Daleview Care Center

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to ensure each resident has the right to be free from chemical restraints not required to treat the resident's medical symptoms. This was identified for one (Resident #1) of five (5) residents reviewed for Unnecessary Medications. Specifically, Resident #1 with diagnosis of major depressive disorder was seen by a psychiatrist on 03/31/2026 who provided a recommendation to reduce the resident's quetiapine (an antipsychotic) dosage from 100 milligrams twice a day to 25 milligrams twice a day for seven days and then discontinue the medication. The facility did not respond to the psychiatry consultation until 05/06/2026, when the facility lowered the dosage as per the psychiatrist recommendation.

Inspectors wroteBased on observations, record review, and interviews during the survey, the facility failed to ensure it implemented a comprehensive person-centered care plan that includes measurable objectives and time frames to meet each resident's medical and nursing needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #43) of two (2) residents reviewed for skin conditions. Specifically, Resident #42 had a physician's order to offload heels at all times. On multiple occasions while the resident was in bed, the resident's heels were directly in contact with a pillow and were not being offloaded.

Inspectors wroteBased on observations, record review and staff interviews during survey, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (1) (Resident #117) of three (3) residents reviewed for skin conditions. Specifically, Resident # 117 had a physician order for compression socks for both legs in the morning and remove at bedtime. Resident #117's care plan did not include the use of ace bandage (an elastic compression wraps designed to reduce swelling) on both legs during the day and remove at night for chronic venous insufficiency (a condition when the leg vein valves are damaged or weakened).

Inspectors wroteBased on observations, record review, and interviews during survey the facility failed to ensure that pain management was provided to each resident consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was identified for one (Resident #148) of one resident reviewed for pain management. Specifically, Resident #148 was admitted to the facility with chronic bilateral elbow pain; however, there was no pain medication ordered. In addition, when the resident reported sever pain rating of 8 out of a scale of 0-10 (a scale used to measure pain intensity, where 0 equals no pain and 10 represents the worst imaginable pain) to a Registered Nurse Supervisor, the resident did not receive pain medication for more than two hours.

Inspectors wroteBased on observation, record review and interviews during the survey the facility failed to ensure it provided pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #146) of five (5) residents observed during the medication administration task. Specifically, during the medication administration observation for Resident#146, Licensed Practical Nurse #5 crushed an extended-release (designed to slowly release the medication) potassium chloride tablet. The blister pack for the extended-release potassium chloride tablet had a direction sticker that read do not crush.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure that all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This was identified for one (1) (unit 3) of three (3) units observed during the initial tour and for one (1) (medication cart for Unit 2) of three (3) medication carts reviewed during the medication storage and labeling task. Specifically, 1) Unit Three (3) shower room had unlabeled cream on the ledge in the shower room. 2) Unit Two (2) medication cart was observed with an insulin pen, and an eye drop bottle without a date to indicate when the medications were first opened to determine when the medications should be discarded.

Inspectors wroteBased on observations, interviews, and record review during the survey, the facility failed to maintain medical records that are complete and accurately documented. This was identified for one (1) (Resident #28) of three (3) residents reviewed for catheter. Specifically, Resident #28's contact precautions were discontinued on 04/21/2026; however, the resident's medical record was not updated to reflect discontinuation of the contact precautions in Resident #28's electronic medical record (EMR).

Inspectors wroteBased on observations, record review, and interviews during the survey, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections. This was identified for one (Resident #43) of two residents reviewed for skin conditions and for one (1) (Unit 2 medication cart) of three (3) medication carts reviewed during the medication storage and labeling task. Specifically, 1) during the wound care observation for Resident #43, Licensed Practical Nurse #6 did not sanitize the overbed table before placing the wound care supplies on top of the table. Additionally, Licensed Practical Nurse #6 did not sanitize their hands after removing the dirty dressings from the foot wounds and prior to applying the clean treatments. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey, initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for two (Resident #90 and Resident #237) of three residents reviewed for Pressure Ulcers. Specifically, 1) during a wound care observation of Resident #90's left buttock Stage 2 Pressure ulcer (wound with partial thickness loss of skin) on 2/26/2025, another stage Stage 2 Pressure Ulcer was observed on the right buttock. There was no documented evidence of an assessment or a Physician's order for treatment for the right buttock pressure ulcer. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that each resident's environment remained free of accident hazards. This was identified for one (Resident #21) of four residents reviewed for Accidents. Specifically, an oxygen E-Cylinder tank (portable oxygen tank) was observed on the right side of Resident #21's bed. The E-Cylinder tank was not secured in a rolling safety stand or a metal rack. The finding is: The facility's policy, titled Oxygen Closet last revised on 9/2024, documented the facility would maintain an adequate supply of oxygen needed for the administration of oxygen. A minimum of two small E-Cylinder tanks will be maintained on each unit for emergency purposes. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that the staff implemented and provided care and services according to the resident's needs and professional standard of practice for each resident with a feeding tube. This was identified for one (Resident #27) of one resident reviewed for Tube Feeding, specifically, on 2/24/2025 at 11:30 AM and 1:00 PM. Resident #27 was observed receiving enteral tube feeding (a method of providing nutrition directly into the gastrointestinal (GI) tract through a tube); the enteral tube feeding bottle and the water bag was observed hanging on a feeding tube stand without a label including the resident's name and the time the tube feeding was started. The finding is: The facility's policy titled Tube Feedings: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure the Physician documented in the resident's medical record that the irregularity identified by the Pharmacist has been reviewed and what action has been taken to address it. This was identified for two (Resident #121 and Resident #116) of five residents reviewed for Unnecessary Medications. Specifically, Nurse Practitioner #1 disagreed with recommendations provided by the Consultant Pharmacist for Resident # 121 and Resident #116; however, the reason for the disagreement was not documented.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025 the facility did not ensure each resident was free of any significant medication errors. This was identified for one (Resident #284) of six residents observed during medication administration. Specifically, Resident #284 had a do not crush physician's order for Metoprolol extended-release medication tablet (a blood pressure medication). During the medication administration observation, Licensed Practical Nurse #5 crushed and administered the Metoprolol extended-release medication tablet to Resident #284. The finding is: The facility's policy titled Medication Administration: [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #1) of four residents reviewed for Accident Hazards. Specifically, Resident #1 was observed with an Albuterol inhaler (medication used to treat difficulty breathing) on top of their bed and there was no nursing staff in the vicinity. There was no Physician's order for Albuterol inhaler and the resident was not assessed to self-administer their medication. The finding is: The facility's policy titled Medications: Storage and Handling last revised on 12/12/2024, documented medications are stored according to procedures established in compliance with State and Federal regulations. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure it maintained an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This was identified for one (Resident #283) of one resident reviewed for Respiratory Infection. Specifically, Resident #283 was re-admitted to the facility on [DATE] from the hospital with a diagnosis of Influenza. The resident was placed on Contact and Droplet Precautions. During two separate observations, [NAME] #1 and [NAME] #2 were cleaning the resident's room without wearing appropriate Personal Protective Equipment. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not conduct a comprehensive assessment of a resident not less than once every 12 months while a resident. This was identified for one (Resident #78) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #1's admission Minimum Data Set assessment was completed on 2/7/2024. The Annual Minimum Data Set (MDS) assessment was completed on 2/10/2025, which was 369 days from the previous comprehensive assessment. Additionally, the Assessment Reference Date for the Annual Minimum Data Set was 1/20/2025 and the assessment was not completed until 21 days after the Assessment Reference date. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 2/24/2025 and completed on 2/28/2025, the facility did not ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of the resident assessment completion. This was identified for one (Resident #78) of one resident reviewed for the Resident Assessment Task. Specifically, Resident #78's Annual Minimum Data Set (MDS) assessment was completed on 2/10/2025; however, the assessment was not electronically submitted to the Center for Medicare and Medicaid Services (CMS) until 2/25/2025, 15 days after the completion date. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record review during an abbreviated survey with complaint # NY00350920, the facility did not ensure that the environment remained secure and free from accident hazards for one (Resident #1) of three residents reviewed for elopement. Specifically, Resident #1 with severe impaired cognition and assessed as an elopement risk exited the facility undetected by staff through an unalarmed south stairwell emergency exit door at 5:55PM. Resident #1 was found by local law enforcement 0.2 miles away from the facility at 6:40PM. The facility staff identified Resident #1 missing at 8PM. There are 12 other residents identified as elopement risk.

Inspectors wroteF602 Based on observations, interviews, and record reviews conducted during an abbreviated survey (Case #NY00329271), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for 2 (Resident #1 and Resident #2) of 3 residents reviewed. Specifically, Resident #1 credit cards was fraudulently used, and 30 dollars was taken while a resident in the facility, Resident #2 had 500 dollars taken from their purse. This is evidenced by: A Policy and Procedure (P&P) titled Abuse Prevention dated February 2023 documented the following: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 12/10/2023 and completed on 12/14/2023 the facility did not ensure each resident remained free of significant medication errors. This was identified for three (Resident #29, Resident #95, and Resident #92) of three residents reviewed for significant medication errors. On 12/10/2023 multiple residents received their medications late because the 11:00 PM-7:00 AM shift Licensed Practical Nurse #8 completed the medication administration pass late which then caused Licensed Practical Nurse #5 to administer medications to the residents late on the 7:00 AM-3:00 PM shift. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 00323920) initiated on 12/8/2023 and completed on 12/14/2023 the facility did not ensure that all injuries of unknown source were reported immediately, but not later than 2 hours if there are serious bodily injury, or not later than 24 hours if there are no serious bodily injuries. Specifically, on 7/21/2023 Resident #274 was identified with an injury of unknown origin. There was no documented evidence that the injury was reported to the New York State Department of Health (NYSDOH) as required. The finding is: The facility's Abuse Prevention policy and procedure effective February 2023 documented that all alleged violations must be immediately reported to the Administrator, state agency, and any other required law enforcement agencies within the specified time frame. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 12/10/2023 and completed on 12/14/2023, the facility did not ensure that the Office of the Long-Term Care Ombudsman was notified of each resident's transfer or discharge to the hospital. This was identified for one (Resident #75) of two residents reviewed for Hospitalization. Specifically, Resident #75 was discharged to the hospital on [DATE] and no notification of the discharge was sent to the Office of the Long-Term Care Ombudsman. The finding is: Resident #75 was admitted to the facility with diagnoses including Parkinson's Disease with Dyskinesia and Alzheimer's Disease. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making with long and short term memory problems. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 12/10/2023 and completed on 12/14/2023, the facility did not ensure that each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs. This was identified for one (Resident #21) of one resident reviewed for Skin Conditions (non-pressure). Specifically, Resident #21 had Physician Orders to receive treatments to bilateral lower extremities and an ACE wrap (compression bandages) to be applied to bilateral lower extremities. On 12/10/2023 during a tour of the 2nd floor Nursing Unit, the dressings to the lower extremities of Resident #21 were observed with a date of 12/8/2023. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 12/10/2023 and completed on 12/14/2023, the facility did not ensure each resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #327) of four residents reviewed for Accidents. Specifically, Resident #327 was observed on multiple occasions without the use of the Physician ordered ACE wraps or [NAME] (compression stocking) stockings to bilateral lower extremities due to complaint of pain and bilateral lower extremity edema. Additionally, when the ACE wrap was applied, the staff did not remove the ACE wraps as per the Physician's orders. The finding is: Resident # 327 has diagnoses of Edema, Cellulitis, and Diabetes Mellitus. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey, initiated on 12/10/2023 and completed on 12/14/2023, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #328) of two residents reviewed for Pressure Ulcers. Specifically, Resident #328 was admitted to the facility on [DATE] with a Stage 4 pressure ulcer to the right ischium (a bony prominence of the pelvis). Treatment for the Stage 4 pressure ulcer was not started until 10/23/2023. The initial wound assessment by the wound care Registered Nurse (RN) and the wound care physician documented an incorrect wound depth. [...]

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification Survey initiated on 12/10/2023 and completed on 12/14/2023, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (Resident #425) of five residents reviewed for Respiratory Care. Specifically, Resident #425 had a Physician's order to receive 2 liters of oxygen per minute continuously. The resident was observed receiving 4 liters and 5 liters of oxygen per minute respectively on two consecutive days. The finding is: The facility's Administration and Maintenance of Oxygen policy revised June 2023 documented attending physicians are to provide a written order for the use of oxygen in non-emergency situations noting: the device to be used; the amount of oxygen flow; the duration of use; [...]