Bethlehem Commons Care Center

F-F550 as it pertains to the facility's failure to resident dignity.

Please refer to

F-F554 as it pertains to the facility's failure to assess the resident's ability to self-administer medications.

Please refer to

F-F577 as it pertains to the facility's lack of accessibility of the survey results in the facility.

Please refer to

F-F584 as it pertains to the facility's failure to provide a a safe, clean, comfortable and homelike environment.

Please refer to

F-F585 as it pertains to the facility's failure to provide availability for residents to file a grievance or complaint.

Please refer to

F-F600 as it pertains to the facility's failure to ensure residents were free from abuse and neglect.

Please refer to

F-F609 as it pertains to the facility's failure to ensure injuries from unknown sources were reported to the State Survey Agency.

Please refer to

F-F622 as it pertains to the facility's failure to provide residents with a safe and appropriate discharge.

Please refer to

F-F623 as it pertains to the facility's failure to notify the Office of the State Long-Term Care ombudsman office on discharges.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Please refer to

F-F625 as it pertains to the facility's failure to provide a notice of discharge or bed hold policy when discharged to the hospital. Level of Harm - Minimal harm or potential for actual harm Please refer to

F-F645 as it pertains to the facility's failure to assess residents with mental or intellectual disabilities received preadmission screening. Residents Affected - Some Please refer to

F-F656 as it pertains to the facility's failure to develop and implement a comprehensive person-centered care plan for each resident.

Please refer to

F-F657 as it pertains to the facility's failure to review and revise a comprehensive person-centered care plan for each resident.

Please refer to

F-F679 as it pertains to the facility's failure to provide activities based on comprehensive assessment, care plan, and preferences of each resident.

Please refer to

F-F684: Quality of Care

Resident #34 was admitted to the facility with diagnoses of disruption or dehiscence (splitting open) of internal surgical wound of abdominal wall muscle, surgical aftercare following surgery on the digestive system, and personal history of malignant neoplasm (cancer) of the large intestine. The Minimum Data Set (an assessment tool) dated 1/2/2025, documented the resident was cognitively intact. The resident was able to make themselves understood and was able to understand others.

During an observation on 1/13/2025 at 1:53 PM, Resident #34's abdominal dressing was noted with dry, brown-colored drainage and was dated 1/11/2025. Resident #34 stated they had abdominal surgery and had stitches. They stated that when they were in the previous rehabilitation facility, the wound opened, and they had to close it. They stated they did not feel facility nursing staff was monitoring their incision and abdomen

the way they should be.

The Order Recap Report dated 12/1/2024 to 1/31/2025, documented an order dated 12/23/2024 to cleanse abdominal wound with normal saline wet; pat dry with clean gauze; apply saline wet-to-moist gauze to wound bed; cover with abdominal pad; secure with dressing retention tape; every evening shift for wound care.

Review of the Treatment Administration Record dated January 2025, documented the resident's abdominal wound treatment was administered by Licensed Practical Nurse #8 on 1/12/2025.

During an interview on 1/23/2025 at 8:53 AM, Registered Nurse #2 stated they were not aware that Licensed Practical Nurse #8 had signed the Treatment Administration Record on 1/12/2025, but did not do the treatment. They stated they were not aware Resident #34 had a concern about their dressing changes not being done. Registered Nurse #2 stated the only time they knew the dressing was changed for certain was

on Monday 1/20/2025, during wound rounds.

During an interview on 1/23/2025 at 9:39 AM, Director of Nursing #1 stated that the minute they found out

the dressing was not changed on 1/12/2025, Licensed Practical Nurse #8 was written up and received a final warning. They stated Licensed Practical Nurse #8 documented the treatment was done on 1/12/2025, but did not change the dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During an interview on 1/23/2025 at 10:57 AM, Licensed Practical Nurse #8 stated that on 1/12/2025, there was a patient that needed to be sent to the hospital, and they were called off the unit. They stated they did Level of Harm - Minimal harm or click it as being done before it was done, and their intention was to go back in the room and change the potential for actual harm dressing.

