Polaris Healthcare And Rehabilitation Center

Review of R81's clinical record revealed: 3/25/24 - R81 was admitted to the facility. 3/30/24 - An admission packet for the facility was completed for R81 and revealed that Exhibit G: advanced directed form documented R81 was a full code.

The remainder of the form was left blank relating to questions regarding formulating an advanced directive. 10/2/24 - A quarterly MDS assessment documented a BIMS score of 15 indicating R81 was cognitively intact. 1/13/25 11:34 AM - An interview with R81 revealed that he was not offered to formulate an advanced directive. 1/14/25 1:35 PM - An interview with E41 (SW) revealed that advanced directives get discussed during the initial care plan meeting. 1/14/25 2:33 PM - An interview with E6 (Admissions) revealed that nursing staff is expected to ask resident questions on admission sheet regarding advanced directive. E6 confirmed that she did not ask R81 if he would like to formulate an advanced directive. 1/14/25 2:45 PM - An interview with E27 (RN) confirmed that nursing staff is responsible to discuss advanced directive with newly admitted residents. E27 presented R81's preferred intensity of medical care and treatment form from the clinical record dated 3/25/24 and 8/9/24. E27 confirmed that these forms were completed with R81 post admission.

The aforementioned form addresses a resident's preferred code status and lacks evidence of information regarding advanced directive. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

notification to the provider of R46's lab results.

updating 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/30/24 - A grievance form was filed by FM3 regarding missing clothing for 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 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 R64 and she told FM3 about her pants being missing. FM3 stated that 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

The surveyor requested a copy of the Medicaid denial, any appeal documents, a bill, and discharge notice.

The requested documents were not received from the facility. 1/23/25 9:19 AM -

During an interview E1 (NHA) confirmed the facility had no evidence of a discharge notice or discharge summary for R148. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4(CCS).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R61's electronic clinical record lacked evidence of a corresponding bed hold notification provided to R61 or a representative upon R61's transfer. 1/17/25 2:56 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R27's clinical record revealed: 10/14/24 - R27 was admitted to the facility with vascular dementia. 10/21/24 - An admission MDS documented R27 was cognitively intact and diagnosis of non-Alzheimers dementia.

Review of 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 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R85's clinical record revealed: 12/12/24 - R85 was admitted to the facility with the diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait. 12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain. 12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain.

The care plan documented the goal as pain medication will be effective in controlling discomfort by next review.

The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide diversional activities. 12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions.

The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator.

The MDS also documented that R85's BIMS score was 15 indicating R85 was cognitively intact. 1/23/25 3:34 PM - An interview with E17 (RN UM) revealed that R85's care plan lacked revision related to acceptable pain level and appropriate interventions related to pain.

The care plan lacked evidence of an acceptable pain level and pain level goal for R85.

The care plan also lacked non-pharmacological interventions for addressing R85's pain.

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R6's clinical record revealed: 12/12/24 - 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 R6. 1/21/25 10:47 AM - An interview with E17 (UM RN) confirmed that R6's admission assessments were completed by an LPN.

• Review of R27's clinical record revealed:

10/14/24 - 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 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 R27. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R6's clinical record revealed: 12/12/24 - R6 was admitted to the facility. 12/13/24 - A care plan was initiated and documented that R6 was unable to do own activities of daily living (ADLs) without assistance related to general weakness and goal that 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 R6 to pick out clothes, assist to attend activities, and toileting schedule as R6 allows. 12/19/24 - An admission MDS documented that R6 had an impairment to lower extremity on one side and also documented R6 was dependent for showering. 1/13/25 2:34 PM - An interview with R6 revealed that she had a shower on the previous day and no one had assisted her to clip her nails. R6 stated that no one had offered to clip her nails. 1/14/25 10:19 AM - An observation of R6 with long overgrown nails. 1/15/25 12:24 PM - An observation of R6 with long overgrown nails. 1/16/25 3:33 PM - An observation of R6 with long overgrown nails. An interview with E35 (RN) confirmed that R6 was supposed to have a shower on 1/15/24 and that R6 had long overgrown nails.

