Polaris Healthcare And Rehabilitation Center

F-F657.

April 2002 - The pain management standards by the American Geriatrics Society included: appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management.

November 2009 - The American Academy of Pain Medicine, Pharmacological Management of Persistent Pain in Older persons, stated to refer to the previous American Geriatrics Society for specific recommendations for pain assessment in older persons that remain relevant.

Review of Resident R85's clinical record revealed:

12/12/24 - Resident 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 Resident 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 Resident 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 Resident 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 Resident 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 Resident R85 had a BIMS score of 15 indicating Resident R85 is cognitively intact.

12/2024 - A review of the December MAR documented that Resident R85's pain level ranged from a score of 2/10 to 8/10. Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 1/6/25 1:25 AM - The Januaury MAR documented Resident R85 received a dose of PRN oxycodone 10 mg tablet documented 10/10 pain and a result of effective post pain assessment. The facility failed to use a pain scale Level of Harm - Actual harm for evaluation of pain with consistent measurement of pain pre and post administration.

Residents Affected - Few 1/6/25 - 1/8/25 - A review of the MAR documented Resident R85's pain score was 10/10 every shift. Resident R85 received PRN Tylenol during the aforementioned dates indicating 10/10 pain level and post administration score of ineffective during this time. The MAR lacked evidence of an oxycodone order in place or administered. The facility failed to use a pain scale for evaluation of pain with consistent measurement of pain pre and post administration.

1/7/25 1:38 PM - A progress noted documented 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 .

1/8/25 00:01 AM - A physician's (E20) progress note documented a follow up visit with Resident R85 to discuss pain medication use. The note stated that Resident R85 continues to complain of low back pain and will be looking at long term use of narcotic pain medication use. E20 documented that he would provide temporary pain medication twice daily as needed and consult to pain management.

1/8/25 5:58 PM - A physician's (E20) order documented oxycodone 10 mg tablet, give one tablet every twelve hours as needed for chronic pain, fibromyalgia for ten days.

1/8/25 7:02 PM - A progress note documented .Patient has chronic pain and complains of pain being a 10/10. Patient was referred to pain management due to pain and narcotic dependence .

1/13/25 10:04 AM - An interview with Resident R85 revealed she has had chronic pain in her lower back and was currently on a scheduled pain medication regimen. Resident R85 revealed that recently that her pain medication perscription was no longer active and Resident R85 was without scheduled pain medication for multiple days. Resident R85 stated that when her pain was uncontrolled she was unable to participate in therapy and unable to get out of bed. Resident R85 stated that she reported these pain levels to staff and no medication was ordered during that time.

1/17/25 8:30 AM - An interview with E2 (DON) confirmed that oxycodone is available in the facility emergency medication stock.

1/17/25 12:11 PM - An interview with E11 (NP) revealed that Resident R85 was under E20's care for pain management. E11 stated that [Resident R85] is pain medication seeking and I will not prescribe [Resident R85] narcotics. Also E11 stated that is why Resident R85 is under E20's care. E11 stated staff did not notify her that Resident R85 was out of pain medication.

1/17/25 12:22 PM - An interview with E25 (scheduler) and E26 (RN UM) confirmed that Resident R85 was referred to pain management with an outside provider and it was ordered on 1/8/25. E26 confirmed that the appointment was made on 1/16/25 due to E26 not being told of the aforementioned appointment. E26 stated Resident R85 will be seen on 2/26/25 by pain management.

1/22/25 2:30 PM - An interview with E27 (RN) confirmed that Resident R85 did not have a current order for pain medication from 1/6/25 to 1/8/25 and notified E11 on 1/7/25. E27 was unable to provide documentation that

she reported Resident R85 was out of medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 1/23/25 2:44 PM - An interview with E20 confirmed he was not notified of the oxycodone prescription being discontinued and did refer Resident R85 to pain management. E20 confirmed he will continue the current pain Level of Harm - Actual harm medication regimen until Resident R85 is seen by pain management. E20 also stated he was unaware that the E11 was notified that Resident R85 did not have any pain medication. Residents Affected - Few 1/23/25 3:00 PM - Review of findings with E1 (NHA) confirmed that the facility did not have an active order for pain medication from 1/6/25 to 1/8/25 and should have consulted the provider regarding the ineffective pain medication administered in the absence of oxycodone. At this time, E1 confirmed that the facility failed to provide medication to control Resident R85's pain resulting in approximately sixty four hours of severe uncontrolled pain rated at a level of 10 out of 10.

1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or 32810 potential for actual harm Based on record review and interview it was determined that for one (E39) out of five CNA's reviewed for Residents Affected - Few annual performance reviews, the facility failed to ensure that the annual performance review was completed at least once every twelve months. Findings include:

1/2/23 - E39's most recent performance review was completed on 1/17/25. The facility lacked evidence of a performance review completed in 2024.

1/15/25 1:21 PM - During an interview E1(NHA) confirmed the findings.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Few Based on record review and interview it was determined that for one (Resident R32) out of one resident reviewed for medication administration, the facility failed to provide pharmacy services to refill medications to avoid missed doses. Findings include:

Review of Resident R32's clinical record revealed:

9/1/23 - Resident R32 was admitted to the facility with multiple diagnoses including cirrhosis of the liver.

8/27/24 - A physician's order was written for Resident R32 to receive lactulose 45ml twice a day for cirrhosis of the liver.

12/7/24 - A quarterly MDS assessment documented that Resident R32 was cognitively intact.

12/30/24 9:02 AM - An order administration note in Resident R32's clinical record documented, medication (lactulose) ordered not delivered, nurse called pharmacy.

12/31/24 9:59 AM - An order administration note in Resident R32's clinical record documented, medication (lactulose) ordered, not delivered, will notify supervisor and call pharmacy.

12/31/24 3:09 PM - An order administration note in Resident R32's clinical record documented, med (lactulose) not delivered, pharmacy called and said it would arrive by 3:00 pm, was not delivered.

December 2024 - Review of Resident R32's MAR lacked evidence the resident received the ordered doses of lactulose on 12/30/24 and 12/31/24.

1/13/25 9:30 AM - During an interview Resident R32 stated One time I had no lactulose for the three days. I was worried because without it I get confused, but I didn't.

1/17/25 11:45 AM - Review of pharmacy refill request for Resident R32 revealed the request for lactulose was made

on 12/30/24. The same date as the missed dose on 12/30/24.

1/17/25 11:48 AM - E2 (DON) confirmed that a delay in ordering resulting in Resident R32's missed doses of lactulose.

1/23/25 8:42 AM - E2 provided the surveyor with an undated pharmacy memorandum regarding refilling of medications. The memorandum read the following Attention Nursing Personnel then listed pharmacy contact information as well as a table of timeframe's to order medications and expected delivery time. The memorandum also indicated that STAT orders must be called into the pharmacy to notify the pharmacy that it's a STAT order.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2, and E4(CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Immediate 46988 jeopardy to resident health or safety Based on record review and interview, it was determined that for two (Resident R299 and Resident R46) out of five residents reviewed for unnecessary medication, the facility failed to ensure residents were free from a significant Residents Affected - Some medication error when staff failed to administer insulin. Additionally, staff failed to conduct finger stick blood sugar monitoring, which included sliding scale insulin coverage based on the results. The facility's failure placed the residents at risk for a serious adverse outcome including diabetic ketoacidosis, diabetic coma or even death from untreated elevated blood sugar. Due to this failure an Immediate Jeopardy (IJ) was called

on 1/23/25 at 11:52 AM. The IJ was abated on 1/23/25 at 11:00 PM. Findings include:

1. Review of Resident R299's clinical record revealed:

10/4/24 5:00 PM - Resident R299 was admitted with diagnoses including but not limited to diabetes mellitus.