Residents Affected - Some 10 New York Code of Rules and Regulations 415.22(a)(1-4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 48413 potential for actual harm Based on interviews, record reviews, and review of facility policy, the facility failed to maintain a quality Residents Affected - Some assurance committee that met with the participation of all required members, including the director of nursing, Medical Director or designee, Administrator, and Infection Preventionist. The failure to meet to coordinate and evaluate the need for performance improvement projects had the potential to affect all residents of the facility.

This is evidenced by:

A review of the facility's undated Quality Assurance and Performance Improvement Plan, revealed that the Quality Assurance and Performance Improvement Plan provides leadership through its committee. The Quality Assurance and Performance Improvement committee shall be comprised of the Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Facility Educator, Unit Managers, Wound Nurse, nursing and ancillary staff, and all department heads. The Administrator is the chairperson of the Quality Assurance and Performance Improvement committee and is responsible for ensuring that Quality Assurance and Performance Improvement are implemented throughout the facility. The Quality Assurance and Performance Improvement Committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees. The overall responsibility of the steering committee is to develop and modify the Quality Assurance and Performance Improvement, identify teams who will problem solve as well as set priorities for the Performance Improvement Projects.

A Review of Policy and Procedure titled Infection Prevention and Control created 10/2015 and revised 5/30/2024 documents under Policy Implementation: Through oversight of the Quality Assessment and Assurance Committee, the Infection Prevention and Control Committee, shall oversee the implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments: and, inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing Services.

A review of the last six months of Quality Assurance meeting attendance records revealed that meetings were held from July 2024 through December 2024. A review of the sign-in sheets for these meetings revealed no evidence that the Medical Director or designee attended the 2024 meeting or Infection Preventionist attended any of these meetings.

During an interview conducted on 01/17/2025 at 12:05 PM, Director of Nursing #1 stated they were the current Infection Preventionist as well as the Nurse Educator. They stated there had not been anyone available to complete the role of Infection Preventionist up to the current time. They stated they had been trying to promote a nurse to the Assistant Director of Nursing role and stated they thought the nurse already had their Infection Preventionist certification. They stated the nurse would be offered training if they did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 During an interview on 1/23/2025 at 4:05 PM, Administrator #1 stated that they held meetings every month and it was the responsibility of the staff to sign in for the meetings. They stated that the Medical Director was Level of Harm - Minimal harm or at the December 2024 meeting but must have failed to sign in. They stated that they were unaware that the potential for actual harm Infection Control Preventionist was their own role and could not be a dual role with the Director of Nursing.

Residents Affected - Some 10 New York Code of Rules and Regulations 415.27(b)(3)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34630 potential for actual harm Based on observation, record review, and interviews during the recertification survey the facility did not Residents Affected - Many provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections; and maintain an infection prevention and control practices designed to help prevent the development and transmission of communicable diseases and infection for all resident's and staff on 4 of 4 units. Specifically, (a.) during general observations staff were observed not putting on and taking off Personal Protective Equipment or practicing hand hygiene while entering and exiting residents' rooms with Transmission and Enhanced Barrier Precautions; (b.) for Resident #218, oxygen tubing was observed lying on the floor; (c.) Resident #17 was observed with urinary catheter bag lying on the floor; and (d.) catheter care for Resident #364 was not maintained as ordered to prevent urinary tract infection and urinary catheter bag was observed lying on the floor.

48413

This was evidenced by:

Cross referenced to

F-F689 as it pertains to the facility's failure to ensure residents were free of accidents and hazards.

Please refer to

F-F692 as it pertains to the facility's failure to ensure acceptable parameters of nutritional status and sufficient fluid intake to maintain proper hydration .

Please refer to

F-F695 as it pertains to the facility's failure to ensure respiratory care services provided met professional standards.

Please refer to

F-F725 as it pertains to the facility's failure to ensure sufficient staffing services provided met professional standards.

Please refer to

F-F726 as it pertains to the facility's failure to ensure competent nursing services provided met professional standards.

Please refer to

F-F727 as it pertains to the facility's failure to provide Registered Nursing staff for a minimum of 8 consecutive hours 7 days per week.

