Inspection Reports for Polaris Healthcare & Rehabilitation Center LLC
21 W. Clarke Avenue, Milford, DE, 19963
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 11, 2025, identified deficiencies related to insufficient nursing staff, delayed call bell responses, inadequate dental services, and incomplete resident medical records. Earlier inspections showed a pattern of issues including medication errors, emergency preparedness, resident rights, care planning, and discharge planning, with several substantiated complaints over time. Deficiencies have mainly involved nursing staffing, medication management, resident care documentation, and timely reporting of incidents. Complaint investigations were mostly substantiated when deficiencies were found, including one with immediate jeopardy related to medication errors that was later abated. The facility’s inspection history shows ongoing challenges with regulatory compliance, with some fluctuations but no clear sustained improvement trend.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
39.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
349% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
147 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 2
Date: Aug 11, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with nursing staff adequacy and dental service provision for residents.
Findings
The facility failed to provide sufficient nursing staff to meet resident needs, resulting in prolonged call bell response times and unmet care needs for several residents. Additionally, the facility failed to ensure timely dental services for a resident awaiting teeth extraction and dentures.
Deficiencies (2)
Failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed call bell responses and unmet care needs.
Failed to ensure a resident received timely dental services, including teeth extraction and denture provision.
Report Facts
Residents reviewed for staffing: 20
Residents affected by staffing deficiency: 7
Census on Riverwalk unit: 58
Residents independent with ADLs: 5
Residents requiring assistance from 1-2 staff: 35
Residents dependent on staff for ADL support: 50
Residents sampled for dental services: 3
Residents affected by dental service deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Confirmed delay in resident R6's teeth extraction and denture process |
| E4 | Unit Secretary | Stated dental team can perform teeth extractions and discussed scheduling for resident R6 |
| PC1 | Dental Company Scheduler | Stated resident R6 was not scheduled for teeth extractions at the time |
| E6 | Supervisor | Confirmed receiving calls about resident A1 waiting for assistance |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
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.
The facility failed to assist residents in obtaining routine and emergency dental services as required.
The facility failed to maintain accurate, complete, and readily accessible medical records for residents.
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
Date: May 22, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from May 22, 2025 through May 23, 2025.
Complaint Details
The complaint survey was unannounced and no deficient practices were found, indicating no substantiated complaints.
Findings
No deficiencies or deficient practices were identified during the survey.
Report Facts
Survey sample residents: 3
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 4
Date: 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.
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.
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.
Deficiencies (4)
Failure to report alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property within required timeframes.
Failure to thoroughly investigate all alleged violations of abuse, neglect, exploitation, or mistreatment.
Failure to prevent further potential abuse, neglect, exploitation, or mistreatment while investigations are in progress.
Failure to maintain resident records that are complete, accurately documented, readily accessible, and systematically organized.
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
Deficiencies: 13
Date: Jan 28, 2025
Visit Reason
The inspection was conducted as part of the annual survey and complaint investigations related to resident care, medication management, discharge procedures, and regulatory compliance.
Findings
The facility was found deficient in multiple areas including failure to ensure timely access to residents' personal funds, failure to notify responsible parties and providers of significant changes in condition, failure to report and investigate allegations of misappropriation of resident property, failure to comply with discharge and readmission requirements, incomplete and inadequate care plans, failure to follow physician orders including medication administration and dietary orders, inadequate supervision leading to resident falls, failure to maintain accurate and complete medical records, and failure to promptly notify providers of laboratory results. An Immediate Jeopardy was identified related to medication errors involving insulin administration but was abated during the survey period.
Deficiencies (13)
Failure to ensure residents had timely access to their personal funds.
Failure to consult provider and notify responsible party of significant change in condition for resident R64.
Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failure to respond appropriately to allegations of misappropriation of resident property.
Failure to meet discharge requirements and allow readmission for resident R148.
Failure to develop and implement complete, person-centered care plans for multiple residents.
Failure to review and revise care plan within 7 days of comprehensive assessment for resident R85.