10/4/24 - A discharge summary from hospital documented Resident R299 had a diagnosis of diabetes mellitus, orders for insulin, and orders to monitor blood sugar.

10/4/24 - Resident R299's medication administration record (MAR) lacked evidence of a blood glucose reading at dinner time and bed time. The MAR also lacked evidence of coinciding sliding scale insulin administration based on blood glucose reading.

10/5/24 12:04 AM - A telephone physician's order for Lispro (insulin) was entered into the electronic medical record. The order read as follows: Insulin Lispro (1 unit dial) subcutaneous solution pen-injector 100 unit/mL: Inject as per sliding scale: 0-150 = 0 units; 151-200 = 2 units; 201-250 - 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; greater than 400 give 10 units and call MD; give subcutaneously before meals and at bed time.

10/5/24 - An admission MDS documented Resident R299 was diabetic and was receiving insulin.

10/5/24 8:00 AM - Resident R299's MAR documented a blood glucose of 432 mg/dL (normal blood glucose is 80 mg/dL to 120 mg/dL) and fifteen units of Lispro was administered.

10/5/24 11:30 AM - A progress note documented Patient's (Resident R299) family observed giving patient medications from home. Supervisor educated family that medications from home could not be given because there is no way to tell what exactly was given. Family stated patient needed pain medication. Supervisor explained to family the procedure with pain medications and informed them they were being delivered today. [Provider Group] NP and DON made aware.

10/5/24 untimed - A pharmacy manifest documented Resident R299's medications were delivered to the facility. The manifest lacked evidence that Resident R299's Lispro was delivered or ordered.

10/5/24 5:00 PM - A progress note documented that Resident R299 was discharged .

1/16/25 2:20 PM - A copy of the emergency facility medication stock revealed that insulin was not available for emergency use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 1/17/25 8:30 AM - An interview with E2 (DON) confirmed that Lispro is not available in the facility emergency medication stock. Level of Harm - Immediate jeopardy to resident health or 1/22/25 10:55 AM - An interview with FM1 revealed that at 9:00 PM on 10/4/24 Resident R299 had not received bed safety time medications and FM1 notified the staff. FM1 stated that staff told her that medications needed to be ordered and were not available at this time. Residents Affected - Some 1/22/25 11:03 AM - An interview with FM2 revealed that FM2 requested to speak to a supervisor after dinner

on 10/4/24 to address multiple concerns. FM2 stated that the supervisor confirmed that Resident R299's medications would not be delivered until 10/5/24 in the morning.

1/22/25 11:35 AM - An interview with E3 (ADON) stated the expectation for medication reconciliation and submission of orders is within an hour of admission. The primary nurse is expected to call the on call provider to review medication orders and input into the electronic medical system. E3 confirmed that Resident R299 did not receive a blood glucose check on 10/4/24 at 5:00 PM or 9:00 PM and coinciding sliding scale insulin.

1/23/25 2:13 PM - An interview with E16 (LPN) revealed that E16 was unable to recall details of Resident R299's admission.

1/23/25 3:34 PM - An interview with E17 (RN, UM) revealed that E17 was unaware of the expectation of reconciling medications within an hour of admission and unable to recall details of Resident R299's admission.

32810

2. Review of Resident R46's clinical record revealed:

11/17/22 - Resident R46 was originally admitted to the facility with several diagnoses including diabetes.

11/15/24 - A physicians order was written for Resident R46 to receive Insulin Glargine inject 20 units at bedtime for diabetes.

11/22/24 - An annual MDS assessment documented that Resident R46 was cognitively intact and received insulin injections.

12/23/24 9:09 PM - An orders administration note in Resident R46's clinical record documented that the ordered Insulin Glargine was not given due to awaiting for delivery.

12/24/24 8:42 PM - An orders administration note in Resident R46's clinical record documented, that the ordered Insulin Glargine was not given due to being on order.

12/28/24 8:48 PM - An orders administration note in Resident R46's clinical record written by E9 (LPN) documented,

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 sic Supervisor and the DON is aware of the situation. Still no delivery.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 December 2024 - Review of Resident R46's MAR lacked evidence that Resident R46 received the ordered dose of 20 units Insulin Glargine at bedtime on 12/23, 12/24, 12/28, and 12/29. It is unclear how Resident R46 received the insulin on Level of Harm - Immediate 12/25, 12/26, and 12/27 when the refill had not been delivered and there were no insulins in the back up jeopardy to resident health or medication/Pixus. safety 1/16/25 10:23 AM - During an interview E7 (LPN) explained that all medications are Reordered in the Residents Affected - Some software if low and that we have insulin in the reserve/emergency box.

1/16/25 10:37 AM - During an interview E2 (DON) stated that refills Can take 24 to 48 hours but that the pharmacy delivers at least twice a day to the facility. E4 (CCS) then stated We did identify some issues and have been working with them to improve. E2 then stated We started working to improve at least a few weeks ago.

1/17/25 8:30 AM - E2 (DON) provided a pharmacy order summary that indicated a request for a refill of Resident R46's Insulin Glargine medication was sent on 12/22/24.

1/17/25 10:20 AM - During an interview with E9 (LPN) the re-ordering process was clarified and E9 stated that to refill medications staff Clicks on re-order meds to go straight to the pharmacy and maybe call to make sure you have it for the next day. If they have in the Pixus you can go to the supervisor for the Pixus. Insulin is not usually in the back up so most of the time we reorder that. The first time I ordered and called they said

it was too early and we need a supervisor. I did go to the [DON] and he said he would take care of it. When I came back the med was not there and I called again and the pharmacy hung up on me.

1/17/25 10:41 AM - E2 (DON) provided the surveyor an inventory list of emergency medications held in the facility and confirmed Insulin Glargine was not on the list.

1/17/25 12:05 PM - During an interview E11 (NP) confirmed knowledge of Resident R46's missed doses of the Insulin Glargine. E11 stated, They called me and I told them to monitor. E11 then showed the surveyor a composition note book with a dated hand written note regarding Resident R46's missed doses of insulin.

1/23/25 8:42 AM - E2 provided the surveyor with an undated pharmacy memorandum regarding refilling of medications. E2 stated it was part of an education to staff provided a month ago and it's improved things.

The memorandum read the following Attention Nursing Personnel then listed pharmacy contact information as well as a table of timeframe's to order medications and expected delivery time. The memorandum also indicated that STAT orders must be called into the pharmacy to notify the pharmacy that it's a STAT order.

1/23/25 1:53 PM - During an interview E13 (agency LPN) was unable recall Resident R46 being out of the ordered insulin Glargine, E13 (LPN) stated, They are often out of medications at that facility and some people use other residents insulin's but I don't.

