Cycle 1
Health 2025-05-22 · Fire 2025-05-22
43 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Anchorage, AK
Polaris Extended Care
1-star overall rating with 1-star inspections with abuse icon flag with $220,373 in total fines with 43 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
920 Compassion Circle, Anchorage, AK
(907) 212-9200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2013-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
Yes
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.88
Registered nurse staffing · state 2.15 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.86 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 4.17 · national 2.35
Total nurse hours
5.33
All reported nurse hours · state 7.00 · national 3.89
Licensed hours
2.75
RN + LPN hours · state 2.83 · national 1.54
Weekend hours
4.65
Weekend nurse staffing · state 6.21 · national 3.43
Weekend RN hours
1.50
Weekend registered nurse coverage · state 1.62 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.70
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,612
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0102
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.99
Baseline 46.62% · Performance 39.20% · Measure score 5.99 · Achievement 5.99 · Improvement 2.91
Adjusted total nurse staffing
5.06
Baseline 4.66 hours · Performance 4.52 hours · Measure score 5.06 · Achievement 5.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.18% |
8.2%
5 pts worse
|
Numerator 5 · Denominator 157 |
| Staff flu vaccination coverage | 47.25% |
42%
5.2 pts better
|
Numerator 86 · Denominator 182 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.5% |
93.8%
31.3 pts worse
|
93.4%
30.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 77.3% · Q3 43.3% · Q4 38.6% · 4Q avg 62.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.6% |
96.0%
5.4 pts worse
|
95.5%
4.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.0%
1.9 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 1.1% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
5.3%
3.4 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.3% · Q3 1.2% · Q4 1.2% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
4.9%
1.7 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.4% · Q3 3.4% · Q4 3.4% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
14.3%
1.8 pts worse
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 15.1% · Q3 11.5% · Q4 20.7% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
18.4%
5.6 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 26.2% · Q3 23.9% · Q4 22.5% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.0% |
0.1%
1.9 pts worse
|
0.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.3% · Q3 2.2% · Q4 2.3% · 4Q avg 2.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.3% |
16.3%
3 pts better
|
14.9%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 14.8% · Q3 12.1% · Q4 15.2% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.3%
0.1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.6% · Q3 0.9% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
3.5%
1.8 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.2% |
19.9%
1.7 pts better
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 17.6% · Q3 16.6% · Q4 19.7% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
7.8%
1.6 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 9.5% · Q3 9.6% · Q4 7.2% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.5% |
78.4%
34.9 pts worse
|
81.7%
38.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q4 45.0% · 4Q avg 43.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2024-07-19
24 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-04-14 · Fire 2023-04-14
15 health deficiencies
Top issue: Resident Rights (6 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-07-06
F · Potential for more than minimal harm
2025-05-22
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-07-06
F · Potential for more than minimal harm
2025-05-22
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-07-06
F · Potential for more than minimal harm
2025-05-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-06
F · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-06
F · Potential for more than minimal harm
2025-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-06
F · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-06
E · Potential for more than minimal harm
2024-07-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-22
F · Potential for more than minimal harm
2023-04-14
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-29
F · Potential for more than minimal harm
2023-04-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-06
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2026-01-12
D · Potential for more than minimal harm
2026-01-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-12
D · Potential for more than minimal harm
2026-01-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-12
G · Actual harm
2025-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-07-29
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-07-30
E · Potential for more than minimal harm
2025-07-29
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-30
F · Potential for more than minimal harm
2025-07-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-16
G · Actual harm
2025-05-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-09
G · Actual harm
2025-05-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-07-09
F · Potential for more than minimal harm
2025-05-22
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-05-22
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-05-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-05-22
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-05-22
F761 · Pharmacy Service Deficiencies
Health
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 locked, compartments for controlled drugs.
Corrected 2025-07-09
E · Potential for more than minimal harm
2025-05-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-09
C · Minimal harm
2025-05-22
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-07-09
G · Actual harm
2025-03-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-04
G · Actual harm
2025-03-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-17
F761 · Pharmacy Service Deficiencies
Health
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 locked, compartments for controlled drugs.
Corrected 2025-04-04
D · Potential for more than minimal harm
2024-11-26
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-30
I · Actual harm
2024-07-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-09-02
I · Actual harm
2024-07-19
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-09-02
H · Actual harm
2024-07-19
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2024-09-02
H · Actual harm
2024-07-19
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-09-02
G · Actual harm
2024-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-02
F · Potential for more than minimal harm
2024-07-19
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-07-28
E · Potential for more than minimal harm
2024-07-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-07-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-07-19
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-07-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-30
E · Potential for more than minimal harm
2024-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-07-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-07-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-02
E · Potential for more than minimal harm
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F761 · Pharmacy Service Deficiencies
Health
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 locked, compartments for controlled drugs.
Corrected 2024-09-02
D · Potential for more than minimal harm
2024-07-19
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-27
B · Minimal harm
2024-07-19
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-09-02
E · Potential for more than minimal harm
2023-04-14
F761 · Pharmacy Service Deficiencies
Health
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 locked, compartments for controlled drugs.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-04-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-29
D · Potential for more than minimal harm
2023-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-29
Penalties and ownership
What sits behind the stars
$98,865
2025-05-22
Fine
Fine · fine $98,865
Fine
$10,358
2025-03-17
Fine
Fine · fine $10,358
Fine
$111,150
2024-07-19
Fine
Fine · fine $111,150
Fine
$0
2024-07-19
Payment Denial
Payment Denial · denial start 2024-08-25 · 8 days
8 day denial
Ownership
Flagstone Healthcare Central LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cullifer, Jared
Corporate Officer · Individual
Hancox, Neil
Operational/Managerial Control · Individual
Sato, Ami
Corporate Officer · Individual
Willits, Adam
Corporate Director · Individual
Willits, Adam
Corporate Officer · Individual
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1-star overall rating with 1-star inspections with $76,749 in total fines with 34 recent health deficiencies with 23 fire-safety deficiencies in the latest cycle
#3
Maple Springs Of Wasilla
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5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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