelike environment was established and maintained for a resident who had been admitted over a month prior. Despite the resident's history of having a personalized room at a previous facility, observations revealed that the resident's personal belongings remained packed in boxes, with minimal personal items displayed in the room. The only visible personal effects were a few pictures on a corkboard, which was obscured behind a television and not easily visible from the resident's bed. The room otherwise lacked any personal touches or homelike features. Interviews with facility staff indicated that it was the responsibility of the assigned CNA to inventory and put away personal items upon admission, and that family members were typically contacted to assist with unpacking. However, there was no documentation that staff had reached out to the family or the resident's representative for assistance, nor was there any record of resistance from the resident or representative regarding the personalization of the room. The facility's policy required social services to contact family or responsible parties to help personalize the resident's environment, but this was not done, resulting in the resident being denied a homelike environment.
Improper Food Storage and Labeling in Facility Kitchens
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper labeling and storage of food items in the main kitchen and dining room kitchens. During an inspection, it was observed that several food items in the dry storage, walk-in cooler, and walk-in freezer were either expired or lacked proper labeling with received, open, or use-by dates. Specifically, expired cans of Monarch Pork & Beans, Premier Protein Chocolate Shakes, and various other food items were found in the main kitchen. Additionally, the Northside and Southside dining room kitchens had missing temperature logs for their refrigerators and freezers, and several food items were found without open date labels. The Dietary Manager confirmed that all containers should have been labeled with received, open, and use-by dates, and that expired food should be discarded. The facility's policy on labeling and storage of food items was not followed, as evidenced by the presence of expired and unlabeled food items. This failure to comply with food safety standards had the potential to cause or spread foodborne illness to all residents receiving food from the affected kitchens.
Failure to Obtain Informed Consent for Psychotropic Medication Changes
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to a resident, which is a violation of the residents' rights to be informed about their treatment. Specifically, the facility made changes to the medication orders for a resident diagnosed with schizophrenia, anxiety, agitation, and insomnia, without obtaining informed consent from the resident or their representative. The resident was prescribed Hydroxyzine, an antihistamine used for anxiety, and Aripiprazole, an antipsychotic for schizophrenia. The facility increased the frequency of Hydroxyzine administration from twice daily to three times daily and increased the dosage of Aripiprazole from 25mg to 30mg daily without documenting the risks and benefits or obtaining approval from the resident's representative. Interviews with the resident's representative and the nursing supervisor revealed that the facility did not inform the representative about the changes in medication dosage and frequency. The facility's policy on psychotropic medications requires that residents or their representatives be advised of the potential risks and benefits of psychotropic medication therapy. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and communication regarding the changes in the resident's medication regimen.
Failure to Provide Quarterly Financial Statements to Resident's POA
Penalty
Summary
The facility failed to provide quarterly statements for personal fund accounts to the resident's designated financial representative, which is a requirement according to the facility's policy. The resident in question, who has schizophrenia, had a Power of Attorney (POA) assigned for financial obligations. However, the facility was sending the quarterly bank statements to the resident's home address instead of the POA. This oversight was confirmed during interviews with the resident's representative and facility staff, including a Licensed Nurse (LN) and a Business Officer (BO). The Business Officer was unaware of the POA designation and stated that the facility had been sending the statements directly to the resident. A review of the resident's face sheet incorrectly listed the resident as the financially responsible party, despite the existence of a POA document that clearly designated the resident's representative as the agent for banking transactions. This failure to provide accurate and complete accounting of the resident's personal funds to the appropriate representative placed the resident and their representative at risk of not receiving necessary financial information.
Failure to Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance for a resident who reported being catheterized without consent while in a ceiling lift sling. The resident expressed feeling violated and stated that their complaints were not always investigated and resolved. Documentation revealed that the facility did not show evidence of a thorough investigation or inform the resident of the outcome of the grievance process. The incident involved a resident who was somnolent and unable to void, leading to a bladder scan that showed 590 ml of urine. A straight catheterization was ordered, but the resident felt uncomfortable and requested the procedure to stop. Despite this, the resident later reported being catheterized without consent while in a sling, which was not documented as having occurred. The facility's grievance log showed incomplete documentation and follow-up regarding the resident's complaint. Interviews with facility staff, including the DON and DOQ, revealed that the grievance process was not properly followed. The DON admitted to not documenting the follow-up with the ombudsman or the resident, and the DOQ acknowledged that the investigation and resident follow-up were incomplete. The facility's grievance policy requires prompt resolution and written follow-up, which was not adhered to in this case.