1/23/25 1:56 PM - During an interview E14 (agency LPN) was unable to recall Resident R46 being out of the ordered insulin Glargine. E14 stated, If the resident is out then we have to give it depending whatever the insulin is.

They keep a lot of insulin in the refrigerator and sometimes if its not then I guess we call the pharmacy and

the doctor but I haven't run into that situation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 The four missed doses of the ordered Insulin Glargine for Resident R46 placed the resident at risk for having a serious adverse outcome including diabetic ketoacidosis, diabetic coma or even death. Level of Harm - Immediate jeopardy to resident health or 1/23/25 11:52 AM - Based on interviews and review of the facility documentation and other sources, an safety Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA) and E4 (Corporate Clinical Support). Residents Affected - Some 1/23/25 11:00 PM - The facility's Immediate Jeopardy was abated at this time. The acceptable abatement plan included implementation of new policies titled Verifying Diabetic Medications for New Admit Residents and Diabetic Medication administration for current residents. The proposed plan included education to one hundred percent of working staff and ongoing for the remaining staff currently unavailable and not working, and new hires. Staff confirmed no new admissions were scheduled for the rest of the day. Staff interviews confirmed completion of staff training. Staff confirmed that all current residents had insulin available on hand and current medication orders. E4 stated the facility is in the process of updating identified delivery issues with current pharmacy provider and will add insulin as an emergency medication to the supply.

1/28/25 11:30 AM - The facility's abatement was reviewed with E1 (NHA) and E4 (Corporate Clinical Support). It was determined through observation, interview and record review that the facility met all requirements for abatement on 1/23/25 at 11:00 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40163 Residents Affected - Few Based observation, interview and review of other facility documentation, it was determined that for three out of five medication storage refrigerators, the facility failed to facilitate the safe administration of medication to residents and staff. In addition, the facility failed to ensure that testing materials for COVID-19 would accurately reflect residents and employees COVID status. Findings include:

[DATE REDACTED] 9:02 AM - An observation of the back-up medication refrigerator in the facility conference room revealed that the temperature monitoring logs were incomplete.

The following are the incomplete daily temperature log monitoring for the medications stored in the facility conference room refrigerator.

- [DATE REDACTED] - 18 out of 31 days were incomplete.

- [DATE REDACTED] - 10 out of 30 days were incomplete

- [DATE REDACTED] - 8 out of 31 days were incomplete.

- [DATE REDACTED] - 19 out of 31 days were incomplete.

- [DATE REDACTED] - 16 out of 30 days were incomplete.

- [DATE REDACTED] - 9 out of 31 days were incomplete.

- [DATE REDACTED] - 27 out of 30 days were incomplete.

- [DATE REDACTED] - The facility lacked evidence of any refrigerator temperature monitoring.

- [DATE REDACTED] - The facility lacked evidence of any refrigerator temperature monitoring until the surveyor brought it to the attention of the facility on [DATE REDACTED].

[DATE REDACTED] 9:17 AM - During an observation and interview, E2 (DON) confirmed the missing temperature monitoring of the conference room refrigerator.

Medications that were stored inside of the conference room refrigerator were as follows:

- 10 five milliliters of flu vaccines.

- 83 single dose pre-filled syringes of flu vaccine.

- 17 single dose pre-filled doses of Hepatitis B vaccines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 - 2 COVID-19 pre-filled doses of COVID-19 vaccines.

Level of Harm - Minimal harm or [DATE REDACTED] 10:33 AM - During an observation and interview with E3 (ADON), it was confirmed that in the potential for actual harm Riverwalk number 1 medication refrigerator was a box of Tylenol suppositories that had been expired since [DATE REDACTED]. Residents Affected - Few [DATE REDACTED] 10:45 AM - During an observation and interview with E3, it was confirmed that in the Riverwalk number 2 medication room was two holding boxes of COVID-19 testing mediums. One of which the holding boxes had 10 testing mediums that was noted to have approximately ,d+[DATE REDACTED] of an inch of water in (one of which had a black substance in it). The other holding box did not have water in it but had a piece of tape

on it with the date of ,d+[DATE REDACTED]. E3 stated that there was a laboratory technician in the building, and we should consult her regarding the test mediums.

[DATE REDACTED] 11:12 AM - During an observation and interview L1 (Lab Tech) confirmed that the vials of medium were not recommended to be used. L1 stated that she would contact the owner and operator of the lab about how to proceed. The lab owner on the phone with the lab tech stated that the vials should be disposed of in

the biohazard trash.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on observation, interview and record review, it was determined that for one (Resident R27) out of seven Residents Affected - Few sampled residents for dental services, the facility failed to assist the residents in obtaining routine dental services. Findings include:

Review of Resident R27's clinical record revealed:

10/12/24 - An admission packet for Resident R27 documented that Resident R27 elected to receive dental services through the facility.

10/14/24 - Resident R27 was admitted to the facility with vascular dementia.

10/21/24 - An admission MDS documented Resident R27 was cognitively intact and diagnosis of non-alzheimers dementia. The MDS also documented that Resident R27 does not have dentures, broken teeth, or any abnormal mouth issues.

1/13/25 9:11 AM - An interview revealed that Resident R27 wanted to see the dentist and stated she had not seen one since before she was admitted to the facility.

1/15/25 3:29 PM - A review of the electronic medical records lacked evidence that Resident R27 had received dental services.

1/21/25 8:26 AM - An interview with E1 (NHA) confirmed that Resident R27 had not received dental services because

the dentist only comes to the facility on ce a year. E1 stated that the dentist had not come for the annual visit yet.

1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38302

Residents Affected - Few Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include:

1/13/25 10:26 AM - During a tour of the kitchen, the surveyor observed E15 (Account Manager) test the sanitizer level of the solution in two red sanitizing buckets. When E15 tested the sanitizing solution, the test strips from each of the buckets indicated that the level of chemical concentration in the buckets was not at a sufficient level to provide proper sanitization.

1/13/25 10:28 AM - During a tour of the walk-in freezer there were several discarded food items, including a breaded fish patty, a hash brown, and several other debris items laying on the freezeer floor.

1/13/25 10:53 AM - During the rinse cycle the automatic dishwashing machine temperature was too low. Several test trials revealed a max temp of 130 degrees Fahrenheit. The temperature in this type of warewashing machine must be [NAME] than 180 degrees Fahrenheit for proper sanitization during the rinse cycle.

1/13/25 12:30 PM - The refrigerator in the first nourishment room contained two turkey and cheese sandwiches with a creation date of 1/7/25, which should have been discarded before 1/10/25. The refrigerator in the second nourishment room contained an undated/labeled jar of spinach dip and an opened package of processed cheese food dated 10/24/24.

1/13/25 12:52 PM - The refrigerator in the dining room contained an opened half used bottle of prune juice with no date label, as well as several other opened and unopened items with room numbers, but no date lables.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Support)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0941 Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Few Based on record review and interview it was determined that for two (E28 and E49) out of six employees reviewed, the facility failed to ensure that mandatory communication training was completed. Findings include:

1/15/25 - A review of the facility training worksheets lacked evidence of required communication training for

the following staff:

E28 date of hire 6/29/23 - no record of communication training.

E49 date of hire 12/11/23 - no record of communication training.