Failure to follow physician orders for diet and provide fluids in a form designed to meet individual needs for resident R64.
Failure to provide supervision to prevent resident R47 from falling out of bed resulting in head injury.
Failure to obtain physician's order and ensure medical care supervised by physician for pressure ulcer care for resident R300.
Failure to ensure residents were free from significant medication errors including missed insulin doses and failure to conduct blood sugar monitoring, resulting in Immediate Jeopardy.
Failure to maintain complete, accurate, and readily accessible medical records for resident R500.
Failure to promptly notify ordering practitioner of laboratory results for resident R64.
Report Facts
Residents reviewed for care plans: 37
Residents reviewed for laboratory services: 4
Residents reviewed for pressure ulcers: 5
Residents reviewed for medication errors: 5
Residents reviewed for medical records: 34
Residents reviewed for nutrition: 1
Residents reviewed for accidents: 2
Residents reviewed for discharge: 3
Residents reviewed for bowel and bladder care: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E17 | DON | Named in multiple findings including care plan deficiencies, notification failures, and medication issues |
| E1 | NHA | Named in findings review and interviews related to multiple deficiencies |
| E4 | Corporate Clinical Support | Named in findings review and interviews related to multiple deficiencies |
| E5 | BOM | Named in findings related to personal funds mismanagement and grievance investigation |
| E6 | Admissions | Named in findings related to discharge and readmission of resident R148 |
| E11 | NP | Named in findings related to wound care and medication administration |
| E2 | DON | Named in findings related to medication errors and facility policies |
| E48 | CNA | Named in findings related to dietary and continence care |
| E9 | LPN | Named in medication administration and reorder process |
| E10 | CNA | Named in observation of resident care and care plan deficiencies |
| E12 | LPN | Named in observation of resident care and care plan deficiencies |
| E21 | Controller | Named in findings related to discharge and readmission of resident R148 |
| E22 | SW | Named in findings related to discharge and readmission of resident R148 |
| E23 | RN | Named in findings related to discharge and readmission of resident R148 |
| E24 | RN | Named in findings related to discharge and readmission of resident R148 |
| E27 | RN | Named in findings related to failure to notify provider and responsible party of change in condition |
| E37 | CNA | Named in findings related to resident fall |
| E42 | RN | Named in findings related to resident fall |
| E43 | RN | Named in findings related to resident fall |
| E44 | COTA | Named in findings related to resident fall |
| E53 | Dietician | Named in findings related to dietary communication failures |
| E58 | CNA | Named in findings related to catheter care |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 24
Date: Jan 28, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident rights, care planning, medication management, infection control, and staff training.
Findings
The facility was found deficient in multiple areas including failure to honor resident care preferences, incomplete advance directive discussions, inadequate notification of changes in condition, unresolved resident grievances, improper discharge procedures, lack of bed hold notifications, incomplete care plans, unlicensed staff performing assessments, inadequate assistance with activities of daily living, failure to follow physician orders, delayed contracture evaluations, improper medication management including missed insulin doses, inadequate respiratory care, failure to provide dental services, food safety violations, and incomplete staff training in communication, infection control, compliance, and behavioral health.
Deficiencies (24)
Failed to ensure care preferences were honored for one resident regarding shower scheduling.
Failed to offer opportunity to formulate an advance directive for one resident.
Failed to notify provider and responsible party of significant change in condition for one resident.
Failed to ensure resident grievances received prompt efforts to resolve problems.
Failed to meet discharge requirements including notice and documentation for one resident.
Failed to notify residents or representatives in writing of bed hold policies upon hospital transfer for three residents.
Failed to develop person-centered care plans for eight residents.
Licensed Practical Nurses completed admission assessments and progress notes, contrary to state regulations requiring RN completion.
Failed to provide activities of daily living assistance to one dependent resident, resulting in overgrown nails.
Failed to follow physician orders for thickened liquids for one resident, resulting in serving thin liquids and coughing.