Failure to Update Care Plan for Resident's Dental Status
Penalty
Summary
The facility failed to update a comprehensive care plan according to a resident's current dental status, which placed the resident at risk of not receiving appropriate care. The resident, who was admitted with diagnoses including a femur fracture, facial weakness, and dysphagia, reported losing their dentures in their room. Despite the staff, including the Director of Nursing (DON), searching for the dentures, they were not found. The resident expressed difficulty chewing foods and was downgraded to a soft and bite-sized diet texture by the nurse supervisor. The resident also reported being unable to eat the provided meals and requested specific food items that were easier to consume. The care plan, dated prior to the loss of dentures, indicated the need for dentures due to swallowing problems and required staff assistance with denture care. However, the care plan was not updated to reflect the resident's edentulous status and dietary needs following the loss of dentures. The DON acknowledged that the care plan should have been updated to indicate the absence of dentures and confirmed that the comprehensive care plan was not revised according to the resident's current dental status. The facility's policy requires the care plan to be updated every 90 days and as changes occur, which was not adhered to in this case.
Failure to Label Medications and Supplies for Wound Care
Penalty
Summary
The facility failed to ensure that medications and supplies used for wound care were appropriately labeled, which placed a resident at risk of receiving expired medications and wound cleansing solutions. During an observation of wound care for a resident, two licensed nurses placed wound care dressing supplies on a clean field. Among these supplies was an opened tube of Triamcinolone Acetonide Ointment with a manufacturer's expiration date of January 2027, which was marked only with a handwritten letter 'B' and lacked any indication of who opened it or when it was opened. Additionally, two opened bottles of Vashe wound cleansing solution with a manufacturer's expiration date of August 2025 were used, but they also lacked labels indicating the date they were opened or the initials of the person who opened them. In an interview, one of the licensed nurses admitted that the ointment and wound cleanser were not labeled with the necessary information, such as the initials of the person who opened them and the date they were opened, acknowledging that they should have been properly labeled. The facility's nursing protocol for medication labeling, dated March 2024, requires that medications with defined expiration periods be labeled with open and expiration dates, as well as the initials of the person who opened them. This protocol was not followed, leading to the use of potentially expired medications and wound cleansing solutions on the resident.
Medication Transcription Error Leads to Resident's Death
Penalty
Summary
The facility failed to implement pharmaceutical services that ensured the accurate dispensing and administration of medications for two residents. Specifically, the facility did not have procedures in place to confirm the Five Rights (right patient, right medication, right dose, right route, and right time) during the transcription of prescriber's original hand-written medication orders into the electronic Medication Administration Record (eMAR). This failure led to a medication error where a nurse transcribed an order for Lovenox intended for one resident into another resident's eMAR, resulting in the incorrect administration of the medication. Resident #1, who was already on Heparin therapy, received seven doses of Lovenox due to this transcription error. This error caused a significant drop in the resident's blood values, leading to an anemic crisis. Despite receiving multiple blood transfusions, the resident's condition did not improve, and they eventually passed away. The error was discovered and discontinued after four days, but the damage had already been done. Resident #2 experienced a delay in receiving their prescribed Lovenox due to the transcription error. The facility's process for handling medication orders involved physicians handwriting orders into paper charts, which were then transcribed into the eMAR by nursing supervisors. The pharmacy was alerted electronically but did not receive the original hand-written orders, leading to a lack of verification and control over the accuracy of transcriptions. This systemic failure in the medication order process contributed to the severe outcomes for the residents involved.
Significant Medication Error Due to Incorrect Transcription
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically involving two residents. The error occurred due to the incorrect transcription of a physician's handwritten order for an anticoagulant medication. A Licensed Nurse (LN) mistakenly transcribed an order for Lovenox, intended for one resident, into the electronic medication administration record (eMAR) of another resident who was already receiving Heparin. This resulted in the concurrent administration of two different anticoagulants to the wrong resident over several days, leading to severe health complications and eventual death of the resident due to an anemic crisis and critically low blood values. The resident who received the incorrect medication had a history of chronic kidney disease, liver abscess, and was on long-term anticoagulant therapy. The error was discovered after the resident's blood values showed a significant drop, prompting an emergency evaluation and hospitalization. Despite multiple blood transfusions, the resident's condition did not improve, and they were eventually placed on comfort care and passed away. The facility's process for handling medication orders involved handwritten entries by physicians, which were then transcribed into the eMAR by nursing supervisors. However, the 24-hour chart check process failed to catch the transcription error. The involved nurses admitted to not following the protocol correctly, leading to the oversight. The facility's policies and procedures did not include a step to ensure that all transcribed orders in the eMAR had corresponding written orders in the hard chart, contributing to the error.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Anchorage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Polaris Extended Care | 0 mi | — | 4 | 0 |
| Centennial Post Acute | 2.5 mi | — | 9 | 0 |
| Maple Springs Of Wasilla | 29.4 mi | — | 0 | 0 |
| Maple Springs Of Palmer | 34 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.