Inspection Reports for Polaris Healthcare & Rehabilitation Center LLC
21 W. Clarke Avenue, DE, 19963
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
Severe
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Aug 11, 2025
Visit Reason
An unannounced complaint survey was conducted at Polaris Healthcare & Rehab Center LLC from August 6, 2025, through August 11, 2025, based on observations, interviews, and clinical record reviews.
Findings
The facility was found deficient in several areas including insufficient nursing staff to meet resident needs, delays in call bell responses, inadequate dental services, and failure to maintain accurate and complete resident medical records.
Complaint Details
The visit was complaint-related, triggered by allegations of inadequate nursing staff and delayed call bell responses. The complaint was substantiated as evidenced by interviews and observations confirming delays and insufficient staffing.
Severity Breakdown
D: 2
A: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in prolonged call bell response times and unmet care needs. | D |
| The facility failed to assist residents in obtaining routine and emergency dental services as required. | D |
| The facility failed to maintain accurate, complete, and readily accessible medical records for residents. | A |
Report Facts
Residents present: 89
Investigative sample: 20
Call bell delay: 25
Call bell delay: 90
Residents dependent on staff for ADL support: 50
Residents independent with ADLs: 5
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
May 22, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from May 22, 2025 through May 23, 2025.
Findings
No deficiencies or deficient practices were identified during the survey.
Complaint Details
The complaint survey was unannounced and no deficient practices were found, indicating no substantiated complaints.
Report Facts
Survey sample residents: 3
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Apr 3, 2025
Visit Reason
An unannounced Complaint and Follow-up Survey to the Annual, Complaint, Emergency Preparedness and Extended Survey ending January 28, 2025, was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from March 27, 2025 through April 3, 2025.
Findings
The facility was found not to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care as of April 3, 2025. Deficiencies were identified related to failure to report alleged violations of abuse and misappropriation of resident property timely, failure to thoroughly investigate allegations, failure to prevent further potential abuse during investigations, and failure to maintain complete and accurate resident medical records.
Complaint Details
The complaint involved allegations of misappropriation of resident property/funds for resident R18. The facility failed to recognize and report the allegation within 24 hours and failed to thoroughly investigate the allegation. The resident denied missing funds due to misappropriation or exploitation. The facility also failed to continue investigation after the allegation was denied to the police. The complaint was substantiated as evidenced by the deficiencies cited.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property within required timeframes. | SS=D |
| Failure to thoroughly investigate all alleged violations of abuse, neglect, exploitation, or mistreatment. | SS=D |
| Failure to prevent further potential abuse, neglect, exploitation, or mistreatment while investigations are in progress. | SS=D |
| Failure to maintain resident records that are complete, accurately documented, readily accessible, and systematically organized. | SS=D |
Report Facts
Facility census: 93
Sample size: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Business Office Manager | Assigned to review grievance related to missing money for resident R18 |
| E7 | Social Worker | Assigned to complete investigation of grievance related to resident R18 |
| E1 | Former Nursing Home Administrator | Aware of allegations regarding resident R18 |
| E4 | Director of Nursing | Interviewed regarding allegations and investigation of resident R18 |
| E2 | Nursing Home Administrator | Participated in exit meeting and review of findings |
| E6 | Registered Nurse | Responsible for neurological assessments related to resident R500's fall |
| R85 | Resident interviewed regarding misappropriation of funds allegation |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 13
Jan 28, 2025
Visit Reason
An unannounced Annual and Complaint Survey was conducted at Polaris Healthcare & Rehab Center LLC from January 13, 2025 through January 28, 2025, including an Emergency Preparedness survey.
Findings
The survey identified multiple deficiencies related to emergency preparedness training, resident discharge procedures, incident reporting, care planning, pain management, medication administration, and resident rights. Several residents were found to have unmet care needs and the facility failed to follow certain regulatory requirements.
Deficiencies (13)
| Description |
|---|
| Failure to ensure staff received annual Emergency Preparedness training. |
| Failure to notify resident and State LTC Ombudsman of discharge and transfer as required. |
| Failure to report significant injuries and incidents timely to the State agency. |
| Failure to maintain comprehensive care plans addressing residents' needs including pain management, bowel and bladder continence, and mobility. |
| Failure to provide adequate supervision and assistance to prevent falls and injuries. |
| Failure to provide pain management according to professional standards. |
| Failure to provide medication services to avoid missed doses and ensure proper storage and labeling. |
| Failure to maintain resident rights including self-determination and grievance procedures. |
| Failure to provide adequate nutrition and hydration and maintain acceptable nutritional status. |
| Failure to provide quality care including wound care, contracture management, and skin care. |
| Failure to follow bed hold and discharge policies and procedures. |
| Failure to maintain accurate and complete clinical records and documentation. |
| Failure to provide adequate emergency preparedness training and testing. |
Report Facts
Facility census: 91
Residents reviewed: 28
Staff without emergency preparedness training: 3
Residents reviewed for discharge procedures: 3
Residents reviewed for incident reporting: 3
Residents reviewed for care planning: 37
Residents reviewed for pain management: 37
Residents reviewed for medication administration: 1
Residents reviewed for grievance procedures: 1
Residents reviewed for nutrition and hydration: 74
Residents reviewed for quality of care: 9
Residents reviewed for bed hold and discharge: 3
Residents reviewed for clinical record documentation: 3
Inspection Report
Complaint Investigation
Deficiencies: 15
Jan 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration errors, psychotropic drug use, medication errors involving insulin, labeling and storage of drugs, laboratory services, dental services, food safety, communication training, resident rights training, infection control, compliance and ethics training, and behavioral health training.