1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0942 Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Few Based on record review and interviews it was determined that for two (E29 and E30) of out of six employees reviewed, the facility failed to ensure resident rights training was ongoing. Findings include:

1/15/25 - A review of the facility training worksheets revealed lack of evidence of ongoing training on resident's rights for the following staff:

E29 date of hire 4/10/23 -most recent date of residents rights training 4/11/23.

E30 date of hire 10/23/23- most recent date of residents rights training 10/23/23.

1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.

1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Few Based on record review and interview it was determined that for two (E28 and E47) out of six employees reviewed, the facility failed to ensure that staff completed QAPI training. Findings include:

1/15/25 - A review of the facility training worksheets lacked evidence of required QAPI training:

E28 6/29/23 date of hire, no record of training.

E47 7/19/23 date of hire, no record of training.

1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0945 Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Few Based on record review and interview it was determined that for two (E29 and E30) out of six employees reviewed for required training the facility failed to ensure that infection control training was completed and consistent with policy standards. Findings include:

The facility policy on Infection Prevention and Control Plan last updated 2024, indicated there would be ongoing education for all facility personnel.

1/15/25 - A review of the facility's training worksheet lacked evidence of ongoing infection control training for

the following staff:

E29 date of hire 4/10/23 most recent infection control training completed on 4/10/23.

E30 date of hire 10/23/23 most recent infection control training completed on 10/23/23.

1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.

1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 32810 potential for actual harm Based on record review and interview it was determined that for three (E28, E29, and E30) out of six Residents Affected - Few employees reviewed, the facility failed to ensure that annual training of the compliance and ethics program was completed for an organization operating five or more facilities. Findings include:

1/15/25 - A review of the facility's training worksheet lacked evidence of required training on the facilities compliance and ethics programs for the following staff:

E28 6/29/23 date of hire, no record of training.

E29 4/10/23 date of hire, last date of training 4/10/23.

E30 10/23/23 date of hire, last date of training 10/23/23.

1/23/25 4:34 PM - During an interview E1(NHA) confirmed the findings.

1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Few Based on record review and interview it was determined that for four (E30, E32, E39, and E40) out of five CNA'S reviewed, the facility failed to ensure that the required minimum twelve hours of in-service training was completed. Findings include:

1/15/25 - A review of the facility training worksheet lacked evidence of the required twelve hours minimum in-service training for the following CNA's:

E39 had a hire date of 1/2/23. From 1/2/24 - 1/2/25, 1.05 hours of training were completed.

E32 had a hire date of 9/26/23. From 9/26/23 - 9/26/24, 0.0 hours of training were completed.

E40 had a hire date of 10/9/23. From 10/9/23 - 10/9/24, 0.0 hours of training were completed.

E30 had a hire date of 10/23/23. From 10/23/23 - 10/23/24, 0.0 hours of training were completed.

1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the findings.

1/24/25 1:30 PM - Findings were reviewed with E1, E2 (DON) and E4 (CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Minimal harm or 32810 potential for actual harm Based on record review and interview it was determined that for two (E28 and E29) out of six staff reviewed, Residents Affected - Few the facility failed to ensure that required behavioral health training was completed in accordance with the Facility Assessment. Findings include:

The Facility Assessment last updated December 2024, indicated that the facility maintained an average of one to ten residents with behavioral symptoms. Staff training, education and competencies, indicated that All staff are assigned training and attend training sessions in the facility annually and as designated.

1/15/25 - A review of the facility training worksheet lacked evidence of behavioral health training for the following staff:

E28 (DA)- date of hire 6/29/23 no documented behavioral health training.

E29 (RN) - date of hire 4/10/23 no documented behavioral health training.

1/22/25 10:46 AM - During an interview E1 (NHA) confirmed the missed training's.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 41 085058

F-F697

1. Review of Resident R85's clinical record revealed:

12/12/24 - Resident 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 Resident 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 Resident 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 Resident 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 Resident 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 Resident R85's BIMS score was 15 indicating Resident R85 was cognitively intact.

1/23/25 3:34 PM - An interview with E17 (RN UM) revealed that Resident 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 Resident R85. The care plan also lacked non-pharmacological interventions for addressing Resident R85's pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on record review and interview, it was determined that for two (Resident R6 and Resident R27) out of thirty seven Residents Affected - Few residents sampled, the facility failed to provide services that meet professional standards of quality by having Licensed Practical Nurses (LPN) complete admission assessments and admission progress notes. Findings include:

Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2024 . Admission Assessments * - RN .* = Once a care plan is established, the LPN may do assessments .

1. Review of Resident R6's clinical record revealed:

12/12/24 - Resident R6 was admitted to the facility.

12/12/24 - E45 (LPN) completed the following assessments: admission evaluation, bowel and bladder continence evaluation, elopement risk evaluation, fall risk evaluation, pain evaluation, side rail evaluation, transfer evaluation, and Braden scale assessment.

An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for Resident R6.

1/21/25 10:47 AM - An interview with E17 (UM RN) confirmed that Resident R6's admission assessments were completed by an LPN.

2. Review of Resident R27's clinical record revealed:

10/14/24 - Resident R27 was admitted to the facility.

10/14/24 - E46 (LPN) completed the following assessments: admission evaluation, bowel and bladder continence evaluation, elopement risk evaluation, fall risk evaluation, side rail evaluation, and Braden scale assessment.

1/21/25 10:47 AM - An interview with E17 (UM RN) confirmed that Resident R27's admission assessments were completed by an LPN.

An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for Resident R27.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on observation and interview, it was determined that for one (Resident R6) out of nine residents reviewed for Residents Affected - Few ADLs, the facility failed to ensure ADLs were provided to dependent residents. Findings include:

Review of Resident R6's clinical record revealed:

12/12/24 - Resident R6 was admitted to the facility.

12/13/24 - A care plan was initiated and documented that Resident R6 was unable to do own activities of daily living (ADLs) without assistance related to general weakness and goal that Resident R6 will be well groomed and odor free with the assist of staff while participating to their best ability for ninety days. The care plan documented interventions to assist Resident R6 to pick out clothes, assist to attend activities, and toileting schedule as Resident R6 allows.

12/19/24 - An admission MDS documented that Resident R6 had an impairment to lower extremity on one side and also documented Resident R6 was dependent for showering.

1/13/25 2:34 PM - An interview with Resident R6 revealed that she had a shower on the previous day and no one had assisted her to clip her nails. Resident R6 stated that no one had offered to clip her nails.

1/14/25 10:19 AM - An observation of Resident R6 with long overgrown nails.

1/15/25 12:24 PM - An observation of Resident R6 with long overgrown nails.

1/16/25 3:33 PM - An observation of Resident R6 with long overgrown nails. An interview with E35 (RN) confirmed that Resident R6 was supposed to have a shower on 1/15/24 and that Resident R6 had long overgrown nails. E35 stated she would make sure Resident R6's nails were clipped.

1/17/25 8:37 AM - An interview with E48 (CNA) confirmed that she gave Resident R6 a shower and clipped her nails

this morning.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on interview and record review, it was determined that for one (Resident R64) out of two residents reviewed for Residents Affected - Few change in condition, it was determined that the facility failed to follow physician orders. Findings include:

Review of Resident R64's clinical record revealed:

11/27/24 - Resident R64 was admitted to the facility.

