Polaris Healthcare And Rehabilitation Center
POLARIS HEALTHCARE AND REHABILITATION CENTER in MILFORD, DE — inspection on January 28, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R85's clinical record revealed:
12/12/24 - R85 was admitted to the facility with diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait.
12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain.
12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain.
The care plan documented the goal as pain medication will be effective in controlling discomfort by next review.
The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide disversional activities.
12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions.
The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator.
The MDS also documented that R85 had a BIMS score of 15 indicating R85 is cognitively intact.
12/2024 - A review of the December MAR documented that R85's pain level ranged from a score of 2/10 to 8/10. R85's pain level was noted at 10/10 prior to pain medication administration and scored as effective or score of 8/10 or below post pain medication administration.
1/2/25 5:41 PM - A physician's order documented oxycodone (narcotic pain medication) 10 mg tablet, give one tablet every six hours as needed for pain for six days ending on 1/6/25.
085058
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085058 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963
Review of R85's clinical record revealed:
12/12/24 - R85 was admitted to the facility with the diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait.
12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain.
12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain.
The care plan documented the goal as pain medication will be effective in controlling discomfort by next review.
The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide diversional activities.
12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions.
The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator.
The MDS also documented that R85's BIMS score was 15 indicating R85 was cognitively intact.
1/23/25 3:34 PM - An interview with E17 (RN UM) revealed that R85's care plan lacked revision related to acceptable pain level and appropriate interventions related to pain.
The care plan lacked evidence of an acceptable pain level and pain level goal for R85.
The care plan also lacked non-pharmacological interventions for addressing R85's pain.
085058
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085058 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963
The facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems.
1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).
085058
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085058 B.
Wing 01/28/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963