Findings
The facility was found deficient in multiple areas including failure to deliver ordered medications timely, failure to limit psychotropic PRN orders to 14 days, significant medication errors with insulin administration, incomplete temperature monitoring logs for medication refrigerators, failure to promptly notify physicians of lab results, failure to assist residents in obtaining dental services, failure to ensure food safety and proper dietary orders, lack of mandatory communication, resident rights, infection control, compliance and ethics, and behavioral health training for staff. Immediate Jeopardy was identified and later abated with corrective actions.
Complaint Details
The complaint investigation substantiated multiple deficiencies including medication errors, failure to limit psychotropic drug use, and failures in staff training and resident care. Immediate Jeopardy was identified related to insulin administration errors but was abated by 1/23/25.
Severity Breakdown
Level D: 13
Level K: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Medication (lactulose) ordered but not delivered, causing missed doses and resident confusion. | — |
| Failure to limit PRN psychotropic drug orders to 14 days and lack of stop dates on orders. | Level D |
| Residents not free from significant medication errors, including insulin administration errors and failure to conduct finger stick blood sugar monitoring. | Level K |
| Failure to label and store drugs and biologicals properly in locked compartments with temperature controls. | Level D |
| Failure to maintain complete and accurate temperature logs for medication refrigerators. | Level D |
| Failure to promptly notify ordering medical practitioners of abnormal laboratory results. | Level D |
| Failure to assist residents in obtaining routine and emergency dental services. | Level D |
| Failure to provide food and fluids in a form designed to meet individual needs and failure to ensure food safety and sanitation. | Level D |
| Failure to provide mandatory communication training for direct care staff. | Level D |
| Failure to provide ongoing resident rights training for staff. | Level D |
| Failure to provide mandatory QAPI training for staff. | Level D |
| Failure to provide mandatory infection control training for staff. | Level D |
| Failure to provide mandatory compliance and ethics training for staff. | Level D |
| Failure to provide required in-service training for nurse aides, including dementia management and resident abuse prevention. | Level D |
| Failure to provide required behavioral health training for staff. | Level D |
Report Facts
Deficiencies cited: 14
Missed insulin doses: 4
Incomplete temperature log days: 18
Incomplete temperature log days: 10
Incomplete temperature log days: 8
Incomplete temperature log days: 19
Incomplete temperature log days: 16
Incomplete temperature log days: 9
Flu vaccines: 10
Single dose flu vaccines: 83
Hepatitis B vaccines: 17
COVID-19 vaccines: 2
Hours of CNA training: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Named in multiple findings related to medication errors, audits, and staff education. |
| E4 | Corporate Clinical Support (CCS) | Involved in review of findings and corrective actions. |
| E1 | Nursing Home Administrator (NHA) | Involved in review of findings and corrective actions. |
| E11 | Nurse Practitioner (NP) | Interviewed regarding medication orders and knowledge of missed doses. |
| E9 | Licensed Practical Nurse (LPN) | Interviewed regarding medication refill process and pharmacy communication. |
| E3 | Assistant Director of Nursing (ADON) | Interviewed regarding medication reconciliation and lab results. |
| E16 | Licensed Practical Nurse (LPN) | Interviewed regarding resident admission details. |
| E17 | Registered Nurse (RN), Unit Manager (UM) | Interviewed regarding medication reconciliation and lab results. |
| E48 | Certified Nursing Assistant (CNA) | Interviewed regarding dietary communication. |
| E51 | Licensed Practical Nurse (LPN) | Interviewed regarding dietary orders. |
| E53 | Dietician | Interviewed regarding dietary orders. |
| E28 | Employee with missing communication and training records. | |
| E49 | Employee with missing communication and training records. | |
| E29 | Employee with missing resident rights and behavioral health training. | |
| E30 | Employee with missing resident rights and behavioral health training. | |
| E39 | Employee with missing nurse aide training. | |
| E40 | Employee with missing nurse aide training. | |
| E47 | Employee with missing QAPI training. | |
| E28 | Employee with missing compliance and ethics training. | |
| E30 | Employee with missing compliance and ethics training. | |
| E32 | Employee with missing nurse aide training. | |
| E49 | Employee with missing behavioral health training. | |
| E27 | Employee with missing dental services. | |
| E1 | Nursing Home Administrator (NHA) | Confirmed findings and interviewed multiple times. |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Oct 2, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility from October 1 through October 2, 2024.
