Inspection Report Summary
The most recent inspection on August 1, 2025, found no deficiencies during a complaint investigation survey. Earlier inspections showed a mixed record, with prior reports citing deficiencies related mainly to resident care, medication administration, and safety, as well as staff training and infection control. A notable substantiated complaint in April 2024 involved abuse by nursing staff, resulting in termination of an employee, and other reports confirmed issues with emergency preparedness and documentation. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving abuse, fall reporting, and training deficiencies. The facility’s recent inspections indicate improvement, with the last two surveys showing no deficiencies after a period of multiple citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% better than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
85 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Aug 1, 2025
Visit Reason
An unannounced complaint survey was conducted at the Delaware Veterans Home from July 30, 2025, through August 1, 2025.
Complaint Details
The survey was complaint-related but no deficient practice was found, indicating no substantiated deficiencies.
Findings
No deficient practice was identified during the survey. The survey sample included fourteen residents.
Report Facts
Survey sample size: 14
Inspection Report
Follow-Up
Census: 71
Deficiencies: 0
Date: May 15, 2025
Visit Reason
An unannounced Follow-Up and Complaint Survey was conducted at the facility from May 13, 2025 through May 15, 2025.
Complaint Details
The survey was both a Follow-Up and Complaint Survey, but no deficiencies were identified.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities as of April 30, 2025. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 14
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 9
Date: Mar 6, 2025
Visit Reason
An unannounced Annual and Complaint survey was conducted at Delaware Veterans Home from February 27, 2025, through March 6, 2025, to assess compliance with state and federal regulations for skilled and intermediate care nursing facilities.
Complaint Details
The survey included a complaint investigation component. Specific complaint details are not separately stated, but findings include substantiated deficiencies related to resident care and safety.
Findings
The survey identified multiple deficiencies related to resident care, medication administration, coordination of assessments, quality of care, accident prevention, and medical record documentation. The facility failed to meet several regulatory requirements, including permitting residents to return to the facility, care plan development and revision, ADL care, accident prevention, and timely reporting of lab results.
Deficiencies (9)
Permitting residents to return to the facility after hospitalization or therapeutic leave was not properly documented or followed.
Coordination of PASARR and assessments failed to ensure referrals for mental health diagnosis were completed.
Care plan timing and revision lacked required input from interdisciplinary team members and physicians.
ADL care was not provided adequately to dependent residents, including nail care and hygiene.
Quality of care issues included failure to provide timely treatment for urinary tract infections and follow physician orders.
Accident prevention was inadequate; the facility failed to prevent falls and ensure adequate supervision and assistance devices.
Bowel and bladder incontinence care was insufficient, including failure to maintain continence and provide appropriate toileting schedules.
Lab services and notification of abnormal results were not timely or properly documented.
Resident records were not complete, accurate, or readily accessible; medical records were not properly maintained or safeguarded.
Report Facts
Facility census: 69
Survey sample size: 19
Deficiency completion dates: Apr 30, 2025
Resident counts for findings: 1
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 3
Date: Apr 25, 2024
Visit Reason
A Recertification, Complaint and Emergency Preparedness survey was conducted by Healthcare Management Solutions LLC on behalf of the State of Delaware, Department of Health and Social Services, Division of Health Care Quality.
Complaint Details
The complaint investigation substantiated abuse by nursing staff toward residents, including verbal and physical abuse. CNA4 was terminated following investigation and substantiation of abuse.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to protect residents from abuse and neglect, failure to provide proper notice before transfer or discharge, and failure to maintain an effective infection prevention and control program.
Deficiencies (3)
Failure to protect two residents from abuse by nursing staff, including use of profanity and physical aggression.
Failure to provide proper notice requirements before transfer or discharge for residents.
Failure to establish and maintain an infection prevention and control program, including failure to follow infection control procedures during wound dressing changes.
Report Facts
Survey Census: 66
Sample size: 18
Supplemental Residents: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Turin | Staff Educator, MSN, RN | Named in relation to training and education on abuse/neglect and infection control |
| Sandra Redick | Admissions Director, LCSW | Named in relation to auditing Bed Hold Letters for transfers |
| RN1 | Registered Nurse | Named in relation to failure to follow infection control procedures during wound care |
| ADON1 | Assistant Director of Nursing | Named in relation to investigation and substantiation of abuse |
| UM1 | Unit Manager | Named in relation to resident supervision and transfer |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Sep 19, 2023
Visit Reason
An unannounced Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on September 19, 2023.