Failed to complete annual contracture measurement evaluation on time for one resident.
Failed to maintain appropriate catheter care and bowel/bladder continence programs for multiple residents.
Failed to label tube feeding bottles with date and time and lacked physician order for tube feeding upon readmission for two residents.
Failed to provide respiratory care consistent with professional standards including undated nebulizer masks not stored properly for four residents.
Failed to limit PRN psychotropic medication to 14 days for one resident.
Failed to provide pharmacy services to refill medications timely, resulting in missed doses for one resident.
Failed to ensure residents were free from significant medication errors including missed insulin doses and lack of blood sugar monitoring for two residents, resulting in immediate jeopardy.
Failed to ensure medication storage refrigerators were properly monitored and maintained, including expired medications and compromised COVID-19 testing mediums.
Failed to assist one resident in obtaining routine dental services.
Failed to ensure mandatory communication training was completed for two staff members.
Failed to ensure ongoing infection control training was completed for two staff members.
Failed to ensure annual compliance and ethics training was completed for three staff members.
Failed to ensure required minimum twelve hours of in-service training was completed for four nurse aides.
Failed to ensure required behavioral health training was completed for two staff members.
Report Facts
Residents reviewed: 37
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 8
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Employees affected: 2
Employees affected: 2
Employees affected: 3
Employees affected: 4
Employees affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | NHA | Reviewed findings with surveyors and confirmed multiple deficiencies |
| E2 | DON | Reviewed findings with surveyors and confirmed multiple deficiencies; confirmed insulin refill issues |
| E4 | Corporate Clinical Support | Reviewed findings with surveyors and confirmed multiple deficiencies |
| E17 | UM RN | Confirmed care plan deficiencies and admission assessments completed by LPNs |
| E11 | NP | Pain management provider for R85; stated patient was pain medication seeking and refused to prescribe narcotics |
| E9 | LPN | Documented insulin reorder issues and pharmacy communication problems |
| E35 | RN | Confirmed nebulizer mask storage deficiencies |
| E36 | LPN | Confirmed nebulizer mask storage deficiencies |
| E48 | CNA | Interviewed regarding shower scheduling and ADL assistance |
| E28 | CNA | Lacked communication, infection control, compliance, and behavioral health training |
| E29 | RN | Lacked communication, infection control, compliance, and behavioral health training |
| E30 | CNA | Lacked communication and compliance training; lacked required in-service training |
| E39 | CNA | Lacked required in-service training |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 13
Date: 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)
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
Date: 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.
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.
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.
Deficiencies (15)
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.
Residents not free from significant medication errors, including insulin administration errors and failure to conduct finger stick blood sugar monitoring.
Failure to label and store drugs and biologicals properly in locked compartments with temperature controls.
Failure to maintain complete and accurate temperature logs for medication refrigerators.
Failure to promptly notify ordering medical practitioners of abnormal laboratory results.
Failure to assist residents in obtaining routine and emergency dental services.
Failure to provide food and fluids in a form designed to meet individual needs and failure to ensure food safety and sanitation.
Failure to provide mandatory communication training for direct care staff.
Failure to provide ongoing resident rights training for staff.
Failure to provide mandatory QAPI training for staff.
Failure to provide mandatory infection control training for staff.
Failure to provide mandatory compliance and ethics training for staff.
Failure to provide required in-service training for nurse aides, including dementia management and resident abuse prevention.
Failure to provide required behavioral health training for staff.
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
Date: Oct 2, 2024
Visit Reason
An unannounced complaint survey was conducted at the facility from October 1 through October 2, 2024.
Complaint Details
The complaint survey was unannounced and no deficiencies were found, indicating no substantiated issues.
Findings
No deficient practice was identified during the survey.
Report Facts
Survey sample residents: 6
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 9, 2024
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to implement an effective discharge plan for resident R2, addressing his medical and social service needs, including wound care, insulin administration, and continuity of care after discharge.