Findings
No deficient practice was identified during the survey.
Complaint Details
The complaint survey was unannounced and no deficiencies were found, indicating no substantiated issues.
Report Facts
Survey sample residents: 6
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
Jul 9, 2024
Visit Reason
An unannounced complaint survey was conducted at Polaris Healthcare and Rehab Center from June 27, 2024 through July 9, 2024 based on observations, interviews, and clinical record reviews.
Findings
The facility failed to implement an effective discharge planning process for one resident, resulting in inadequate discharge preparation and continuity of care. Additionally, the facility failed to ensure continuity of medically related social services upon discharge for the same resident. Multiple deficiencies were identified related to discharge planning and social service provision.
Complaint Details
The complaint investigation was substantiated based on record review and interviews indicating the facility failed to properly discharge one resident (R2), including inadequate education on insulin administration and dressing changes, and lack of coordination with community social services.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement an effective discharge plan addressing resident needs including coordination with community providers and education on self-care. | SS=D |
| Failure to ensure continuity of medically related social services upon resident discharge. | SS=D |
Report Facts
Residents present: 79
Investigative sample: 6
Discharge audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E6 | Registered Nurse (RN) | Documented discharge instructions and medication review for resident R2 |
| E5 | Registered Nurse (RN) | Documented wound care progress notes for resident R2 |
| E8 | Certified Nurse's Aide (CNA) | Reported care provided to resident R2 |
| E13 | Nurse Practitioner (NP) | Confirmed medication orders and discharge care for resident R2 |
| E12 | Former Social Worker (SW) | Signed discharge form for resident R2 |
| PO1 | Police Officer | Interviewed regarding incident involving resident R2 |
| CW1 | Case Worker | Care conference person for resident R2 and involved in discharge planning |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and confirmed facility actions |
| E2 | Director of Nursing (DON) | Participated in exit conference and involved in investigation |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Jun 14, 2024
Visit Reason
An unannounced Complaint Survey was conducted at the facility on June 14, 2024.
Findings
No deficient practice was identified during the survey.
Complaint Details
The survey was complaint-related and no deficient practice was found, indicating no substantiated deficiencies.
Report Facts
Survey sample residents: 11
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 14
Apr 11, 2024
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness Survey was conducted at Polaris Healthcare & Rehab Center from April 7, 2024 through April 11, 2024. The survey included observations, interviews, and review of clinical records and other facility documentation.
Findings
The survey identified multiple deficiencies related to resident rights, care planning, safety, medication management, and facility environment. The facility failed to meet several regulatory requirements including dignity and respect for residents, accurate assessments, proper care planning, and maintenance of a safe environment.
Deficiencies (14)
| Description |
|---|
| Resident Rights/Exercise of Rights - Facility failed to treat residents with dignity and respect, including incidents of staff speaking inappropriately and leaving doors open exposing residents. |
| Right to be Informed/Make Treatment Decisions - Facility failed to notify residents or their representatives of changes in medical condition or treatment. |
| Reasonable Accommodations Needs/Preferences - Facility failed to ensure residents had access to functioning call bell systems. |
| Medicaid/Medicare Coverage/Liability Notice - Facility failed to provide proper notice to residents regarding changes in charges and discharge procedures. |
| Accuracy of Assessments - Facility failed to ensure assessments accurately reflected residents' status. |
| PASARR Screening for MD & ID - Facility failed to ensure timely PASARR screening and referral for residents with mental health disabilities. |
| Develop/Implement Comprehensive Care Plan - Facility failed to develop and implement comprehensive, person-centered care plans. |
| Treatment/Services to Prevent/Heal Pressure Ulcer - Facility failed to provide adequate turning and repositioning to prevent pressure ulcers. |
| Free of Accident Hazards/Supervision/Devices - Facility failed to provide adequate supervision and accident prevention measures, resulting in past non-compliance. |
| Bowel/Bladder Incontinence, Catheter, UTI - Facility failed to provide appropriate continence care and services. |
| Drug Regimen Review, Report Irregular, Act On - Facility failed to conduct timely drug regimen reviews and report irregularities. |
| Care Plan Timing and Revision - Facility failed to develop care plans timely and include required interdisciplinary input. |
| Free from Unnecessary Psychotropic Meds/PRN Use - Facility failed to monitor and manage psychotropic medication use appropriately. |
| Food Procurement, Store, Prepare, Serve-Sanitary - Facility failed to maintain nourishment refrigerators in sanitary condition and properly label food items. |
Report Facts
Facility census: 77
Investigative sample: 24