Complaint Details
The survey was complaint-related and no deficiencies were identified, indicating no substantiated issues.
Findings
Based on observation, interview, and document review, no deficiencies were identified during the survey.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 8
Date: Apr 25, 2023
Visit Reason
An unannounced annual and complaint survey was conducted at Delaware Veterans Home from April 19, 2023 through April 25, 2023 to assess compliance with federal and state regulations.
Complaint Details
The survey included complaint investigation components. Findings related to abuse, neglect, and exploitation training deficiencies were confirmed during interviews and record reviews.
Findings
The survey identified multiple deficiencies including failure to ensure pre-employment tuberculosis testing for new employees, inadequate emergency preparedness training for staff, failure to ensure reasonable accommodations for residents, incomplete significant change assessments, inaccurate resident assessments, incomplete drug regimen reviews, and insufficient training on abuse, neglect, and dementia management for staff.
Deficiencies (8)
Failure to ensure two-step tuberculosis testing for new employees prior to employment.
Failure to provide initial and ongoing emergency preparedness training to all staff.
Failure to ensure residents' call devices were within reach and call lights were functioning.
Failure to complete significant change assessments timely and accurately for residents.
Failure to accurately complete resident assessments reflecting status changes.
Failure to conduct monthly drug regimen reviews and report irregularities.
Failure to provide required training on abuse, neglect, exploitation, and dementia management to staff.
Failure to provide required in-service training for nurse aides including dementia management and abuse prevention.
Report Facts
Facility census: 59
Investigative sample: 32
New employees sampled for TB testing: 10
New employees failed TB testing: 2
Staff members failed emergency preparedness training: 4
Residents reviewed for accommodation: 2
Residents reviewed for significant change assessments: 4
Residents reviewed for assessment accuracy: 1
Residents reviewed for drug regimen: 5
Staff members failed abuse training: 1
Nurse aides reviewed for in-service training: 3
Nurse aides failed dementia training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Agency CNA | Failed to complete required pre-employment TB testing |
| E12 | Agency LPN | Failed to complete required pre-employment TB testing |
| E1 | Nursing Home Administrator (NHA) | Interviewed and confirmed findings during exit conference |
| E2 | Interim Director of Nursing (DON) | Interviewed and confirmed findings during exit conference |
| E13 | CNA | Failed to complete emergency preparedness training |
| E14 | RN | Failed to complete emergency preparedness training |
| E15 | RN | Failed to complete emergency preparedness training |
| E8 | CNA | Failed to complete abuse training and dementia training |
| E9 | CNA | Failed to complete required in-service training |
| E10 | CNA | Failed to complete required in-service training |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Mar 2, 2022
Visit Reason
An unannounced Complaint Survey was conducted at the Delaware Veterans Home on March 2, 2022.
Complaint Details
An unannounced Complaint Survey was conducted; no deficiencies were identified.
Findings
No deficiencies were identified at the time of the survey.
Report Facts
Survey sample residents: 3
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Nov 23, 2021
Visit Reason
An unannounced complaint survey was conducted at the facility from November 23, 2021 through November 24, 2021.
Complaint Details
The survey was complaint-related and no deficiencies were identified.
Findings
No deficiencies were identified during the survey.
Report Facts
Survey sample residents: 3
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 12
Date: Sep 10, 2021
Visit Reason
An unannounced annual and complaint survey was conducted from September 2, 2021 through September 10, 2021, including an Emergency Preparedness survey as required by 42 CFR 483.73.
Findings
The facility was found deficient in several areas including emergency preparedness training, influenza immunizations for staff, nursing staffing postings, medication self-administration assessments, accuracy of Minimum Data Set assessments, baseline care planning, hearing and vision care, medication management, psychotropic drug monitoring, food safety, and abuse and dementia training. Deficiencies were based on observations, interviews, and record reviews.
Deficiencies (12)
Emergency Preparedness training was not completed by all staff in the previous twelve months.
Facility failed to provide evidence of influenza vaccination or declination for sampled employees.
