Nursing Investigation Results -

Pennsylvania Department of Health
DELAWARE VALLEY VETERANS' HOME
Building Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
DELAWARE VALLEY VETERANS' HOME
Inspection Results For:

There are  46 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
DELAWARE VALLEY VETERANS' HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Name: - Component: -- - Tag: 0000


Based on an Emergency Preparedness Survey completed on May 10, 2022 at Delaware Valley Veterans' Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.





 Plan of Correction:


Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000


Facility ID# 12720200
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on May 10, 2022, it was determined Delaware Valley Veterans' Home was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected non-combustible construction, with a basement, which is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Means of Egress - General:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0211

Based on observation and interview, it was determined the facility failed to maintain means of egress on one of two floors.

Findings include:

1. Observation on May 10, 2022 at 11:20 am, revealed multiple pieces of furniture blocking the exit near room A108 on the 1st floor.

Interview at the time of the exit conference with the facility commandant and facility maintenance director on May 10, 2022, at 2:30 pm, confirmed the items were blocking the exit.




 Plan of Correction - To be completed: 05/26/2022

All furniture was removed at the time of survey.

Affected areas will be monitored throughout the day by security guards and nursing supervisors.

Any issues will be reported immediately and at monthly QA meeting
NFPA 101 STANDARD Vertical Openings - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0311

Based on observation and interview, it was determined the facility failed to maintain vertical openings on one of two floors.

Findings include;

1. Observation on May 10, 2022 at 12:35 pm, revealed the 1st floor metal door to the C-stair tower had a gap in excess of 3/16 of an inch along the header on the latch side.

Interview at the time of the exit conference with the facility commandant and facility maintenance director on May 10, 2022, at 2:30 pm, confirmed the excessive gap between the door and the frame.



 Plan of Correction - To be completed: 05/26/2022

Affected door was adjusted 5/11/22.

Facility inspected all fire doors and going forward will inspect fire doors semi-annually rather than annually as required.

Findings will be reported at monthly QA meeting.
NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous areas on one of two floors.

Findings include;

1. Observation on May 11, 2022 at 12:00 pm, revealed an egg crate style ceiling tile located in the clean utility room near the nurse station in B-wing, the room contained combustible storage.

Interview at the time of the exit conference with the facility commandant and facility maintenance director on May 10, 2022, at 2:30 pm, confirmed the room ceiling was not smoke tight.





 Plan of Correction - To be completed: 05/26/2022

When Delaware Valley Veterans Home was originally constructed it was designed with open air return plenums. This facility has not changed any duct work from the original design intent. The returns noted during the life safety walkthrough are open air plenum returns for the fan coil units.


The egg crate style ceiling tile noted in the clean utility room is a return grill for the open air plenum.
NFPA 101 STANDARD Portable Fire Extinguishers:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to maintain portable fire extinguishers in one location of over twenty inspected.

Findings include;

1. Observation on May 10, 2022 at 12:15 pm, revealed the K type fire extinguisher in the B dining room pantry did not have a placard with instructions indicating proper use.

Interview at the time of the exit conference with the facility commandant and facility maintenance director on May 10, 2022, at 2:30 pm, confirmed the lack of a required placard.





 Plan of Correction - To be completed: 05/11/2022

Proper placard has been placed.

Signage will continue to be monitored during monthly fire extinguisher inspections.

Any issues will be reported at monthly QA meeting.
NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0521

Based on observation and interview, it was determined the facility failed to maintain the HVAC system on one of two floors.

Findings include;

1. Observation on May 10, 2022, at 12:18 pm, revealed the ceiling space in the service corridor behind B-wing was being used as a plenum.

Interview at the time of the exit conference with the facility commandant and facility maintenance director on May 10, 2022, at 2:30 pm, confirmed the ceiling space was a plenum.





 Plan of Correction - To be completed: 05/11/2022

When Delaware Valley Veterans Home was originally constructed it was designed with open air return plenums. This facility has not changed any duct work from the original design intent. The returns noted during the life safety walkthrough are open air plenum returns for the fan coil units.
NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0911

Based on observation and interview, it was determined the facility failed to protect resident beds from electrical outlets in one location of approximatley one hundred inspected.

Findings include:

1. Observation on May 10, 2022 at 12:20 pm, revealed the "door" bed in room 118, C-wing was in direct contact with an unprotected electrical outlet.

Interview at the time of the exit conference with the facility commandant and facility maintenance director on May 10, 2022, at 2:30 pm, confirmed the bed was in contact with the outlet.




 Plan of Correction - To be completed: 05/11/2022

All facility beds will be monitored to assure no direct contact with an outlet.

Any findings will be reported at the monthly QA meeting.

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