12/4/24 - An admission assessment for documented that Resident R64 was independent for eating.

1/14/25 7:23 PM - A physician's order documented that Resident R64 was on thickened liquids.

1/15/25 1:15 PM - An observation of Resident R64's lunch tray revealed that Resident R64 was served water, coffee, and juice all thin liquids. Resident R64 was actively eating and drinking when observation occurred, during this time an

observation of Resident R64 drinking the thin liquids resulting in coughing.

1/15/25 1:30 PM - An interview with E48 (CNA) revealed that E48 was not informed that Resident R46 was on thickened liquids during report and E48 went to replace the thin liquids with thickened.

1/15/25 1:35 PM - An interview with E51 (LPN) and E35 (RN) revealed that when a new diet is ordered the order gets entered in the electronic medical record (EMR) and a dietary communication slip is completed. If

the order is completed after dietary is closed the nurse will deliver the dietary communication to the front desk to give to dietary in the morning.

1/15/25 1:45 PM - An interview with E52 (Secretary) confirmed that no dietary communication slip was left at

the front desk for the dietary department.

1/15/25 2:00 PM - An interview with E53 (Dietician) revealed that she was unaware of the new order for Resident R64. E53 reviewed the new order in the EMR and confirmed that the diet order was not input as a dietary order so therefore the electronic system did not communicate the new order to dietary. E53 also confirmed that no dietary communication slip was completed and given to the dietary department.

The facility failed to follow a physician's order when Resident R64 was served thin liquids.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Few Based on record review and interview it was determined that for one (Resident R37) out of two residents reviewed for ROM the facility failed to ensure that Resident R37 received appropriate treatment and services to prevent further decrease in range of motion when the annual contractures measurement comparison evaluation was not completed on time. Findings include:

The facility policy on Prevention and screening for contractures management last updated January 2025, indicated Secondary prevention targets early identification of a contractures to limit it's course and complications through scheduled screenings such as annual screenings or during clinical reviews.

1. Review of Resident R37's clinical record revealed:

12/15/23 - An entry MDS assessment was created for Resident R37.

12/18/23 - A contractures measurement comparison evaluation was completed for Resident R37 that documented the resident had All joints within functional limits.

12/19/23 - A discharge return not anticipated MDS assessment was completed for Resident R37.

1/2/24 - Resident R37 was readmitted to the facility with several diagnoses including history of stroke, generalized muscle weakness, abnormalities of gait and mobility, and limitation of activities due to disability.

1/8/24 - An admission MDS assessment documented that Resident R37 had an impairment on one side of an upper extremity.

1/26/24 - A care plan was created related to Resident R37's potential for contractures. Interventions in the care plan included Therapy department to assess ROM and record findings yearly.

7/29/24 - An OT clarification order was written for Resident R37's recertification of services to continue with OT 3-4x/wk for 30 days to address limitations. Treatment: ortho fit and train.

8/27/24 - An order was written for an OT evaluation for Trigger finger/use of carrot and Ortho consult for trigger finger.

8/28/24 - An order was written for Resident R37 to wear a left extension splint placed at PM care, removed at AM care as tolerable. Resident able to self manage and remove as needed.

11/5/24 - Resident R37's care plan related to potential for contractures was reviewed by the facility with no changes.

1/8/25 - An annual MDS assessment documented that Resident R37 had an impairment on one side of an upper extremity.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 1/13/25 10:34 AM - During an interview Resident R37 stated, I want to see a doctor because my [left] hand worsened.

Level of Harm - Minimal harm or 1/15/25 9:30 AM - The surveyor sent an email to E2 (DON) that requested the most recent contractures potential for actual harm measurement comparison evaluation completed for Resident R37.

Residents Affected - Few 1/15/25 10:11 AM - A contracture measurement comparison evaluation was completed by E34 (PT) for Resident R37 that documented, Left joint contractures status severe; all joints functional limits except left hand Resident continues with left hand contractures. The evaluation was past the annual date of 12/18/24.

1/16/25 1:29 PM - During an interview Resident R37 confirmed that prior to 1/15/25 therapy had not been to assess

the residents hand in a long time.

1/16/25 1:56 PM During an interview E34 (PT) confirmed that the contracture measurement comparison evaluation was completed late. E34 stated, they should be done annually. The problem is our software doesn't alert on their anniversary date. When asked what prompted E34 to complete Resident R37's recent assessment E34 stated, [E4 (CCS) asked me for it, I saw it wasn't done and went and did it. E4 present

during the interview confirmed the request for Resident R37's contractures measurement comparison evaluation was relayed to her by E2 (DON). When asked if the facility identified a change from the prior contractures evaluation, E34 stated, [Resident R37] had no significant changes between the two. [Resident R37] already has a palm-guard for that issue so that was established from OT in the summer. Review of Resident R37's clinical record revealed an OT evaluation and corresponding interventions on 8/27/24 and 8/28/24 related to Resident R37's left hand. However

the clinical record lacked evidence of measurements and evaluation to determine degree of changes until the surveyor requested an evaluation on 1/15/25.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (CCS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on interview and record review it was determined that for four (Resident R4, Resident R27, Resident R61, Resident R64 and Resident R3) out of seven residents reviewed for bowel and bladder, the facility failed to respond to or provide services to maintain or restore bowel and bladder continence. Findings include:

1. Review of Resident R4's clinical record revealed:

12/5/24 - Resident R4 was admitted to the facility.

12/5/24 - A care plan was initiated for Resident R4 but lacked evidence of addressing continence and plan of care related to continence.

12/5/24 3:30 PM - A bowel and bladder evaluation documented that Resident R4 was continent of urine and lacked documentation regarding bowel continence.

12/12/24 - An admission MDS documented that Resident R4 was always continent of bladder and occasionally continent of bowel and that no toileting program was indicated. The MDS also documented that Resident R4 required partial or moderate assistance for toileting.

12/2024 - A review of the December CNA documentation record revealed that Resident R4 was continent of bowel four times out of eighty opportunities.

1/2025- A review of the January CNA documentation record revealed that Resident R4 was continent of bowel eight times out of forty six opportunities.

1/9/25 9:07 AM - An admission bowel and bladder evaluation documented that Resident R4 was continent of urine and incontinent of bowel. The evaluation documented that a toileting program was not in use to manage Resident R4's bowel continence.

1/13/25 2:16 PM - An interview with Resident R4 revealed that he was continent of bowel at home and able to use the toilet independently. Resident R4 stated that he can use a urinal and uses a brief while at the facility.

1/17/25 9:25 AM - An interview with E48 (CNA) confirmed that Resident R4 requires staff assistance with toileting and is continent of urine. E48 stated that Resident R4 is normally incontinent of bowel and does not use any assistive devices. E48 stated that Resident R4 was not on a toileting program to her knowledge.

1/21/25 10:47 AM - An interview with E17 (RN, UM) confirmed that Resident R4 was not on a toileting program and does not use assistive devices to maintain continence.

There was no evidence that the facility attempted to maintain bowel function for Resident R4.

2. Review of Resident R27's clinical record revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 10/14/24 - Resident R27 was admitted to the facility.

