Pennsylvania Department of Health
DELAWARE VALLEY SKILLED NURSING & REHABILITATION CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 11 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 SKILLED NURSING & REHABILITATION CENTER - 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 20, 2025, at Delaware Valley Skilled Nursing and Rehabilitation Center, 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#50600201
Component 01
Main Building
Based on a Medicare/Medicaid Recertification Survey completed on May 20, 2025, it was determined that Delaware Valley Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of the Life Safety Code for new 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 one story, Type V (111), protected, wood frame structure, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in one of seven smoke compartments.

Findings include:

1. Observation on May 20, 2025, at 12:00 pm, revealed the kitchen sprinklers were loaded with what appeared to be dust.

Interview with the administrator, administrator intern, and maintenance representative on May 20, 2025, at 12:00 pm, confirmed the sprinklers were covered in debris.

Plan of Correction - To be completed: 05/28/2025

1.Sprinkler Heads in the kitchen were cleaned

2. Director of Maintenance or designee will complete an audit of all sprinkler heads to ensure they are free of dust.

3. Nursing Home Administrator will provide education to Maintenance Director to ensure sprinkler heads are free of dust.

4. Director of Maintenance or designee will complete an audit to ensure Sprinkler Heads are free from dust weekly for 4 weeks and monthly times 2 months. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. Committee will determine the need for further audit and/or recommendations.

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