Deficiency completion dates: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E16 | Former CNA | Named in findings related to inappropriate speech and termination |
| E12 | Agency RN | Interviewed regarding care and staff interactions with residents |
| E28 | RN Unit Manager | Interviewed about call bell system and maintenance |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and interviews |
| E2 | Director of Nursing (DON) | Participated in exit conference and interviews |
| E35 | CNA | Observed providing care with door open |
| E33 | CNA | Observed providing care with door open |
| E37 | CNA | Observed assisting resident |
| E13 | LPN | Interviewed about diet changes and notifications |
| E14 | Unspecified staff | Interviewed about diet texture changes and notifications |
| E17 | Former DON 1 | Interviewed about resident interactions |
| E36 | Respiratory Therapist | Interviewed about resident's ability to call for help |
| E20 | Former DON 2 | Interviewed about resident fall incident |
| E23 | RN Supervisor | Interviewed about resident incident |
| E24 | LPN | Documented incident report |
| E25 | RN | Documented incident report |
| E26 | Former CNA | Provided statements in investigation |
| E27 | RT | Provided statements in investigation |
| E31 | CNA | Interviewed about resident toileting |
| E32 | COTA | Interviewed about resident toileting |
| E38 | Supervisor | Confirmed removal of food from refrigerator |
| E42 | Pharmacist Consultant | Documented medication regimen review |
| E45 | Director of Reimbursement Services | Confirmed findings during interview |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Nov 9, 2023
Visit Reason
An unannounced complaint survey was conducted at the facility on November 9, 2023.
Findings
No deficiencies or deficient practices were identified during the survey, which included observation, interviews, and document review.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found, indicating no substantiated issues.
Report Facts
Facility census: 76
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 23
Oct 18, 2022
Visit Reason
An unannounced Annual and Complaint Survey was conducted at Polaris Healthcare from October 6, 2022 through October 18, 2022 to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies related to resident rights, safe environment, notification of changes, privacy/confidentiality, care planning, medication administration, infection control, and other regulatory requirements. The facility failed to ensure proper pre-employment TB screening, respect and dignity for residents, adequate notification of changes, privacy of medical records, and proper care planning and medication management.
Deficiencies (23)
| Description |
|---|
| Facility failed to ensure pre-employment tuberculosis (TB) screening was performed for two employees. |
| Facility failed to ensure residents were treated with respect and dignity during observations. |
| Facility failed to notify appropriate parties of changes in resident condition and room assignment. |
| Facility failed to ensure privacy and confidentiality of resident medical records. |
| Facility failed to provide a safe, clean, comfortable, and homelike environment, including maintaining appropriate room temperatures. |
| Facility failed to ensure immediate consultation with physician for residents with significant change in condition. |
| Facility failed to report allegations of abuse in a timely manner to the State Agency. |
| Facility failed to ensure residents' rights to voice grievances and complaints were respected and properly managed. |
| Facility failed to ensure proper notification before transfer or discharge of residents. |
| Facility failed to provide adequate oral care and hygiene for residents. |
| Facility failed to develop and implement comprehensive, person-centered care plans for residents. |
| Facility failed to provide adequate respiratory care and oxygen administration consistent with physician orders. |
| Facility failed to ensure proper medication administration and documentation, including narcotic counts and medication storage. |
| Facility failed to maintain accurate nurse staffing information and post daily staffing data as required. |
| Facility failed to provide routine and emergency dental services to residents. |
| Facility failed to provide adequate specialized rehabilitative services and speech therapy as ordered. |
| Facility failed to ensure proper infection prevention and control practices, including cleaning and disinfecting equipment and environment. |
| Facility failed to maintain medical records that are complete, accurate, and systematically organized. |
| Facility failed to provide adequate hearing and vision treatment and assistive devices. |
| Facility failed to provide adequate pain management and medication for residents. |
| Facility failed to provide adequate dialysis services and transportation arrangements for residents. |
| Facility failed to ensure psychotropic medication orders were properly reviewed and administered. |
| Facility failed to provide adequate COVID-19 immunization education and documentation for residents and staff. |
Report Facts
Facility census: 46
Survey sample size: 38
Employees sampled for TB screening: 16
Residents reviewed for care plans: 25
Residents reviewed for respiratory care: 4
Residents reviewed for medication review: 6
Residents reviewed for pain management: 3
Residents reviewed for dental services: 4
Residents reviewed for hearing/vision: 2
Residents reviewed for dialysis: 1
Residents reviewed for psychotropic medication: 1
Residents reviewed for COVID-19 vaccination: 5
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