Level of Harm - Minimal harm or 10/14/24 - A care plan was initiated (Resident R27) for incontinence of bowel and bladder with no memory recall potential for actual harm and/or ability to retrain with the goal that Resident R27 will be clean, dry, and comfortable with no skin breakdown for ninety days. The interventions included bowel and bladder assessments upon admission and quarterly, call Residents Affected - Few bell within reach, check resident every two hours, and encourage highest level of independence of toileting as possible.

10/21/24 10:58 AM - A bowel and bladder assessment documented that Resident R27 was incontinent of urine and was wet one to two times a day and continent of stool. The evaluation documented that a toileting program was not in use to manage Resident R27 urinary continence.

10/21/24 - An admission MDS documented that Resident R27 was dependent for toileting and requires assist of one for ADLs. The MDS also documented that Resident R27 was frequently incontinent of bowel and bladder and that a urinary toileting program was initiated with no improvement.

10/2024 - A review of the October CNA documentation record revealed that Resident R27 was continent of urine nine times out of fifty seven opportunities.

11/2024 - A review of the November CNA documentation record revealed that Resident R27 was continent of urine eleven times out of ninety two opportunities.

12/2024 - A review of the December CNA documentation record revealed that Resident R27 was continent of urine eleven times out of ninety five opportunities.

1/2025 - A review of the January CNA documentation record revealed that Resident R27 was continent of urine five times out of fifty two opportunities.

1/17/25 9:33 AM - An interview with E48 (CNA) confirmed that Resident R27 is staff assist of one for toileting and confirmed that resident is incontinent of bowel and bladder. E48 confirmed that Resident R27 does not use a bed pan or commode for toileting and was not on a toileting program.

1/21/25 10:47 AM - An interview with E17 (RM UM) confirmed that Resident R27 was not on a toileting program and does not use assistive devices to maintain continence.

There was no evidence that the facility attempted to maintain bladder function for Resident R27.

3. Review of Resident R61's clinical record revealed:

12/27/24 - Resident R61 was admitted to the facility.

12/27/24 - A care plan was initiated for incontinence of bowel and bladder with no memory recall and/or ability to retrain with the goal that Resident R61 will be clean, dry, and comfortable with no skin breakdown for ninety days. The interventions included bowel and bladder assessments upon admission and quarterly, call bell within reach, check resident every two hours, and encourage highest level of independence of toileting as possible

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 12/27/24 11:28 PM - A bowel and bladder assessment documented that Resident R61 was occasionally incontinent of bowel and bladder and was a candidate for scheduled or prompted voiding. Level of Harm - Minimal harm or potential for actual harm 12/2024 - A review of the December CNA documentation record revealed that Resident R61 was incontinent of urine four times out of fourteen opportunities. Residents Affected - Few 1/2025 - A review of the January CNA documentation record revealed that Resident R61 was incontinent of urine twenty eight times out of forty seven opportunities.

1/3/25 - An admission assessment documented that Resident R61 was dependent for toileting. The MDS also documented that Resident R27 is occasionally incontinent of bowel and bladder and was not on a toileting program. Resident R27 is also a BIMS of 15 indicating fully competent.

1/13/25 10:31 AM - An interview with Resident R61 revealed that she was continent at home and is usually incontinent at the facility due to staff taking too long to answer the call bell.

1/17/25 9:41 AM - An interview with E28 (CNA) confirmed that Resident R61 is a one person assist for toileting and is occasionally incontinent. E28 confirmed that Resident R61 will use the toilet if staff assists her.

1/21/25 10:47 AM - An interview with E17 (RM UM) confirmed that Resident R61 was not on a toileting program and does not use assistive devices to maintain continence.

There was no evidence that the facility attempted to maintain bladder function for Resident R61.

4. Review of Resident R64's clinical record revealed:

11/27/24 - Resident R64 was admitted to the facility.

11/27/24 - A bladder and bowel evaluation documented Resident R64 as frequently incontinent of both bowel and bladder. The evaluation also documented Resident R64 was a candidate for scheduled or prompted voiding.

11/2024 - A review of the November CNA documentation record revealed that Resident R64 was incontinent of urine two out of eleven opportunities and incontinent of bowel zero times out of eleven opportunities.

12/4/24 - An admission MDS documented Resident R64 was a partial or moderate assist for toileting and Resident R64 was occasionally incontinent of bladder and always continent of bowel. The MDS also documented Resident R64 was not

on a toileting program.

12/8/24 - A care plan documented that Resident R64 had bladder incontinence related to activity intolerance, dementia, and impaired mobility with a goal of Resident R64 being continent during waking hours through the review date. Interventions included checking Resident R64 as needed and as required for incontinence and notify the provider of any possible medical causes for incontinence.

12/2024 - A review of the December CNA documentation record revealed that Resident R64 was incontinent of urine fifteen times out of ninety six opportunities and incontinent of bowel seven times out of ninety six opportunities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 1/2025 - A review of the January CNA documentation record revealed that Resident R64 was incontinent of urine fourteen times out of fifty two opportunities and incontinent of bowel ten times out of forty eight opportunities. Level of Harm - Minimal harm or potential for actual harm 1/13/25 12:26 PM - An interview with FM3 revealed that Resident R64 was occasionally incontinent of bowel and bladder while at home and FM3 expressed concern that she had come in to visit and found Resident R64 soaked in Residents Affected - Few urine on multiple occasions.

1/17/25 9:22 AM - An interview with E28 (CNA) confirmed that Resident R64 is an assist of one staff for toileting and Resident R64 remains continent if staff encourages Resident R64 to toilet. E28 did not recall Resident R64 being on a toileting schedule or program.

1/21/25 10:47 AM - An interview with E17 (RN, UM) confirmed that Resident R64 was not on a toileting program.

There was no evidence that the facility attempted to maintain bladder or bowel function for Resident R64.

40163

5. Review of Resident R3's clinical record revealed:

A CDC recommendation to prevent infection included: Maintain the bag below the level of the bladder. (https://www.cdc.gov Indwelling Urinary Catheter Insertion and Maintenance).

9/26/23 - Resident R3 was admitted to the facility with obstructive uropathy.

12/16/24 - Resident R3 had a physician order for a foley catheter.

1/2/25 - A quarterly MDS assessment documented that Resident R3 was dependent on staff for ADL's and had an indwelling catheter.

1/13/25 - 08:52 AM - During an observation, Resident R3's foley catheter drainage bag was noted to be lying on the foot of Resident R3's bed.

1/13/25 8:57 AM - During an interview, E58 (CNA) confirmed that Resident R3's foley catheter drainage bag was on

the bed.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or 40163 potential for actual harm Based on record review and interview, it was determined that for two (Resident R11 and Resident R91) out of two residents Residents Affected - Few reviewed for tube feeding the facility failed to implement current professional standards of practice, to maintain acceptable parameters of nutritional status. Findings include:

for Resident R11 the facility failed to label Resident R11's tube feeding bottle to discern the tube feeding's date and time of expiration per standard of care. For Resident R91, the facility failed to obtain an order for Resident R91 to resume her tube feeding at the time of readmission to the facility. Findings include:

1. Review of Resident R11's clinical record revealed:

10/2/23 - Resident R11 was admitted to the facility with quadriplegia.

12/22/24 - A discharge MDS assessment documented that Resident R11 required tube feeding for nutrition.