E35 stated she would make sure R6's nails were clipped. 1/17/25 8:37 AM - An interview with E48 (CNA) confirmed that she gave 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R64's clinical record revealed: 11/27/24 - R64 was admitted to the facility. 12/4/24 - An admission assessment for documented that R64 was independent for eating. 1/14/25 7:23 PM - A physician's order documented that R64 was on thickened liquids. 1/15/25 1:15 PM - An observation of R64's lunch tray revealed that R64 was served water, coffee, and juice all thin liquids. R64 was actively eating and drinking when observation occurred, during this time an observation of 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 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 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 R64 was served thin liquids. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R37's clinical record revealed an OT evaluation and corresponding interventions on 8/27/24 and 8/28/24 related to 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of 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 - R3 was admitted to the facility with obstructive uropathy. 12/16/24 - R3 had a physician order for a foley catheter. 1/2/25 - A quarterly MDS assessment documented that R3 was dependent on staff for ADL's and had an indwelling catheter. 1/13/25 - 08:52 AM - During an observation, R3's foley catheter drainage bag was noted to be lying on the foot of R3's bed. 1/13/25 8:57 AM -

During an interview, E58 (CNA) confirmed that 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R11's clinical record revealed: 10/2/23 - R11 was admitted to the facility with quadriplegia. 12/22/24 - A discharge MDS assessment documented that R11 required tube feeding for nutrition. 1/14/25 10:40 AM - An observation of 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.

• Review of R91's clinical record revealed:

11/5/24 - R91 was admitted to the facility with ALS. 11/12/24 - R91's admission MDS admission assessment documented that R91 required tube feeding for nutrition. 1/13/25 11:51 PM - A nursing progress note included that R91 was readmitted to the facility at 4:23 PM. 1/14/25 -

During an interview, FM4 stated that 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 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 R91's tube feeding became an active order. 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.

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

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

1/12/25 9:56 AM - An observation revealed R29's nebulizer mask attached to tubing that was connected to a nebulizer machine.

The mask was laying inside of R29's bedside table in a closed drawer and not in a plastic bag.

January 2025 - Review of R29's TAR lacked orders when to change and how to store 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.

• R80's clinical record revealed:

10/1/24 - R80 was admitted to the facility. 1/13/25 10:18 AM - During an observation R80's nebulizer mask was attached to the nebulizer machine not dated or stored in a plastic bag.

January 2025 - Review of R80's TAR lacked orders when to change and how to store 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 [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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

pain medication regimen until R85 is seen by pain management. E20 also stated he was unaware that

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 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R32's clinical record revealed: 9/1/23 - R32 was admitted to the facility with multiple diagnoses including cirrhosis of the liver. 8/27/24 - A physician's order was written for R32 to receive lactulose 45ml twice a day for cirrhosis of the liver. 12/7/24 - A quarterly MDS assessment documented that R32 was cognitively intact. 12/30/24 9:02 AM - An order administration note in R32's clinical record documented, medication (lactulose) ordered not delivered, nurse called pharmacy. 12/31/24 9:59 AM - An order administration note in 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 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 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 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 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 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Based on record review and interview it was determined that for one (R27) out of five residents

medication to 14 days.

Findings include: Review of R27's clinical record revealed: 10/14/24 - R27 was admitted to the facility diagnoses including but not limited to visual hallucinations, auditory hallucinations, and vascular dementia with psychotic disturbance. 10/21/24 - An admission MDS assessment documented a BIMS score of 14 indicating R27 is cognitively intact and also documented R27 had physical, verbal, and other behaviors not directed at others. 11/13/24 8:49 PM - A physician's order documented alprazolam (anti-anxiety) 0.5mg: Give 0.5mg by mouth every eight hours as needed for anxiety with an indefinite stop date. 1/17/25 2:57 PM - An interview with E11 (NP) confirmed the order did not have a fourteen day stop date. 1/24/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E4 (Corporate Clinical Support).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

an Immediate Jeopardy was called and reviewed with the facility leadership including E1 (NHA) and

jeopardy to resident health or safety 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

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.