Please refer to

F-F757 as it pertains to the facility's failure to ensure each resident's drug regimen was free from unnecessary medications without adequate indications.

Please refer to

F-F759 as it pertains to the facility's failure to endure medication error rates were less than 5%.

Please refer to

F-F760 as it pertains to the facility's failure to ensure residents were free of any significant medication errors.

Please refer to

F-F761 as it pertains to the facility's failure to ensure the storage of drugs and biologicals met professional standards.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Please refer to

F-F812 as it pertains to the facility's failure to store, prepare, distribute, and serve food met professional food service safety standards. Level of Harm - Minimal harm or potential for actual harm Please refer to

F-F813 as it pertains to the facility's failure to ensure the use and storage of foods, brought to residents by family and other visitors met professional food service safety standards. Residents Affected - Some Please refer to

F-F814 as it pertains to the facility's failure to ensure garbage and refuse were disposed of properly.

Please refer to

F-F842 as it pertains to the facility's failure to ensure medical records for residents were complete and accurate.

Please refer to

F-F868 as it pertains to the facility's failure to maintain a quality assurance program.

Please refer to

F-F880 Infection Control

The Policy and Procedure titled C-IC-14 Antibiotic Stewardship created 10/2017 and revised 7/25/2024, documented under Accountability: The facility Infection Preventionist has oversight of the Antibiotic Stewardship , with input, review, guidance, and actions taken by the facility's Medical Director, Consultant Pharmacist, Director of Nurses, Administrator, and other facility leaders as appropriate; and The Medical Director, Consultant Pharmacist, Administrator, and Director of Nurses shall regularly participate in Infection Prevention and Control Committee/QAA meetings and provide feedback in regards to the Antibiotic Stewardship Program.

The policy further documented under Policy Implementation: Through oversight of the Quality Assessment and Assurance (QAA) Committee, the Infection Prevention and Control Committee (IPCC), shall oversee implementation of infection control policies and practices, and help department heads and managers implement infection prevention and control measures within their departments and, inquiries concerning infection control policies, procedures, and facility practices should be referred to the Infection Preventionist or Director of Nursing Services.

General observations during the entire recertification survey indicated insufficient infection control practices among the staff.

An interview conducted on 01/17/2025 at 12:05 PM, Director of Nursing #1 stated they were the current Infection Preventionist and the Nurse Educator. They stated there had not been anyone available to complete the Infection Preventionist role since they became the Director of Nursing role in October 2024.

They stated they were the Nurse Educator in the facility as well as Infection Preventionist and Director of Nursing. They stated there was no way they could train and observe everyone in the facility.

10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 81 335735

F-F882

Policy and Procedure titled, C-IC-1 Infection Prevention and Control, created 10/2015 and revised 5/30/2024 documented: Policies, procedures, and practices of Infection Prevention and Control in the facility were designed to: Prevent, identify, report, investigate, and control infections and communicable diseases in the facility through a system of surveillance; Identify and determine, when possible, incidents of communicable disease or infections should be stated; Maintain a safe, sanitary, and comfortable environment for residents, healthcare personnel, visitors, and others who may visit the facility. Based on the facility assessment: Establish guidelines for the adherence to Standard Precautions in the care of residents; Establish guidelines for adherence to Enhanced-Barrier Precautions in the care of residents, when applicable; Establish guidelines for implementing Transmission-Based Precautions, when necessary, based on the pathogen and circumstances of the illness/infection and to be the least restrictive possible for the resident under the circumstances; and Establish guidelines and practices for hand hygiene to be observed by healthcare personnel, residents and visitors.

The Policy and Procedure titled, Catheter Guidelines; Urinary, revised 9/11/2023, Infection Prevention and Control documented do not position catheter drainage bag touching the floor. A minimum of standard precautions followed when handling or manipulating the drainage System: Additional precautions (e.g., enhanced barrier, contact, droplet) will be followed based on the resident's plan of care and/or individualized needs; Provide routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering).