1/14/25 10:40 AM - An observation of Resident R11's tube feeding bottle not labeled with a time or date of when the tube feeding had been initiated.

1/14/25 10:42 AM - During an interview, E12 (LPN) confirmed that the tube feeding was not labeled with date and time that the bottle had been hung and started.

2. Review of Resident R91's clinical record revealed:

11/5/24 - Resident R91 was admitted to the facility with ALS.

11/12/24 - Resident R91's admission MDS admission assessment documented that Resident R91 required tube feeding for nutrition.

1/13/25 11:51 PM - A nursing progress note included that Resident R91 was readmitted to the facility at 4:23 PM.

1/14/25 - During an interview, FM4 stated that Resident R91 did not have any tube feeding since the day before (1/13/25).

Review of the readmission physician orders revealed that the facility lacked evidence of a tube feeding order upon return on 1/13/24.

1/14/25 10:47 AM - During an interview, E50 (LPN) confirmed that Resident R91 did not have a physician order to resume her tube feeding since her 1/13/25 readmission.

1/14/25 12:30 PM - A physician order for Resident R91's tube feeding became an active order. Resident R91 did not have an active physician order for approximately 20 hours.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support) at

the exit conference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 47114 potential for actual harm Based on observation, interview and record review it was determined that for four (Resident R10, Resident R29, Resident R67 and Resident R80) Residents Affected - Few out of seven residents sampled for respiratory care the facility failed to provide respiratory care based on professional standards for Resident R10, Resident R29, Resident R67 and Resident R80's nebulizer mask was not dated and not in a plastic bag when not in use. Resident R10's nebulizer mask was dated 12/26/24. Further review of Resident R10, Resident R29, Resident R67 and Resident R80's records lacked evidence of orders to change and store nebulizer masks. Findings include:

A policy and procedure titled Aerosol Nebulizer Compressor undated documented 1. Proper cleaning, maintenance and storage will be followed to prevent infections and ensure the longevity of equipment . 2. Follow standard infection control precautions to prevent the spread of infections.

1. Resident R10's clinical record revealed:

9/27/23 - Resident R10 was admitted to the facility.

January 2025 - Review of Resident R10's TAR lacked orders when to change and how to store Resident R10's nebulizer mask when not in use.

1/13/25 8:59 AM - An observation of Resident R10's nebulizer mask was dated 12/26/24 and laying on top of the resident's blanket.

1/13/25 12:38 PM - Another random observation revealed Resident R10's nebulizer mask was laying on the bedside stand and not stored in a plastic bag.

1/13/25 2:48 PM - During an interview the surveyor asked E17 (RN) the process for storing a resident's nebulizer mask when not in use. E17 stated, I would need to check with someone before I answer that I'm not sure.

1/13/25 2:59 PM - During an interview and observation E35 stated, nebulizer masks should be stored in a Ziplock bag (plastic bag) when not in use. E35 confirmed [Resident R10's] nebulizer mask was dated 12/26/24 and sitting on top of the resident's bedside table and not in a plastic bag.

2. Resident R67's clinical record revealed:

12/2/22 - Resident R67 was admitted to the facility.

January 2025 - Review of Resident R67's TAR lacked orders when to change and how to store Resident R67's nebulizer mask when not in use.

1/12/25 11:11 AM - During an observation Resident R67's nebulizer mask and tubing was attached to the nebulizer machine sitting on the resident's bedside table. The mask was not dated or stored in a plastic bag.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 1/13/25 2:42 - During an interview E36 (LPN) stated, I was trained to store the nebulizer mask at the bedside when not in use, that's what I have been shown. Level of Harm - Minimal harm or potential for actual harm 1/13/25 2:52 PM - During an interview and observation E36 (RN) confirmed Resident R67's nebulizer mask was not dated and attached to the nebulizer machine and not stored in a plastic bag. Residents Affected - Few 3. Resident R29's clinical record revealed:

12/6/22 - Resident R29 was admitted to the facility.

1/12/25 9:56 AM - An observation revealed Resident R29's nebulizer mask attached to tubing that was connected to a nebulizer machine. The mask was laying inside of Resident R29's bedside table in a closed drawer and not in a plastic bag.

January 2025 - Review of Resident R29's TAR lacked orders when to change and how to store Resident R29's nebulizer mask when not in use.

1/13/25 2:46 PM - During an observation and interview E35 stated, the resident's mask is laying inside the bedside table drawer, it's not dated, I will take care of this.

4. Resident R80's clinical record revealed:

10/1/24 - Resident R80 was admitted to the facility.

1/13/25 10:18 AM - During an observation Resident R80's nebulizer mask was attached to the nebulizer machine not dated or stored in a plastic bag.

January 2025 - Review of Resident R80's TAR lacked orders when to change and how to store Resident R80's nebulizer mask when not in use.

1/13/25 2:56 PM - During an observation and interview E35 stated, Oh I can see [Resident R80's] mask from the hallway, it's not in a bag, I don't know why but I will take care of it.

1/13/25 3:25 PM - Findings were confirmed with E1 (NHA).

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Actual harm 46988

Residents Affected - Few Based on record review and interview, it was determined that for one (Resident R85) out of three residents reviewed for pain, the facility failed to provide pain management according to professional standards of practice. Resident R85 was not provided pain medication, causing unrelieved pain for approximately sixty four hours resulting in harm. Findings include:

Cross refer

F-F773

Review of Resident R64's clinical record revealed:

11/27/24 - Resident R64 was admitted to the facility.

12/4/25 - An admission MDS documented Resident R64 was a BIMS of 7 indicating severe cognitive impairment.

1/10/25 - A progress note documented that FM3 reported that Resident R64 was lethargic and not at her baseline. E27 (RN) documented Resident R64's assessment and called the on-call provider.

1/10/25 1:34 PM - A progress note documented that Resident R64 had a non-productive cough, mild confusion, speech unclear at times, elevated heart rate, was drowsy nd not her usual self. Additionally, Resident R64 was given cough medicine, Tylenol, and Tums per provider order.

1/10/25 7:56 PM - A progress note documented that Resident R64 refused dinner and continued with an elevated heart rate. Additionally, the progress note documented the on call provider was notified with new orders.

1/10/25 11:00 PM - A physician's order for Resident R64 documented complete blood count (CBC), comprehensive metabolic panel (CMP), and infuse normal saline at 100 mL/hr total 1 liter.

1/11/25 1:37 PM (Saturday) - A lab result report for Resident R46 documented the white blood cell count was high.

1/11/25 3:48 PM - A progress note documented that Resident R46 pulled out peripheral line from left arm.

1/13/25 4:30 PM - A physician's order for Resident R64 documented a chest x-ray with two views and Rocephin (antibiotic) inject one gram intramuscularly immediately (STAT) for white blood cell elevation.

1/14/25 3:25 PM - A physician's order for Resident R64 documented Bactrim (antibiotic) 800-160 mg give one tablet two times a day for left base infiltrate (pneumonia) for five days.