Complaint Details
The investigation was complaint-driven, focusing on the discharge process for resident R2. The complaint included concerns about inadequate discharge planning, lack of education on wound care and insulin administration, inappropriate discharge circumstances following a behavioral incident, and failure to notify the community caseworker, resulting in a lapse of medically related social services.
Findings
The facility failed to ensure an effective discharge plan for R2, who had multiple medical needs including diabetes, visual impairment, and an open wound. The discharge process lacked proper education and demonstration of self-care abilities, failed to designate a community physician, and did not ensure continuity of medically related social services, resulting in a lapse of care and delayed access to resources after discharge.
Deficiencies (2)
Failure to implement an effective discharge plan addressing R2's needs related to a community primary care physician, open wounds, insulin dependence, and visual impairment.
Failure to ensure continuity of medically related social services upon discharge, resulting in an estimated four-day lapse in community caseworker contact and delayed access to needed services.
Report Facts
Residents reviewed for discharge: 5
Discharge notice period: 30
Discharge date: May 17, 2024
Days until community caseworker contact: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E6 | Registered Nurse (RN) | Documented discharge instructions and confirmed lack of demonstration of R2's ability to self-administer insulin or complete dressing changes |
| E5 | Registered Nurse (RN), Wound Care Nurse (WCN) | Provided wound care education and confirmed lack of observed return demonstration by R2 |
| E13 | Nurse Practitioner (NP) | Provided wound care and medication prescriptions; confirmed no designated community physician for R2 |
| E12 | Former Social Worker (SW) | Signed discharge form but was not involved in discharge planning; confirmed no contact with community caseworker |
| E11 | Social Services Assistant (SSA) | Confirmed no notification to community caseworker of R2's discharge decision |
| CW1 | Case Manager/Case Worker | Reported lack of timely notification and declined meeting requests regarding R2's discharge |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and confirmed no contact with community caseworker |
| E2 | Director of Nursing (DON) | Participated in exit conference and confirmed no contact with community caseworker |
| E15 | Registered Nurse (RN) | Reported behavioral incident involving R2 |
| PO1 | Police Officer | Responded to disorderly complaint involving R2 and documented facility staff's desire to discharge R2 |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
Failure to implement an effective discharge plan addressing resident needs including coordination with community providers and education on self-care.
Failure to ensure continuity of medically related social services upon resident discharge.
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
Date: Jun 14, 2024
Visit Reason
An unannounced Complaint Survey was conducted at the facility on June 14, 2024.
Complaint Details
The survey was complaint-related and no deficient practice was found, indicating no substantiated deficiencies.
Findings
No deficient practice was identified during the survey.
Report Facts
Survey sample residents: 11
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 11, 2024
Visit Reason
The inspection was conducted to investigate complaints related to resident dignity, abuse allegations, and accident prevention at Polaris Healthcare and Rehabilitation Center.
Complaint Details
The complaint investigation included allegations of dignity violations, abuse, and accident prevention failures. The resident-to-resident abuse allegation was substantiated as the facility failed to recognize and immediately report it. The fall incident was determined to be past non-compliance with corrective actions completed.
Findings
The facility failed to maintain resident dignity by providing care with doors open exposing residents, failed to timely report an allegation of abuse between residents, and failed to provide adequate supervision to prevent accidents resulting in harm to a resident. Some deficiencies were determined to be past non-compliance with corrective actions completed.
Deficiencies (3)
Failed to promote care in a manner and environment that maintained or enhanced residents' dignity and respect, exposing residents' unclothed bodies to hallway during care.
Failed to timely report an allegation of abuse involving resident-to-resident incident where a soda can was thrown and verbal threats were made.