48744

Resident #17

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident #17 was admitted to the facility with diagnoses of anxiety disorder, paraplegia (inability to voluntarily move the lower parts of the body), and stage 4 pressure ulcer of buttock. The Minimum Data Set, Level of Harm - Minimal harm or dated dated dated [DATE REDACTED] (an assessment tool), documented the resident was cognitively intact. The potential for actual harm resident was able to make themselves understood and was able to understand others.

Residents Affected - Many During an observation on 1/13/2025 at 1:53 PM, Resident #17 was in bed and the resident's urinary catheter drainage bag was exposed, lying on the floor.

Resident #218

Resident #218 was admitted to the facility with diagnoses of Chronic Obstructive Pulmonary Disease (an inflammatory disorder that causes muscle pain and stiffness); failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity); and dementia (loss of memory, language, problem-solving and other thinking abilities). The Minimum Data Set, dated dated dated ,d+[DATE REDACTED], documented the resident had no impaired cognition, could be understood or understand others.

During an observation on 1/13/2025 at 1:40 PM, Resident #218 was sitting in their room and there was no labeling on either oxygen tubing to their concentrator or portable oxygen bottle. Resident oxygen tubing from

the concentrator was sitting on the floor of the resident's room.

During an interview on 1/13/2025 at 1:41 PM, Resident #218 stated staff never changed the tubing and rarely labelled it either.

51131

Resident # 364

Resident #364 was admitted to the facility with diagnoses of unspecified fall, influenza virus A and other acidosis (a condition where the body has too much acid in body fluids). A Minimum Data Set, dated dated dated [DATE REDACTED] documented Resident #364 was cognitively intact, could be understood, and understand others.

During an observation on 1/13/2025 at 1:41 PM, Resident #364 had a urinary catheter in place connected to

a bed bag. The urinary catheter bag was observed uncovered and lying on the floor.

A care plan titled risk for Multiple Drug-Resistant Organisms (MDRO) colonization/ infection related to indwelling urinary catheter dated 1/08/2025 documented goal of Resident #364 would remain free of Multiple Drug -Resistant Organism infection/colonization. Interventions included: Educate Resident, family and visitors on Enhanced Barrier Precautions; Enhanced barrier precautions: wear personal protective equipment (gown, gloves) when providing high contact activities at bedside including dressing, bathing/showering, transferring, changing bed linens, providing hygiene, changing briefs/assisting with toileting, device care and/or use, or wound care. May additionally wear face protection (e.g., goggles, face shield, face mask) if there is a risk of splash or spray or circulating respiratory viruses in the community; and Remove Personal Protective Equipment , perform hand hygiene and reapply necessary Personal Protective Equipment before caring for another resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 1/14/2025 at 1:47 PM, Resident #364 stated they had never had a nurse check their catheter until 1/14/2025 when the nurse came in the room, did not put on Personal Protective Equipment, Level of Harm - Minimal harm or and looked at the catheter underneath their brief. Resident #364 stated staff left a package of cleansing potential for actual harm wipes on the bedside stand and told them to clean the catheter three times a day. Resident #364 stated they were not given education on how to clean the catheter and they had not had a shower since leaving the Residents Affected - Many hospital on 1/08/2024. Resident #364 stated the Certified Nurse Aides and the nurses who had taken care of them had never worn a gown or a mask until 1/14/2025; and they only recalled seeing staff wearing masks and gloves on 1/14/2025.

During observations on 1/13/2025 at 11:00 AM, a Certified Nurse Aide did not perform hand hygiene, put on or take off personal protective equipment before entering or exiting Resident #83's room [ROOM NUMBER] times to retrieve supplies. Resident #83 was noted to be on enhanced barrier precautions, and the Certified Nurse Aide had provided personal care.

During an observation on 1/13/2025 at 11:31 AM, a shared bathroom was noted to have personal care items not labeled or designated as belonging to which resident in the shared room, including, but not limited to a denture cup, and wash basin.

During an observation on 1/13/2025 at 11:48 AM, a shared bathroom was noted to have personal care items not labeled or designated as belonging to which resident in the shared room, including, but not limited to 2 wash basins, and a bariatric bed pan.

