MILFORD, DE - Federal inspectors found serious medication management failures at Polaris Healthcare and Rehabilitation Center that put diabetic residents at risk of life-threatening complications, including one case where a resident went without required insulin for 64 hours.
During a January 28, 2025 inspection, Centers for Medicare & Medicaid Services (CMS) investigators documented violations ranging from immediate jeopardy medication errors to widespread staff training deficiencies and food safety issues at the 21 W Clarke Avenue facility.
Critical Insulin Management Failures Put Lives at Risk
The most serious violation involved two diabetic residents who were left without their prescribed insulin medications due to pharmacy delivery problems and inadequate emergency protocols. Federal investigators classified this as an "immediate jeopardy" situation - the highest level of concern indicating serious risk to resident health and safety.
In the first case, a resident identified as R299 was admitted on October 4, 2024, with diabetes mellitus. Despite hospital discharge orders requiring insulin monitoring and administration, the facility failed to conduct required blood glucose testing at dinner time and bedtime on the day of admission. When blood glucose was finally checked the morning after admission, it measured 432 mg/dL - more than three times the normal range of 80-120 mg/dL.
The family members noticed the medication oversight. One family member told investigators: "One time I had no lactulose for the three days. I was worried because without it I get confused, but I didn't." Another family member reported that staff confirmed R299's medications would not be delivered until the following morning.
Even more concerning was the case of resident R46, who missed four consecutive doses of prescribed Insulin Glargine between December 23-29, 2024. Documentation showed staff were aware of the missing medication but failed to implement emergency protocols. A nurse's note from December 28 revealed the frustration: "This med was reordered on 12/22, and this nurse call[ed] the pharmacy [to] ask for [Insulin Glargine] pen to be delivered the next day because the resident was out of this meds. The pharmacist hang up in my face... Supervisor and the DON is aware of the situation. Still no delivery."
During interviews, agency nurses revealed that medication shortages were common at the facility. One nurse stated: "They are often out of medications at that facility and some people use other residents insulin's but I don't."
The medical implications of these failures are severe. When diabetic patients miss insulin doses, blood glucose levels can rise dangerously high, leading to diabetic ketoacidosis - a potentially fatal condition where the body begins breaking down fat for energy, producing toxic acids. Without prompt treatment, this condition can progress to diabetic coma and death.
Standard medical protocols require nursing facilities to maintain emergency medication supplies and have clear procedures for obtaining urgent medication when regular supplies are depleted. The inspection revealed that insulin was not included in the facility's emergency medication stock, despite serving diabetic residents who require this life-sustaining medication.
Systematic Pain Management Failures
Federal investigators also documented serious deficiencies in pain management for a resident with chronic conditions including fibromyalgia and low back pain. The resident, identified as R85, experienced approximately 64 hours of severe uncontrolled pain rated at 10 out of 10 when her prescribed oxycodone medication ran out and was not promptly replaced.
The facility's medication administration records showed inconsistent pain assessment practices, with staff failing to use standardized pain scales for pre- and post-medication evaluation. Pain management standards established by the American Geriatrics Society emphasize the importance of consistent quantitative assessment tools and regular reassessment to ensure effective treatment.
During the gap in pain medication coverage from January 6-8, 2025, R85 received only Tylenol, which proved ineffective for her chronic pain condition. Documentation showed the ineffective pain relief prevented her from participating in physical therapy and performing daily activities. A progress note stated: "Patient was unable to do PT today because she did not have her pain medication. The order was discontinued per provider. I gave her Tylenol but patient states that does not help at all."
R85 told investigators that "when her pain was uncontrolled she was unable to participate in therapy and unable to get out of bed" and that "she reported these pain levels to staff and no medication was ordered during that time."
Food Safety and Storage Violations
The inspection revealed multiple food safety violations that could expose residents to foodborne illness. In the kitchen, investigators found sanitizing solution at inadequate concentration levels and a dishwashing machine operating at only 130 degrees Fahrenheit during the rinse cycle - far below the required 180 degrees needed for proper sanitization.
Throughout various storage areas, inspectors documented expired and improperly labeled food items. The nourishment rooms contained turkey and cheese sandwiches six days past their safe consumption date, undated spinach dip, and processed cheese food that had been opened since October 2024. The dining room refrigerator held an undated bottle of prune juice and multiple items lacking proper date labels.
Food safety protocols exist to prevent bacterial growth that can cause serious illness in elderly residents, whose compromised immune systems make them particularly vulnerable to foodborne pathogens. Proper temperature control and dating systems are fundamental requirements for institutional food service.
Training and Supervision Deficiencies
Investigators found widespread failures in mandatory staff training programs. Multiple nursing assistants had not received the required 12 hours of annual in-service training, with some staff members receiving zero training hours during their entire employment period. One certified nursing assistant hired in January 2023 had completed only 1.05 hours of training over a two-year period.
The facility also failed to provide required ongoing training in residents' rights, infection control, behavioral health, and compliance programs. These training requirements exist to ensure staff maintain current knowledge of best practices and regulatory requirements that protect resident safety and rights.
Medical Equipment and Storage Issues
The inspection revealed concerning problems with medication storage and testing equipment integrity. Temperature monitoring logs for medication refrigerators were incomplete for months at a time, with some periods showing no temperature monitoring at all. This creates risks for vaccines and other temperature-sensitive medications that may lose effectiveness if not properly stored.
Investigators also found COVID-19 testing materials that had been compromised by water contamination, including one container with approximately an inch of water and black substance. A laboratory technician confirmed these materials should not be used, as contaminated testing supplies can produce inaccurate results.
Additional Issues Identified
The inspection documented several other violations including:
- Delayed dental services, with one resident reporting she had not seen a dentist since before admission despite electing to receive dental care through the facility - Missed doses of lactulose medication for a resident with cirrhosis, creating risk of confusion and other complications - Incomplete annual performance reviews for nursing staff - Expired medications found in storage areas
Regulatory Response and Corrective Actions
CMS investigators called an immediate jeopardy situation on January 23, 2025, due to the insulin management failures. The facility was required to implement immediate corrective measures, including new policies for diabetic medication verification and administration, comprehensive staff education, and addition of insulin to emergency medication supplies.
The immediate jeopardy status was lifted later that same day after the facility demonstrated compliance with corrective requirements and confirmed all current residents had access to necessary insulin and current medication orders.
The violations demonstrate the critical importance of systematic medication management, proper staff training, and robust quality assurance programs in nursing home operations. Federal nursing home regulations exist specifically to prevent these types of failures that can result in serious harm or death to vulnerable elderly residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Polaris Healthcare and Rehabilitation Center from 2025-01-28 including all violations, facility responses, and corrective action plans.
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