1/15/25 1:15 PM - In an interview FM3 revealed she was unaware that Resident R46 had a chest X-ray done, received labwork, was diagnosed with pneumonia, started on antibiotics as well as being changed to thickened liquids. FM3 stated she had not received an update on Resident R46's condition since 10:00 PM on 1/10/25 when staff nurse called to notify her that Resident R46 was ordered an IV related to dehydration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 1/15/25 1:45 PM - Interview with E27 (RN) confirmed that the progress notes lacked evidence of notification to FM3 about changes to plan of care for Resident R46. Level of Harm - Minimal harm or potential for actual harm 1/15/25 2:13 PM - Interview with E17 (RN, UM) confirmed that the progress notes lacked evidence of notification to the provider of Resident R46's lab results. Residents Affected - Few

The facility lacked evidence of notification to the provider of Resident R46's lab results and lacked evidence of updating Resident R46's responsible party of change in condition that changed the plan of care.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish

a grievance policy and make prompt efforts to resolve grievances. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on interview, record review and review of other facility documentation, it was determined that for one (Resident R64) out of one reviewed for grievances, the facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems. Findings include:

Review of Resident R64's clinical record revealed:

11/27/24 - Resident R64 was admitted to the facility.

12/30/24 - A grievance form was filed by FM3 regarding missing clothing for Resident R64 and a complaint related to staff care. The form documented that the grievance was resolved on 1/6/25 by E2 (DON).

1/13/25 12:33 PM - An interview with FM3 revealed that Resident R64 was missing a pair of pajama bottoms and that

a staff member threw them away. FM3 stated that on 12/30/24 she was in to visit Resident R64 and she told FM3 about her pants being missing. FM3 stated that Resident R64 was very upset and told her that the person who threw

the pants away was not nice to her on the date in question. FM3 also stated that the facility did not rectify the missing pants with her or offer to replace them.

1/15/25 11:23 AM - An interview with E1 (NHA) and E2 (DON) confirmed that the facility had addressed the grievance. E2 stated that the staff member mentioned in the grievance was given education about customer service. E2 stated he did not offer to replace the pants or provide reimbursement. E1 called FM3 and requested a receipt for the pajama pants to reimburse.

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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Some Based on record review and interview it was determined that for eight (Resident R3, Resident R4, Resident R27, Resident R46, Resident R57, Resident R63, Resident R89 and Resident R91) out of thirty-seven residents investigated the facility failed to develop person centered care plans. Findings include:

1. Review of Resident R46's clinical record revealed:

11/22/24 - An annual MDS assessment documented that Resident R46 received insulin.

11/15/24 - A physicians order was written for Resident R46 to receive Insulin Glargine 20 units at bedtime.

11/16/24 - A physicians order was written for Resident R46 to receive Insulin Aspart (with Niacinamide) 12 units one time a day for diabetes.

1/16/25 - Review of Resident R46's care plans lacked evidence of a care plan that addressed the residents use of insulin and diagnosis of diabetes.

1/16/25 2:20 PM - E1 (DON) provided a care plan that addressed Resident R46's diabetes and use of insulin. The creation date of the care plan was 1/16/25. E1 confirmed the finding.

2. Review of Resident R57's clinical record revealed:

8/27/24 - Physicians orders were written for Resident R57 to receive an anti-anxiety and an anti-depressant medication.

9/6/24 - An annual MDS assessment documented that Resident R57 received anti-anxiety and anti-depressant medications.

12/7/24 - A quarterly MDS documented that Resident R57 received anti-anxiety and anti-depressant medications.

1/15/24 - Review of Resident R57's care plans lacked evidence that they addressed Resident R57's anxiety and depression, use of anti-anxiety medications and anti-depressant medications.

1/15/25 1:53 PM - E1 (DON) confirmed the findings and created corresponding care plans to address Resident R57's use of antidepressant and anti-anxiety medications.

40163

3. Review of Resident R63's clinical record revealed:

4/18/22 - Resident R63 was admitted to the facility with dementia.

4/24/24 - An annual MDS assessment documented that Resident R63 was severely cognitively impaired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 1/13/25 8:53, 1/14/25 1:46 PM, 1/15/25 11:41 AM, and 1/17/25 8:33 AM, Resident R63 was observed with approximately one half of an inch of gray and black facial hair on her chin. Level of Harm - Minimal harm or potential for actual harm 1/17/25 8:33 AM - During an interview E10 (CNA) confirmed Resident R63's extensive facial hair. E10 stated that Resident R63 is combative with care and especially showers. E10 added that Resident R63 will not let anyone shave her because Residents Affected - Some she does not like anything near her face.

1/17/25 8:37 AM - During an interview, E12 (LPN) confirmed that Resident R63 did not have a care plan for refusals of shaving and bathing.

4. Review of Resident R89's clinical record revealed:

5/22/24 - Resident R89 was admitted to the facility with multiple sclerosis, a stroke and was paraplegic.

5/22/24 - Resident R63's fall care plan included for her call bell to be in reach and to apply non-skid footwear except

during hygiene.

5/29/24 - A quarterly MDS assessment documented that Resident R89 was totally dependent on staff for all care and could not walk.

Although Resident R89 had a fall care plan in place, it was not comprehensive and patient centered related to Resident R89's paraplegic status, and resultant inability to utilize the call bell and or walk.

1/22/25 approximately 1:45 PM - E2 (DON) confirmed that Resident R89's care plan was not appropriate for Resident R89's status.

5. Review of Resident R91's clinical record revealed:

11/5/24 - Resident R91 was admitted to the facility with a tracheostomy and dependent on a ventilator.

11/12/24 - An admission MDS assessment documented that Resident R91 had a tracheostomy and was ventilator dependent.

Review of Resident R91's care plan revealed that the facility failed to create a comprehensive care plan to include her respiratory status.

1/22/25 approximately 1:45 PM - E2 (DON) confirmed that Resident R91 did not have a care plan for her respiratory status.

46988

6. Review of Resident R3's clinical record revealed:

9/26/23 - Resident R3 was admitted to the facility with a diagnosis of dementia.

1/2/25 - A quarterly MDS documented that Resident R3 was severely cognitively impaired and had a diagnosis of non-Alzheimers dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Review of Resident R3's careplan revealed that the facility failed to create a comprehensive care plan to include dementia care. Level of Harm - Minimal harm or potential for actual harm 1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that Resident R3 did not have a care plan for dementia care. Residents Affected - Some 7. Review of Resident R4's clinical record revealed:

12/5/24 - Resident R4 was admitted to the facility.

12/18/24 - An admission MDS documented that Resident R4 was always continent of urine and occasionally incontinent of bowel.

Review of Resident R4's careplan revealed that the facility failed to create a comprehensive care plan to include bowel incontinence.

1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that Resident R4 did not have a care plan for bowel incontinence.

8. Review of Resident R27's clinical record revealed:

10/14/24 - Resident R27 was admitted to the facility with vascular dementia.

10/21/24 - An admission MDS documented Resident R27 was cognitively intact and diagnosis of non-Alzheimers dementia.

Review of Resident R27's careplan revealed that the facility failed to create a comprehensive care plan to include dementia care.

1/23/25 3:34 PM - An interview with E17 (UM RN) confirmed that Resident R27 did not have a care plan for dementia.

1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 41 085058 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on record review and interview it has been determined that the facility failed to review and revise for one (Resident R85) out of thirty-seven sampled residents' care plans. Findings include:

A facility policy and procedure titled Using the Care Plan last revised 8/2006 documented . 1. Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and or the MDS Assessment Coordinator . 2. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.

Cross refer