Failed to ensure adequate supervision to prevent accidents resulting in harm when a resident fell from a Hoyer lift due to improper transfer by staff.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Dates: Apr 11, 2024
Dates: Oct 19, 2022
Dates: Nov 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E16 | Certified Nursing Assistant (former CNA) | Named in inappropriate speech and behavior toward resident R57 and terminated from facility. |
| E12 | Agency Registered Nurse (RN) | Witnessed and intervened during E16's inappropriate behavior toward resident R57. |
| E35 | Certified Nursing Assistant (CNA) | Observed providing care with door open exposing resident R23. |
| E33 | Certified Nursing Assistant (CNA) | Observed providing care with door open exposing resident R7. |
| E34 | Certified Nursing Assistant (CNA) | Observed providing care with door open exposing resident R7. |
| E26 | Certified Nursing Assistant (former CNA) | Named in fall incident involving resident R57 due to improper use of Hoyer lift and terminated. |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference reviewing findings. |
| E2 | Director of Nursing (DON) | Participated in exit conference and confirmed failure to report abuse allegation. |
| E17 | Former Director of Nursing (DON 1) | Interviewed regarding denial of inappropriate speech by E16. |
| E20 | Former Director of Nursing (DON 2) | Interviewed regarding fall incident involving resident R57. |
| E23 | Registered Nurse Supervisor (RN supervisor) | Interviewed regarding resident-to-resident abuse incident. |
| E24 | Licensed Practical Nurse (LPN) | Provided statement documenting resident-to-resident abuse incident. |
| E25 | Registered Nurse (RN) | Provided statement documenting resident-to-resident abuse incident. |
| E27 | Respiratory Therapist (RT) | Witnessed fall incident involving resident R57. |
| E21 | Licensed Practical Nurse (former LPN) | Documented progress notes and skin evaluation related to resident R57's fall. |
| E22 | Physician | Documented evaluation of resident R57 post fall. |
Inspection Report
Routine
Deficiencies: 15
Date: Apr 11, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate notification of changes in resident condition, failure to ensure call bell accessibility, failure to provide required notices, cleanliness issues, failure to timely report abuse, inaccurate assessments, incomplete care plans, failure to prevent pressure ulcers, inadequate respiratory care, failure to promote continence, and improper food storage.
Deficiencies (15)
Failure to honor residents' right to dignity and respect, including providing care with doors open exposing residents.
Failure to notify resident's contact person of changes in health status, specifically diet texture changes.
Failure to reasonably accommodate residents' needs and preferences, including ensuring call bell accessibility and usability.
Failure to provide Notice to Medicare Provider Non-Coverage (NOMIC) form before service termination.
Failure to maintain cleanliness in resident rooms, including presence of stains and debris.
Failure to timely report suspected abuse, neglect, or theft, specifically failure to recognize and report resident-to-resident abuse.
Failure to ensure accurate assessments, including incomplete MDS assessments.
Failure to develop care plans addressing residents' needs, including anticoagulant medication use.
Failure to have input from all required interdisciplinary team members at care plan meetings.
Failure to provide appropriate pressure ulcer care and reposition residents every two hours to prevent skin breakdown.
Failure to provide appropriate care for residents with incontinence, including failure to promote continence and assist with toileting.
Failure to provide safe and appropriate respiratory care, including failure to change suction equipment and label oxygen tubing and humidifier bottles.
Failure to ensure pharmacist recommendations were reviewed by attending physician during monthly drug regimen review.
Failure to implement required AIMS testing every six months for residents on antipsychotic medications.
Failure to maintain nourishment refrigerators in sanitary condition and store food safely to prevent food-borne illness.
