Delaware Veterans Home

Inspectors wroteBased on record reviews, interviews, and review of the facility's policy, the facility failed to ensure four of nine sampled residents (Resident (R) 4, R46, R8, and R41) reviewed for abuse were free from resident-to-resident physical abuse. On 07/22/25, R8 pushed R4 to the ground. As a result, R4 sustained a closed left radius fracture, a closed, displaced, comminuted right proximal humerus fracture, and a closed, displaced right distal clavicle fracture.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans as well as insured one of two can openers had been cleaned. This failure increased the potential risk of foodborne illness and had the potential to affect 61 of 62 residents that received food through dietary services. One resident received nutrition through tube feeding.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure care plans were revised and updated for one (Resident (R)19) out of 23 resident care plans reviewed. R19 developed two additional wounds and had protective devices added and were not updated to his comprehensive care plan. This had the potential for the resident to have unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide quality for one (Resident (R)47) of one resident reviewed for physician orders in the sample of 23 residents. Specifically, the facility failed to perform R47's daily weights as ordered. Failure to obtain daily weights as ordered for a resident with congestive heart failure can lead to potential worsening of the condition as well as hospitalization and decline in overall condition.

Inspectors wroteBased on observations, record reviews, interviews, and document review, the facility failed to prevent an accidents. Specifically, a resident fell from a Hoyer lift during a transfer for one out of three residents (Resident (R)51) reviewed for Hoyer lifts. This failure to prevent an accident which resulted in R51 experiencing actual harm of a skin tear to the resident's right elbow.

Inspectors wroteBased on observation, record review, and interview, the facility failed to assess the entrapment risk of bedrails used for mobility assistance and failed to obtain consents for three of eight residents (Resident (R)19, R24, and R37) reviewed for accident hazards out of a total sample of 23 residents. Additionally, R24's first bed rail assessment indicated the resident did not need bed rails; however, bed rails were on the bed. Failure to assess and determine hazards could lead to injury, entrapment, or death.

Inspectors wroteBased on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure two of five residents (Resident (R) 5 and R13) reviewed for pneumococcal vaccines out of a total sample of 23 residents were offered an updated pneumococcal vaccine. The facility further failed to ensure their pneumococcal policy was revised to reflect updated guidance per the CDC for the administration of pneumococcal vaccines. This had the potential for the residents to have an increased risk of contracting pneumonia.

Inspectors wroteBased on record review and interview, it was determined that for four (R422, R9, R35 and R41) out of four residents reviewed for quality of care, the facility failed to ensure care/treatment in accordance with professional standards of practice. For R422 the facility failed to provide treatment for a urinary tract infection for four days causing a change in condition that required a transfer to the hospital. This delay in care resulted in harm to R422. For R9, the facility failed to provide treatment for a urinary tract infection for two days. For R35 and R41, the facility failed to follow a doctor's order.

Inspectors wroteBased on record review and interview, it was determined that for five (R1, R11, R64 and R66) out of nineteen sampled residents, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings.

Inspectors wroteBased on record review and interview, it was determined that for one (R47) out of two residents reviewed for hospitalization, the facility lacked evidence that R47 was allowed to return timely to the facility. 11/26/24 - R47 was admitted to the facility. 12/6/24 - R47 was admitted to the hospital for altered mental status and for a psychiatric evaluation. The admission history and physical also reflected that R47 had recently been diagnosed with a urinary tract infection. 12/8/24 - A hospital progress note revealed Barriers: Patient is medically cleared for discharge. VA home is not taking patient on weekends . 12/9/24 - A discharge summary revealed that His mental status has improved, he has been pleasantly confused during the hospital stay, which appears to be his baseline. He is medically stable for discharge. 12/10/24 - A daily medical progress report revealed Barriers to discharge: [...]

Inspectors wroteBased on interviews and record review, it was determined that for one (R4) out of three residents reviewed for accidents, the facility failed to implement the correct assistant device to transfer the resident to prevent accidents. Based on review of the facility's evidence to correct the non-compliance and the facility's substantial compliance at the time of the current survey, the deficiency was determined to be past non-compliance as of 12/20/24.

Inspectors wroteBased on record review and interview, it was determined, for two (R442 and R9) out of three residents sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of abnormal laboratory results.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure resident, and resident's representatives were notified at time of discharge of the location and reason for the discharge for a sample of four of four residents (Resident (R)13, R19. R12 and R39) reviewed for hospitalization. As a result of this deficient practice, residents had the potential for location of residents not known to families or resident representatives.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to protect two of three residents (Resident (R) 51, R63), reviewed for abuse, when facility nursing staff, a Certified Nurse Aide (CNA)4 used profanity toward R51 during care. In addition, when R39 sat on R63's bed and pushed down on R63's chest with his hands. Failure to protect residents from abuse has the potential to result in injury to residents.

Inspectors wroteBased on observation, interviews, record review, policy and procedure review, the facility failed to follow infection control procedures during a dressing change for one of three residents (R)4 reviewed. Specifically, the Registered Nurse (RN)1 failed to clean the over the bed table or place a barrier on the table before placing clean wound supplies on the table. Also, RN1 failed to perform hand hygiene when she returned to the room after obtaining a dressing from the treatment cart. The failure created the potential for an infection to develop in R4's wounds.

Inspectors wroteBased on observation and record review it was determined that for two residents (R19 and R49) out of two residents reviewed for accommodation of needs, the facility failed to ensure that the residents' call device were within reach.

Inspectors wroteBased on record review and interview, it was determined that for one (R56) out of four residents reviewed for activities of daily living (ADL's), the facility failed to complete a significant change MDS (Minimum Data Set) assessment when R56 had a significant decline in functional and mental status.

Inspectors wroteBased on observation, record review and interview, it was determined that for one (R44) out of one resident reviewed for dental, the facility failed to have a MDS (Minimum Data Set) assessment that accurately reflected R44's missing teeth.

Inspectors wroteBased on interview and record review it was determined that for one (R31) out of five residents reviewed for unnecessary medications the facility failed to provide evidence that the attending physician reviewed irregularities/recommendations documented on the monthly Medication Regimen Review (MRR).

Inspectors wroteBased on interview and review of facility documentation as indicated, it was determined that the facility failed to ensure that the required trainings on abuse, neglect and exploitation were completed as required for one (E8) out of ten randomly sampled staff members.

Inspectors wroteBased on interview and review of facility documentation as indicated, it was determined that the facility failed to provide required in-service training (12 hours per year) for three (E8, E9, and E10) out of three CNA's reviewed additionally the facility failed to ensure these three CNA's had trainng on dementia management and care of the cognitively impaired.