Facility failed to conspicuously display nursing supervisor on duty for each shift in common areas.
Facility failed to assess ability to self-administer medications for residents when requested.
Facility failed to ensure accuracy of Minimum Data Set assessments for skin conditions and restraints.
Facility failed to develop and implement baseline care plans including medication lists for residents.
Facility failed to develop comprehensive care plans for communication needs including hearing aids.
Facility failed to provide adequate supervision and safe environment to prevent accidents for residents.
Facility failed to ensure proper medication management including narcotic counts and medication labeling.
Facility failed to ensure psychotropic medications were appropriately ordered, monitored, and limited to 14 days.
Facility failed to ensure food was stored, prepared, and labeled in accordance with food safety standards.
Facility failed to provide adequate abuse and dementia training to staff within the previous twelve months.
Report Facts
Facility census: 50
Sample size: 29
Number of staff lacking influenza vaccination or declination: 4
Number of staff lacking emergency preparedness training: 14
Number of residents reviewed for medication self-administration: 6
Number of residents reviewed for MDS accuracy: 29
Number of residents reviewed for baseline care planning: 1
Number of residents reviewed for hearing and vision care: 3
Number of residents reviewed for accident prevention: 4
Number of medication carts audited: 3
Number of residents reviewed for psychotropic medication monitoring: 4
Number of residents reviewed for food safety: Food safety deficiencies noted in multiple areas
Number of staff reviewed for abuse and dementia training: All staff required to complete training by October 31, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Reviewed findings during Exit Conference |
| E2 | Director of Nursing (DON) | Reviewed findings and participated in interviews |
| E3 | Deputy Director | Reviewed findings during Exit Conference |
| E4 | Assistant Director of Nursing (ADON) | Confirmed staffing posting deficiencies and medication findings |
| E9 | Registered Nurse (RN), Unit Manager (UM) | Interviewed regarding staffing and medication findings |
| E11 | Social Worker (SW) | Documented care plan notes |
| E13 | Registered Nurse (RN) | Confirmed medication labeling deficiency |
| E14 | Nurse Practitioner | Reviewed physician progress notes |
| E16 | Security Director | Confirmed work order for toilet seat repair |
| E17 | Named in emergency preparedness training deficiency | |
| E18 | Named in influenza vaccination deficiency | |
| E19 | Named in emergency preparedness training deficiency | |
| E20 | Named in influenza vaccination deficiency | |
| E21 | Named in influenza vaccination deficiency | |
| E22 | Licensed Practical Nurse (LPN) | Named in emergency preparedness training deficiency |
| E23 | Registered Nurse (RN) | Named in emergency preparedness training deficiency |
| E25 | Licensed Practical Nurse (LPN) | Named in emergency preparedness training deficiency |
| E26 | Occupational Therapist (OT) | Named in influenza vaccination deficiency |
| E28 | Licensed Practical Nurse (LPN) | Named in emergency preparedness training deficiency |
| E29 | Volunteer Services | Named in emergency preparedness training deficiency |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Jun 8, 2021
Visit Reason
An unannounced COVID-19 Focused Infection Control Survey and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection from June 4, 2021 to June 8, 2021.
Complaint Details
The complaint investigation found noncompliance with employee COVID-19 testing requirements. Employee E5 worked from 2/26/21 through 3/13/21 without being tested for COVID-19 and later tested positive. The facility lacked adequate procedures to ensure testing compliance and timely follow-up.
Findings
The facility failed to conduct required COVID-19 testing every seven days for one employee (E5) out of three employees sampled, resulting in noncompliance with COVID-19 testing requirements. The facility lacked adequate follow-up procedures and staff education to ensure compliance with testing guidelines.
Deficiencies (1)
Facility failed to conduct required COVID-19 testing every seven days for one employee (E5) out of three employees sampled.
Report Facts
Facility census: 55
Survey sample size: 10
Employees sampled: 3
Employees audited monthly: 20
Audit reporting period: 2
QAPI committee reporting period: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E5 CNA | Certified Nursing Assistant | Employee who was not tested for COVID-19 as required and tested positive |
| E1 NHA | Nursing Home Administrator | Provided documentation and interview confirming testing failures |
| E2 DON | Director of Nursing | Participated in exit conference reviewing findings |
| E3 CRN | Case Registered Nurse | Participated in exit conference reviewing findings |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 11
Date: Oct 12, 2020
Visit Reason
An unannounced COVID-19 Focused Infection Control and Complaint Survey was conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection, beginning September 30, 2020 and ending October 12, 2020. The visit was complaint-related and focused on infection control and other regulatory compliance issues.