Report Facts
Residents reviewed for dignity: 3
Residents reviewed for call bell accessibility: 40
Residents with care plan meeting deficiencies: 4
Residents reviewed for pressure ulcer care: 4
Residents reviewed for respiratory care: 2
Residents reviewed for medication review: 5
Residents reviewed for abuse: 3
Rooms observed for cleanliness: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E16 | Former CNA | Named in inappropriate speech and argumentative behavior with resident R57. |
| E33 | CNA | Observed providing care with door open exposing resident R7; also involved in incontinent care for R75. |
| E34 | CNA | Observed providing care with door open exposing resident R7; also involved in incontinent care for R75. |
| E35 | CNA | Observed providing care with door open exposing resident R23. |
| E12 | Agency RN | Witnessed inappropriate behavior of E16 towards resident R57. |
| E17 | Former DON | Interviewed regarding denial of inappropriate speech by E16. |
| E1 | NHA | Participated in exit conferences and confirmed multiple findings. |
| E2 | DON | Participated in exit conferences and confirmed multiple findings. |
| E28 | RN Unit Manager | Involved in call bell equipment ordering and resident R131 call bell assessment. |
| E8 | CNA | Interviewed regarding care plan meetings and resident repositioning. |
| E7 | CNA | Interviewed regarding care plan meetings participation. |
| E6 | CNA | Interviewed regarding care plan meetings participation. |
| E13 | LPN | Confirmed respiratory care equipment not changed for resident R3. |
| E31 | COTA | Provided therapy and continence assistance to resident R75. |
| E33 | CNA | Incontinent care for resident R75. |
| E34 | CNA | Incontinent care for resident R75. |
| E29 | Rehab Director | Requested staff to use bedpan and urinal for resident R75. |
| E30 | RN UM | Confirmed continence checks on admission. |
| E11 | RN | Confirmed oxygen tubing and humidifier bottle not dated for resident R66. |
| E3 | ADON | Confirmed lack of AIMS testing for resident R42. |
| E15 | Director of Reimbursement Services | Confirmed incomplete MDS assessment and lack of care plan for anticoagulant use for resident R42. |
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 14
Date: 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)
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
Date: Nov 9, 2023
Visit Reason
An unannounced complaint survey was conducted at the facility on November 9, 2023.
Complaint Details
The complaint investigation was unannounced and no deficiencies were found, indicating no substantiated issues.
Findings
No deficiencies or deficient practices were identified during the survey, which included observation, interviews, and document review.
Report Facts
Facility census: 76
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 10, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely notify the physician of a resident's change in condition and failure to notify the Ombudsman of a resident's hospital transfer.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to timely notify the physician of a resident's change in condition and failure to notify the Ombudsman of a resident's hospital transfer.
Findings
The facility failed to make timely contact with the physician when a resident (R1) had a new onset of vomiting, resulting in a 6.5 hour delay in treatment. Additionally, the facility failed to notify the Ombudsman when another resident (R4) was transferred to the hospital. The facility lacked a written process for contacting an on-call physician if the provider could not be reached.
Deficiencies (3)
Failure to immediately notify the resident, resident's doctor, and family of a significant change in condition (vomiting) for resident R1.
Failure to notify the Ombudsman of resident R4's hospital transfer.
Failure to identify and monitor a significant change of condition for resident R1 for 6.5 hours, resulting in delayed treatment.
Report Facts
Time delay: 6.5
Calls to provider: 2
Vital signs: 71
Vital signs: 45
Vital signs: 108
Pulse oximetry: 78
Resident transfer date: Jan 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Registered Nurse (RN) | Named in findings related to failure to timely notify provider and monitor resident R1 |
| E10 | On-call Provider | Named in findings related to provider call attempts and communication with facility |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conference and confirmed lack of written process for contacting on-call physician |
| E2 | Director of Nursing (DON) | Participated in exit conference and provided information on response times for practitioner calls |
| E3 | Director of Clinical Services | Participated in exit conference and confirmed lack of recognition of change in condition |
| E9 | Family Nurse Practitioner (FNP) | Performed initial assessment of resident R1 and provided expert opinion on change in condition |
| E12 | Certified Nursing Assistant (CNA) | Reported observations of resident R1 vomiting during shift |
| E6 | Registered Nurse (RN), Unit Supervisor | Interviewed regarding communication attempts to provider by E5 |
| E17 | Provider Administrator | Provided information on call logs between facility and provider |
| E4 | Ombudsman | Confirmed facility failed to notify Ombudsman of resident R4 hospital transfer |
Inspection Report
Routine
Deficiencies: 22
Date: Oct 18, 2022
Visit Reason
The inspection was a routine survey of Polaris Healthcare and Rehabilitation Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including resident dignity, timely physician consultation, confidentiality of medical records, environmental comfort, grievance procedures, abuse reporting, transfer notifications, baseline and comprehensive care planning, respiratory care, medication management, infection control, dental services, rehabilitation services, and COVID-19 vaccination documentation.
