Delaware Valley Veteran's Home

Inspectors wroteBased on clinical record review, review of facility policies and staff interview it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for nine of nine residents reviewed (Residents R1, R6, R18, R42, R122, R62, R5, R3, and R2).

Inspectors wroteBased on review of facility documentation, personnel files, and staff interview, it was determined that the facility failed to ensure nurse aides who failed to become certified within four months were not working in the facility for one of four employees reviewed (Employee E5). Findings Include: Review of Title 42 Code of Federal Regulations S483.35(d) Requirement for facility hiring and use of nurse aides-S483.35(d)(1) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless-(i) That individual is competent to provide nursing and nursing related services; and(ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of S483.151 through S483.154. [...]

Inspectors wroteBased on review of clinical records, facility documentation, staff interview and review of facility policy, the facility failed to ensure Resident R3 was free of abuse from Resident R2, who was known to have an aggressive behavior. This failure resulted in actual harm to Resident R3 who was shoved by Resident R2, resulting in a fall sustaining a left eyebrow abrasion, forehead bruising, and a left humeral head fracture for one of six residents reviewed. (Resident R3)

Inspectors wroteBased on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to Resident R1, who was at risk for falls related to decreased mobility, and poor safety awareness, This failure resulted in actual harm, to Resident R1 who sustained a fall and was diagnosed with a hip fracture for one of 30 residents reviewed for one of six residents reviewed. (Resident R1)

Inspectors wroteBased on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to ensure that residents drug regimen reviews were free from unnecessary drugs related to an increased medication dosage for one out of seven residents reviewed. (Resident R1)Findings Include: Review of facility policy titled, Medication Controlled Drug Administration Record Disposal of Schedule CII-CV Medications with a revision date of July 19, 2024 states, Policy-All schedule CII-CV medications will be counted by the outgoing and incoming nurses responsible for the medication cart at shift change on each unit . Under procedure the policy states, 1. Each medication nurse will complete a narcotic count at the beginning and the end of the shift for their medication cart. [...]

Inspectors wroteBased on review of facility documentation, review of clinical record, observation and staff interviews, it was determined that the facility failed to provide adequate supervision for one of one resident observed who utilized outdoor relaxation time. (Resident R21).

Inspectors wroteBased on a review of clinical records, observations, facility policy and staff interviews, it was determined that the facility failed to identify that a resident was free from physical restraint due to locking the wheelchair as a restraint for one of the one resident reviewed. (Resident R70)

Inspectors wroteBased on review of facility policy, review of clinical records and interviews with staff, it was determined that the facility failed to follow and or clarify physician's orders relating to advance directives for one of eight residents reviewed. (resident r 168)

Inspectors wroteBased on review of clinical record, observations, and staff interview, it was determined that the facility failed to ensure the proper care of a resident with an indwelling urinary catheter for one of three residents observed with urinary catheters. (Resident R143)

Inspectors wroteBased on resident interviews, meal tray observations, and staff interviews, it was determined that the facility failed to provide palatable, appealing and attractive meals during lunch for one of one meal observations (lunch meal).

Inspectors wroteBased on observations, review of facility's menu and staff interviews, it was determined that the facility failed to meet resident's food preference for three of three residents reviewed. (Residents R111, R89, R98).

Inspectors wroteBased on observation, policy review, and staff interviews, it was determined the facility failed to develop and implement a water management program for the prevention, detection, and control of waterborne contaminants such as Legionella (a bacteria that may cause [legionnaires disease, a serious type of pneumonia).

Inspectors wroteBased on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision during a planned out-of-facility activities outing to a theater, for one of six residents reviewed who were at risk for elopement. This resulted in Resident R138 exiting the theater and was unable to be located for one hour and 45 minutes. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R138)

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for four of four sampled residents (Resident R128, R24, R74 and R106 ).

Inspectors wroteBased on review of facility policy, review of clinical records, and interview with staff, it was determined that the facility failed to ensure medications were dispensed and administered in according to professional standards of practice relating to medication administration for one of 3 residents reviewed. (Resident R125)

Inspectors wroteBased on review of facility policy, observations, and staff interviews, it was determined that the facility failed to store drugs and biologicals in a locked compartment on one of two nursing carts reviewed. (D unit high cart)

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that garbage was disposed of properly.

Inspectors wroteBased on a review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to a resident eloping during a planned out-of-facility activities outing to a theater, for one of six residents reviewed related to elopement risk. This failure placed Resident R138 at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide care and services for a resident with a diagnosis of diabetes and to assess a resident for hypoglycemia for one of three residents reviewed (Resident R1). Findings Include: Review of facility grievance dated September 3, 2024, revealed a complaint from resident I was sent out on an appointment to (Outside Provider) by myself with no aid, the DON (Director of Nursing) and supervisory reported that they had no staff was available to escort me to this appointment. Myself being a quad (quadriplegia-a person affected by paralysis of all four limbs) patient should never not have someone with me during these appointments. I am unable to do many things for myself and having someone with me makes me feel more secure. [...]

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined to ensure sufficient staff was available to accompany one of three sampled residents to a medical appointment. (Residents R1)

Inspectors wroteBased on a review of facility policy, observations, and staff interviews it was determined the facility failed to meet the daily nutritional and special dietary needs for one of three residents (Resident R1).

Inspectors wroteBased on the review of facility policy, facility documentation and staff interviews, it was determined that the facility failed to ensure that services which was not offered by the facility was provided under an arrangement in writing for transportation of a resident to a medical appointment for one of three sample residents reviewed. Findings Include: Review of the facility policy Transportation to/from the (facility) dated May 12, 2024 revealed that The (facility) will have a contract with non-emergency wheelchair and stretcher transport for as needed use, including after hours or (facility) inability to provide he transportation. [...]

Inspectors wroteBased on select facility policy, CDC guidelines, guidelines form the Pennsylvania Department of Health, observations, record review, and staff interview, it was determined that the facility failed to follow proper infection control practices to potentially stop the spread of RSV (Respiratory Syncytial Virus) infections in the facility.