Complaint Details
The complaint investigation revealed failures in fingerprinting and drug screening of consultants, visitation restrictions violating resident rights, inadequate grievance resolution, failure to investigate and report abuse allegations including sexual abuse, failure to provide podiatry care, and failure to prevent COVID-19 transmission. Some allegations were substantiated, and investigations were ongoing for others.
Findings
The facility failed to ensure fingerprinting and/or drug screening was completed for consultants and contractors prior to their first day of work. The facility also failed to allow window visits and compassionate visits for some residents, failed to make prompt efforts to resolve grievances, failed to develop and implement policies for abuse/neglect investigations including sexual abuse, and failed to provide adequate podiatry care and infection prevention measures. Multiple deficiencies were cited related to resident rights, abuse prevention, care planning, and infection control.
Deficiencies (11)
Failure to ensure fingerprinting and/or drug screening was completed for consultants and contractors prior to first day of work.
Failure to allow window visits and compassionate visits for residents.
Failure to make prompt efforts to resolve grievances with written decisions and proper grievance policy implementation.
Failure to develop and implement written policies and procedures for abuse/neglect including sexual abuse investigations.
Failure to develop and implement policies for reporting reasonable suspicion of a crime including sexual abuse.
Failure to properly investigate and prevent further potential abuse while criminal investigation was ongoing.
Failure to provide comprehensive person-centered care plans for weight loss.
Failure to provide necessary services to maintain cleanliness for dependent residents.
Failure to provide adequate foot care and podiatry services as ordered.
Failure to provide an ongoing activity program to meet residents' needs.
Failure to properly prevent COVID-19 by ensuring residents wore face masks/cloth face coverings and maintained social distancing.
Report Facts
Facility census: 59
Survey sample size: 17
Residents affected: 3
Residents with visitation issues: 2
Residents with grievances investigated: 4
Residents with abuse allegations: 3
Residents with weight loss care plan issues: 1
Residents with foot care deficiencies: 3
Residents with activity program deficiencies: 0
Residents with mask compliance issues: 5
Inspection Report
Routine
Census: 72
Deficiencies: 0
Date: May 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the State of Delaware Division of Health Care Quality, Office of Long Term Care Residents Protection on May 13, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Facility census: 72
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 3
Date: Mar 4, 2020
Visit Reason
An unannounced complaint survey was conducted at the Delaware Veterans Home from March 3, 2020 through March 4, 2020 to investigate allegations related to abuse/neglect training and fall incident reporting.
Complaint Details
The complaint investigation found substantiated deficiencies related to abuse/neglect training and fall incident reporting and documentation.
Findings
The facility failed to ensure abuse/neglect training was provided to one out of ten sampled employees and failed to timely report a fall with injury requiring hospital transfer for one out of three residents reviewed for falls. Documentation of nursing notes and incident assessments were also incomplete.
Deficiencies (3)
Failure to ensure abuse/neglect training was provided to one out of ten randomly sampled employees.
Failure to ensure two falls and the immediate resident assessment were included in nursing notes for one out of three residents sampled for falls.
Failure to timely report a fall with injury requiring transfer to an acute care facility for one out of three residents investigated for falls.
Report Facts
Facility census: 79
Survey sample size: 11
Employees sampled: 10
Residents sampled for falls: 3
Employees non-compliant: 1
Residents with fall reporting deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Confirmed findings and participated in exit conference |
| E2 | Director of Nursing (DON) | Participated in exit conference and review of findings |
| E3 | Assistant Director of Nursing (ADON) | Participated in exit conference and review of findings |
| E4 | Quality Assurance (QA) | Participated in exit conference and review of findings |
| E5 | Custodian | Employee found to have not received abuse/neglect training |
| E6 | Unit Manager (UM) | Confirmed missing fall documentation during interview |
| R7 | Resident | Resident whose records were reviewed for falls and incident reporting |
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