DELMAR, NY - State inspectors documented multiple serious infection control violations at Bethlehem Commons Care Center, including catheter drainage bags left on floors, improper use of protective equipment, and a facility operating without a designated infection preventionist for several months.
Critical Infection Control Failures Put Residents at Risk
The January 2025 inspection revealed numerous instances where staff failed to follow basic infection prevention protocols, potentially exposing vulnerable residents to harmful bacteria and infections. The most concerning violations involved the mishandling of urinary catheter equipment and oxygen tubing, both of which require strict sanitation procedures.
During the inspection, state surveyors found Resident #17's urinary catheter drainage bag "exposed, lying on the floor." Similarly, inspectors discovered Resident #364's catheter bag "uncovered and lying on the floor." These observations violated the facility's own infection control policy, which specifically states that catheter drainage bags should not touch the floor.
Placing catheter bags on floors creates a direct pathway for dangerous bacteria to enter the urinary system. Hospital floors contain numerous pathogens including E. coli, Pseudomonas, and other multi-drug resistant organisms. When drainage bags contact contaminated surfaces, bacteria can travel up the tubing and cause serious urinary tract infections, sepsis, or kidney damage in vulnerable residents.
The facility's infection control policy clearly outlined proper catheter care procedures, including maintaining drainage bags off the floor and following standard precautions when handling the drainage system. However, multiple residents experienced substandard catheter management during the inspection period.
Staff Ignored Personal Protective Equipment Requirements
Inspectors documented widespread failures in personal protective equipment (PPE) usage throughout the facility. Staff members repeatedly entered and exited rooms of residents requiring enhanced barrier precautions without wearing required gowns, gloves, and masks.
During one observation, a Certified Nurse Aide entered Resident #83's room multiple times to retrieve supplies without performing hand hygiene or donning protective equipment, despite the resident being on enhanced barrier precautions. Another aide was observed providing incontinence care to a resident on transmission-based precautions without wearing any protective equipment or washing hands before or after care.
Enhanced barrier precautions are implemented when residents have conditions that increase infection transmission risk. These protocols require healthcare workers to wear gowns, gloves, and masks when providing direct care activities like bathing, transferring, changing linens, or wound care. The precautions protect both residents and staff from spreading infections, particularly antibiotic-resistant organisms.
Resident #364, who had a care plan specifically noting risk for multi-drug resistant organism infection, reported that staff had "never worn a gown or a mask" until the day of the inspection. "They only recalled seeing staff wearing masks and gloves on 1/14/2025," the resident told inspectors. This resident also stated they had received no education on catheter care and were simply given cleansing wipes with instructions to clean the catheter three times daily.
Contaminated Equipment and Inadequate Sanitation Practices
The inspection revealed concerning lapses in equipment sanitation and storage. In multiple shared bathrooms, inspectors found unlabeled personal care items including denture cups, wash basins, and bedpans. Without proper labeling, these items could be used by different residents, creating cross-contamination risks.
Oxygen equipment also presented infection control concerns. Resident #218's oxygen tubing was found sitting on the floor, and the resident reported that "staff never changed the tubing and rarely labelled it either." Oxygen tubing requires regular replacement and should never contact floors or other contaminated surfaces, as bacteria can enter the respiratory system and cause pneumonia or other serious lung infections.
Proper medical equipment protocols require regular cleaning, disinfection, and replacement schedules. Oxygen tubing should be changed according to manufacturer guidelines and facility policies, typically every few days or when visibly soiled. Leaving tubing on floors exposes residents to environmental pathogens that can cause respiratory tract infections, particularly dangerous for residents with chronic obstructive pulmonary disease like Resident #218.
Facility Operated Without Required Infection Preventionist
Perhaps most concerning, the facility operated without a designated infection preventionist from October 2024 through January 2025. Federal regulations require nursing homes to designate qualified infection preventionists responsible for overseeing infection control programs. These professionals develop policies, monitor compliance, investigate outbreaks, and ensure staff receive proper training.
The absence of an infection preventionist likely contributed to the widespread infection control failures documented during the inspection. Without dedicated oversight, staff compliance with protocols deteriorated, potentially exposing residents to preventable infections and complications.
Infection preventionists serve as the central authority for all infection-related policies and procedures. They conduct regular audits, provide staff education, and respond to potential outbreaks. The position requires specialized training in microbiology, epidemiology, and healthcare-associated infection prevention.
Medical Context and Health Implications
These infection control violations pose serious health risks, particularly for elderly residents with compromised immune systems. Urinary tract infections from contaminated catheter equipment can progress to kidney infections, sepsis, and potentially life-threatening complications. Respiratory infections from contaminated oxygen equipment can cause pneumonia, especially dangerous for residents with existing lung conditions.
The Centers for Disease Control and Prevention estimates that healthcare-associated infections affect hundreds of thousands of nursing home residents annually. Many of these infections are preventable through proper infection control practices, including appropriate use of personal protective equipment, regular hand hygiene, and proper equipment handling.
Standard medical protocols require strict adherence to infection prevention measures. Healthcare workers should perform hand hygiene before and after every patient contact, don appropriate protective equipment based on resident conditions, and maintain sterile or clean environments for medical equipment. These protocols exist because vulnerable populations like nursing home residents face significantly higher infection risks and more severe complications.
Additional Issues Identified
The inspection also documented improper mask usage, with one Licensed Practical Nurse observed wearing an N95 mask under their nose, reducing its effectiveness. Staff members were seen moving between clean and dirty utility areas without performing hand hygiene, potentially spreading contaminants throughout the facility.
A Certified Nurse Aide told inspectors that most staff only wore protective equipment during direct personal care, not when simply checking on residents or answering call lights. This practice violates protocols for residents requiring enhanced precautions, where any room entry necessitates full protective equipment.
The facility's Director of Nursing acknowledged that re-education occurred informally when violations were observed but was not documented or tracked systematically. This informal approach may have contributed to the persistent compliance failures noted throughout the inspection.
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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