Inspection Reports for
Delaware Veterans Home

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.

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.

The complaint investigation substantiated abuse by nursing staff toward residents, including verbal and physical abuse. CNA4 was terminated following investigation and substantiation of abuse.

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.

The survey included complaint investigation components. Findings related to abuse, neglect, and exploitation training deficiencies were confirmed during interviews and record reviews.

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.

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.

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.

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.

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.

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.

The complaint investigation found substantiated deficiencies related to abuse/neglect training and fall incident reporting and documentation.

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.