During an observation on 1/13/2025 at 12:07 PM, a shared bathroom was noted to have personal care items not labeled or designated as belonging to which resident in the shared room, including, but not limited to a bed pan.

During an observation on 1/13/2025 at 12:07 PM, a Certified Nurse Aide did not perform hand hygiene, put

on or take off personal protective equipment before entering a resident's room, who was on transmission-based precautions. Upon exiting the room, the Certified Nurse Aide was observed to not be wearing gloves, taking dirty towels and cups from the resident's room to the dirty utility room.

During an observation on 1/13/2025 at 12:09 PM, a Certified Nurse Aide was observed leaving the dirty utility room without completing hand hygiene and directly entered another resident's room.

During an observation on 1/13/2025 at 12:13 PM, a Certified Nurse Aide was observed entering a resident's room, who was on enhanced barrier precautions, and they did not complete hand hygiene or put on personal protective equipment.

During an observation on 1/13/2025 at 1:05 PM, a Certified Nurse Aide was observed providing incontinence care to a resident on transmission-based precautions. The Certified Nurse Aide did not put on or take off personal protective equipment or perform hand hygiene both before and after providing personal care to the resident.

During an observation on 1/22/2025 at 10:31 AM, Licensed Practical Nurse #6 on B Unit was observed wearing their N95 mask under their nose.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 1/15/2025 at 6:00 PM, Certified Nurse Aide #1 stated they needed to wear a gown, gloves and a mask when they entered a room with a Transmission Barrier Precaution or Enhanced Barrier Level of Harm - Minimal harm or Precaution sign. They stated that all Personal Protective Equipment was located on the resident's door. They potential for actual harm stated they could go to the clean utility room and get more Personal Protective Equipment if it had been stocked. Certified Nurse Aide #1 stated that most aides only wore the Personal Protective Equipment when Residents Affected - Many they were giving personal care to a resident, not if they were just answering the light or checking in on them.

During an interview on 01/17/2025 at 12:05 PM, Director of Nursing #1 stated that handwashing must be completed when staff entered the patient's room, exited the room, before and after care was provided and between passing trays and during meals. Director of Nursing #1 stated that Enhanced Barrier Precautions required a mask, gloves and gown; and Transmission Based Precautions required N95 mask, gloves, gown and face shield. They stated staff were trained in Standard Precautions and Enhanced Barrier Precautions/ Transmission Barrier Precautions education, and this was provided at hire, yearly, and as needed. Director of Nursing #1 stated when they saw a staff member not wearing Personal Protective Equipment or applying Personal Protective Equipment incorrectly, they had stopped and re-educated them by asking them what

they had done incorrectly and then walked them through the process of putting on and taking off step by step. Director of Nursing #1 stated they did not complete this as a formal education and had not asked staff to sign off that they were re-educated. They stated they depended on their unit managers from 7 AM to 4:30 PM Monday through Friday to monitor the standard precautions and Registered Nurse supervisors to monitor for noncompliance on weekends and evenings. Director of Nursing #1 stated if someone was noted to be noncompliant on more than one occasion, they were in serviced and retrained and auditing would be done by someone. Director of Nursing #1 stated supplies were located in the central supply room and maintenance, or housekeeping restocked the carts and door containers when they were low. Hand sanitizers were located on the wall in dispensers and there are individual bottles of sanitizer located in the central supply room. Director of Nursing #1 stated employees were expected to put on and take off Personal Protective Equipment in the resident's room; staff were expected to carry linens and soiled clothing in a garbage bag.

10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 81 335735 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335735 B. Wing 01/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Delmar Center for Rehabilitation and Nursing 125 Rockefeller Road Delmar, NY 12054

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 51131

Residents Affected - Some Based on observation and interview during the recertification survey, the facility did not designate one or more individual(s) as Infection Preventionist (s) responsible for the facility's Infection Prevention Control Practices. Specifically, the facility did not have designated individual as their Infection Control Preventionist from October 4th 2024 to January 2025.

This is evidenced by:

Cross referenced to: