DELMAR, NY - Federal inspectors documented significant infection control failures at Bethlehem Commons Care Center during a January 23, 2025 survey, finding that the facility's infection prevention program lacks adequate oversight and staffing.
Understaffed Infection Control Program
The most concerning finding involved the facility's infection prevention leadership structure. During the inspection, the Director of Nursing revealed they were simultaneously serving as the Infection Preventionist, Director of Nursing, and Nurse Educator - three distinct roles that require specialized attention and expertise.
"There had not been anyone available to complete the Infection Preventionist role since they became the Director of Nursing role in October 2024," the Director of Nursing told inspectors on January 17. They acknowledged that wearing multiple hats made it impossible to properly train and observe all facility staff in infection control practices.
Policy Versus Practice Gap
The facility's own policies outlined clear expectations for infection control oversight. According to their Antibiotic Stewardship policy, revised in July 2024, the Infection Preventionist should have dedicated oversight responsibilities with input from the Medical Director, Consultant Pharmacist, and other facility leaders.
The policy specified that these leaders should "regularly participate in Infection Prevention and Control Committee meetings and provide feedback regarding the Antibiotic Stewardship Program." However, the reality documented by inspectors showed a significant gap between written policies and actual implementation.
Widespread Infection Control Deficiencies
Federal surveyors noted "insufficient infection control practices among the staff" throughout their entire inspection process. This observation suggests the staffing shortage in the Infection Preventionist role had real-world consequences for daily operations and resident safety.
Proper infection control in nursing homes requires consistent monitoring, staff education, and immediate response to potential outbreaks. When these responsibilities fall to someone already managing multiple demanding roles, the risk of oversight gaps increases substantially.
Medical Significance of Infection Control
Effective infection prevention in nursing homes is critical because residents typically have compromised immune systems and multiple chronic conditions that make them particularly vulnerable to healthcare-associated infections. Common nursing home infections include respiratory infections, urinary tract infections, and skin infections, which can quickly spread in congregate living environments.
The Centers for Disease Control and Prevention estimates that nursing home residents experience between 1.6 and 3.8 infections per 1,000 resident-days. Without proper oversight and staff training, these numbers can increase dramatically, leading to serious complications, hospitalizations, and even deaths among vulnerable residents.
Industry Standards and Best Practices
Federal regulations require nursing homes to maintain comprehensive infection prevention and control programs. These programs must include designated leadership, regular staff training, surveillance systems to detect infections early, and protocols for containing outbreaks when they occur.
The Infection Preventionist role specifically requires expertise in epidemiology, microbiology, and infection control practices. This specialized knowledge helps facilities identify infection risks, implement evidence-based prevention strategies, and respond appropriately to infectious disease threats.
Regulatory Response
The facility was cited under F880 Infection Control, which relates to federal requirements for nursing homes to establish and maintain infection prevention and control programs. This citation indicates inspectors found the facility's current approach insufficient to meet federal standards for resident safety.
The violation specifically referenced New York Code of Rules and Regulations 483.80, which outlines the comprehensive requirements for infection prevention and control programs in nursing homes.
Path Forward
To address these deficiencies, Bethlehem Commons will need to either hire a dedicated Infection Preventionist or restructure their leadership responsibilities to ensure adequate oversight of infection control practices. The facility must also demonstrate that all staff receive proper training and that infection control policies are consistently implemented throughout the facility.
The inspection findings highlight the challenges many nursing homes face in maintaining specialized staff positions while managing operational costs. However, federal regulators emphasize that resident safety cannot be compromised by staffing decisions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethlehem Commons Care Center from 2025-01-23 including all violations, facility responses, and corrective action plans.
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