Delaware Valley Veteran's Home

In the surveyor’s words

From the most serious findings on record at Delaware Valley Veteran's Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 18, 2024

  Based 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. […]

• Actual harm, isolatedF600Apr 15, 2026

  Based 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)Findings include: Review of the facility policy title Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property updated August 7, 2023 revealed It is the purpose of protocol to give guidance to the Department of Military and Veterans Affairs (DMVA), Bureau of Veterans Homes (BVH), State Veterans Homes… […]

• Actual harm, isolatedF689Apr 15, 2026

  Based 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) Findings include: Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses including Dementia (decline in cognitive function that interferes with daily life), Chronic Obstructive Pulmonary Disease (COPD - airway disease that restricts breathing), and Generalized Anxiety disorder. […]

• No harm, potential for more than minimal, widespreadF812Apr 29, 2022

  Based on observations, interviews with staff, and a review of facility policies, it was determined that the facility did not ensure that food was stored, in accordance with professional standards for food service safety. Findings include: Review of the facility policy title Food Handling, revised January 2019, states open containers labeled to include contents and date. An initial tour of the Food Service Department conducted on April 26, 2022, at 9:45 a.m. with Employee E9, Food Service Director (FSD), revealed the following: Observation in the walk-in freezer revealed a clear plastic bag which contained hoagie rolls which was open to the air. Observation in the walk-in cooler revealed two one-gallon size containers of salad dressing with no date. […]

• No harm, potential for more than minimal, patternF645Jul 10, 2026

  Based 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).Findings include: The PASRR (Preadmission Screening Resident Review), created in 1987 through language in the Omnibus Budget Reconciliation Act (OBRA), has three goals: to identify individuals with mental illness and/or intellectual disability; to ensure they are placed appropriately, whether in the community or in a nursing facility; and to ensure they receive the services they require for their mental illness or intellectual disability. […]