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

since [DATE].

Riverwalk number 2 medication room was two holding boxes of COVID-19 testing mediums.

One of

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 7/10. E3 stated that there was a laboratory technician in the building, and we should consult her regarding the test mediums. [DATE] 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.

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R27's clinical record revealed: 10/12/24 - An admission packet for R27 documented that R27 elected to receive dental services through the facility. 10/14/24 - R27 was admitted to the facility with vascular dementia. 10/21/24 - An admission MDS documented R27 was cognitively intact and diagnosis of non-alzheimers dementia.

The MDS also documented that R27 does not have dentures, broken teeth, or any abnormal mouth issues. 1/13/25 9:11 AM - An interview revealed that 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 R27 had received dental services. 1/21/25 8:26 AM - An interview with E1 (NHA) confirmed that R27 had not received dental services because the dentist only comes to the facility once 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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

serve food in accordance with professional standards.

observation and interview it was determined that the facility failed to ensure food was stored,

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)

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

communications for direct care staff members.

employees reviewed, the facility failed to ensure that mandatory communication training was

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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

care for its residents.

employees reviewed, the facility failed to ensure resident rights training was ongoing.

Findings

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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Improvement Program.

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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

written standards, policies, and procedures for the program.

employees reviewed for required training the facility failed to ensure that infection control training

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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

dementia care and abuse prevention.

five CNA'S reviewed, the facility failed to ensure that the required minimum twelve hours of in-service

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).

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Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

assessment.

reviewed, the facility failed to ensure that required behavioral health training was completed in

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).

Review of R85's clinical record revealed:

12/12/24 - R85 was admitted to the facility with diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait.

12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain.

12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain.

The care plan documented the goal as pain medication will be effective in controlling discomfort by next review.

The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide disversional activities.

12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions.

The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator.

The MDS also documented that R85 had a BIMS score of 15 indicating R85 is cognitively intact.

12/2024 - A review of the December MAR documented that R85's pain level ranged from a score of 2/10 to 8/10. R85's pain level was noted at 10/10 prior to pain medication administration and scored as effective or score of 8/10 or below post pain medication administration.

1/2/25 5:41 PM - A physician's order documented oxycodone (narcotic pain medication) 10 mg tablet, give one tablet every six hours as needed for pain for six days ending on 1/6/25.

085058

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085058 B.

Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

Review of R85's clinical record revealed:

12/12/24 - R85 was admitted to the facility with the diagnoses including but not limited to low back pain, fibromyalgia, muscle weakness, and unspecified abnormalities of gait.

12/12/24 11:09 PM - An admission assessment documented R85 had no complaints of pain, lacked an acceptable level of pain, and lacked treatment for pain.

12/15/24 - A care plan was initiated for R85 that documented potential for alteration in comfort related to pain.

The care plan documented the goal as pain medication will be effective in controlling discomfort by next review.

The following interventions were included: assess for verbal and non-verbal signs and symptoms of pain, assist with turning and repositioning, medication as ordered and notify the physician if not effective or side effects, and provide diversional activities.

12/19/24 - An admission MDS assessment documented that R85 was on a scheduled pain regimen in the last five days, received PRN (as needed) pain medication, and received no non-medication interventions.

The MDS also documented that R85 was having pain frequently, pain occasionally affecting sleep, pain occasionally affecting therapy activities, pain that was occasionally affecting day to day activities, and a pain score of 10/10 with no verbal description indicator.

The MDS also documented that R85's BIMS score was 15 indicating R85 was cognitively intact.

1/23/25 3:34 PM - An interview with E17 (RN UM) revealed that R85's care plan lacked revision related to acceptable pain level and appropriate interventions related to pain.

The care plan lacked evidence of an acceptable pain level and pain level goal for R85.

The care plan also lacked non-pharmacological interventions for addressing R85's pain.

085058

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085058 B.

Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963

The facility failed to ensure that resident concerns received by the facility included prompt efforts to resolve the resident's problems.

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

085058

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 085058 B.

Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Polaris Healthcare and Rehabilitation Center 21 W Clarke Avenue Milford, DE 19963