Deficiencies (22)
Failed to ensure residents were treated with respect and dignity during observations.
Failed to ensure immediate consultation with the resident's attending physician when a significant change in condition occurred.
Failed to secure confidential medical records during medication administration.
Failed to keep temperatures at a comfortable level in the facility.
Failed to make information available to residents regarding how to file grievances anonymously.
Failed to report an allegation of abuse immediately within 2 hours to the State Agency.
Failed to provide timely notification of resident transfers to the Ombudsman.
Failed to notify resident or representative in writing about bed hold policies during hospital transfers.
Failed to develop baseline care plans within 48 hours of admission for some residents.
Failed to develop and implement comprehensive person-centered care plans for residents.
Failed to provide care and assistance for activities of daily living including oral hygiene and bathing.
Failed to provide prescribed medication to treat infection in a timely manner.
Failed to ensure dialysis services were received when scheduled due to failure to arrange transportation.
Failed to post nurse staffing information accurately and completely.
Failed to maintain accurate account of all controlled drugs in medication carts.
Failed to ensure drugs and biologicals were stored properly, including locked compartments and removal of expired or discontinued medications.
Failed to provide or obtain routine dental services for residents.
Failed to provide specialized rehabilitative speech services as ordered.
Failed to ensure monthly medication regimen reviews were acted upon and documented properly.
Failed to safeguard resident-identifiable information and maintain accurate medical records.
Failed to maintain an effective infection prevention and control program, including proper cleaning of blood glucose meters and medication handling.
Failed to educate residents and staff on COVID-19 vaccination and properly document vaccination status.
Report Facts
Number of shifts with no bowel movement: 21
Number of shifts with no bowel movement: 20
Number of shifts with no bowel movement: 13
Number of shifts with no bowel movement: 18
Number of shifts with no bowel movement: 9
Number of shifts with no bowel movement: 9
Number of shifts with no bowel movement: 9
Number of shifts with no bowel movement: 25
Number of shifts with no bowel movement: 12
Number of shifts with no bowel movement: 11
Number of doses of PRN Lorazepam: 17
Number of speech therapy visits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E19 | CNA | Named in dignity deficiency for verbalizing residents as feeders |
| E32 | MD | Named in dignity deficiency for entering resident room without permission |
| E25 | LPN, UM | Named in failure to consult physician timely for oxygen saturation decline |
| E9 | LPN, UM | Named in failure to consult physician timely for oxygen saturation decline |
| E24 | RN | Named in failure to secure confidential medical records and medication cart left unlocked |
| E37 | Agency Nurse | Named in temperature comfort deficiency |
| E36 | Maintenance Director | Named in temperature comfort deficiency |
| E5 | Social Service | Named in grievance procedure deficiency and hearing difficulty unawareness |
| E2 | DON | Named in multiple deficiencies including abuse reporting, care planning, medication management, infection control |
| E1 | NHA | Named in multiple deficiencies including abuse reporting, care planning, medication management, infection control |
| E7 | LPN | Named in medication cart unlocked and respiratory care deficiencies |
| E26 | Agency LPN | Named in failure to respond to low oxygen saturation |
| E33 | MDS coordinator | Named in care plan and hygiene deficiencies |
| E35 | DOR | Named in speech therapy service deficiency |
| E27 | RT | Named in medication room unlocked deficiency |
| E3 | ADON | Named in respiratory care and infection control deficiencies |
| E17 | CNA | Named in oral care deficiency |
| E34 | Former ADON | Named in medication regimen review signature deficiency |
| RPh1 | Pharmacy Consultant | Named in medication regimen review deficiency |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 23
Date: 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)
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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