Delaware Veterans Home

In the surveyor’s words

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

• Actual harm, isolatedF600Mar 12, 2026

  Based 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. Findings include:. 1.Review of the facility's 5-day Follow Up Report dated 07/25/25 provided by the Administrator, revealed that at the time of the incident on 07/22/25 at 5:30 PM, staff heard someone screaming. Upon entering the hallway, staff observed R4 sitting on the floor holding his head. […]

• Actual harm, isolatedF684Mar 6, 2025

  2. Review of R9's clinical record revealed: 1/16/24 - R9 was admitted to the facility. 12/18/24 6:43 PM - A nursing progress note documented that R9 had contacted 911 services due to having hallucinations. Due to the resident having a history of the behaviors, a note was left in the physician communication log and R9 had continued to be monitored. 12/19/24 9:30 AM - A physician's order was written for a urinalysis with a culture and sensitivity to be collected on 12/20/24. 12/20/24 - A urine sample was collected and sent to the lab for analysis and culture. 12/20/24 - A provider note by E13 (NP) documented, . Was asked to see patient [R9] today due to complaints of intermittent hallucinations unit manager reports patient having intermittent visual hallucinations. […]

• No harm, potential for more than minimal, widespreadF812Mar 12, 2026

  Based 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.Findings include:During an observation on 03/09/26 at 10:30 AM, three 6x6x6 stainless steel pans and six 6x24x6 stainless steel pans were stacked together on storage rack were noted to be wet inside with some food debris remaining. During an interview on 03/09/26 at 10:50 AM, the Food Service Director (FSD) stated, The pans are wet and they shouldn't be. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2021

  Based on observations and interviews it was discovered that the facility failed to ensure food was stored, distributed and prepared in a sanitary manner in accordance to FDA food standards. Findings include: The following was revealed during the initial kitchen tour and nourishment rooms on 9/2/21 from 8:30 AM to 10:00 AM: - The walk-in refrigerator had moldy blueberries and a cardboard box storing purple cabbage and bacon; - The hand washing sink in the dish room was blocked by carts; - The ice machine scoop was stored within the hand washing sink splash zone; - The dining room had unlabeled spray bottles; - The nourishment room on the Red Unit refrigerator was dirty with unlabeled sandwiches; - The nourishment room on the Gold Unit refrigerator was dirty on the bottom. […]

• No harm, potential for more than minimal, patternF657Mar 6, 2025

  Based 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. Findings include: 1. 2/11/08 - R1 was admitted to the facility. 1/15/25 - A quarterly MDS was completed. 1/28/25 - A quarterly care plan meeting note lacked evidence of input from the physician. 10/16/24 - A quarterly MDS was completed. 10/29/24 - A quarterly care plan meeting note lacked evidence of input from the physician. 7/17/24 - An annual MDS was completed. 7/30/24 - An annual care plan meeting note lacked evidence of input from the physician. 2. […]