Polaris Healthcare: Patient Suffered 64 Hours Unrelieved Pain - DE
The patient, identified as R85, was admitted December 12 with diagnoses including low back pain, fibromyalgia, muscle weakness, and gait abnormalities. An admission assessment that night documented the resident had no complaints of pain but "lacked an acceptable level of pain" and "lacked treatment for pain."
Three days later, staff initiated a care plan acknowledging the resident's "potential for alteration in comfort related to pain." The plan set a goal that "pain medication will be effective in controlling discomfort by next review" and included interventions to assess pain symptoms, assist with repositioning, provide medication as ordered, and notify physicians if treatments proved ineffective.
But the medication never came.
A December 19 assessment revealed R85 was experiencing pain frequently, with discomfort occasionally affecting sleep, therapy activities, and daily routines. The resident's pain score remained at 10/10. The assessment noted R85 was cognitively intact with a BIMS score of 15, meaning the resident could clearly communicate their suffering.
The facility's own records showed R85 was supposed to be on a scheduled pain regimen and receiving as-needed pain medication. Instead, the resident received no non-medication interventions either.
On January 23, a registered nurse confirmed during an interview that R85's care plan lacked revision related to an acceptable pain level and appropriate interventions. The care plan contained no evidence of an acceptable pain level or pain level goal for the resident. It also lacked non-pharmacological interventions for addressing R85's pain.
The violation represents one of eight deficiencies inspectors documented during their January 28 visit to the 120-bed facility on West Clarke Avenue. Other findings revealed systematic failures in basic care standards.
Licensed practical nurses improperly completed admission assessments for two residents, violating Delaware State Board of Nursing regulations that require registered nurses to perform initial evaluations. LPNs completed admission evaluations, continence assessments, fall risk evaluations, and other critical screenings for residents R6 and R27, despite state law restricting such duties to RNs.
Inspectors found a resident identified as R6 with severely overgrown nails that staff ignored for days. The resident required assistance with daily living activities due to general weakness and lower extremity impairment. During a January 13 interview, R6 said no one had offered to clip her nails. Inspectors observed the long, overgrown nails on January 14, 15, and 16. Only after a registered nurse confirmed the problem on January 16 did staff finally clip the resident's nails the following morning.
Communication breakdowns endangered another resident when staff served thin liquids to someone ordered to receive thickened liquids for swallowing safety. Resident R64 received a physician's order for thickened liquids on January 14 at 7:23 PM. The next day at lunch, inspectors observed R64's tray contained water, coffee, and juice — all thin liquids that posed a choking risk.
R64 was actively drinking the thin liquids and coughing when inspectors arrived. A certified nursing assistant told inspectors she wasn't informed during shift report that R64 needed thickened liquids. The dietary department never received the order because nurses failed to enter it properly in the electronic medical record and didn't complete a dietary communication slip as backup protocol required.
Staff failed to provide toileting assistance to multiple residents despite assessments identifying them as candidates for scheduled bathroom breaks. Four residents experienced unnecessary incontinence because the facility didn't implement toileting programs their own evaluations recommended.
Resident R61, who was continent at home, told inspectors she was "usually incontinent at the facility due to staff taking too long to answer the call bell." Another resident, R4, was continent of bowel at home and could use the toilet independently but became incontinent without a toileting schedule. Documentation showed R4 was continent of bowel only four times out of 80 opportunities in December and eight times out of 46 opportunities in January.
A resident with ALS went nearly 20 hours without tube feeding after readmission because staff failed to obtain physician orders to resume nutrition. R91 was readmitted January 13 at 4:23 PM but didn't receive a tube feeding order until 12:30 PM the following day.
Infection control violations included improper storage of nebulizer equipment for respiratory treatments. Inspectors found nebulizer masks sitting on bedside tables, blankets, and in drawers without proper dating or storage in plastic bags. One mask was dated December 26 but still in use January 13. Staff admitted they weren't sure about proper storage procedures.
The facility also failed to complete annual range-of-motion evaluations on time. A resident with stroke history and muscle weakness didn't receive a contracture assessment for nearly a month past the required annual date. When inspectors requested the evaluation, staff scrambled to complete it, finding the resident's left hand contractures had worsened to "severe" status.
A catheter drainage bag was found lying on a resident's bed instead of hanging below bladder level, violating CDC infection prevention guidelines.
The inspection revealed a facility where basic nursing protocols repeatedly broke down, leaving vulnerable residents without essential care. From uncontrolled pain to infection risks to nutrition failures, the violations documented a pattern of substandard care that federal regulators classified as causing actual harm to at least one resident.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
POLARIS HEALTHCARE AND REHABILITATION CENTER in MILFORD, DE was cited for violations during a health inspection on January 28, 2025.
The patient, identified as R85, was admitted December 12 with diagnoses including low back pain, fibromyalgia, muscle weakness, and gait abnormalities.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.