Delmar Center For Rehabilitation And Nursing
DELMAR CENTER FOR REHABILITATION AND NURSING in DELMAR, NY — inspection on January 23, 2025.
Found 32 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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F-F585 as it pertains to the facility's failure to provide availability for residents to file a grievance or complaint.
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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.
335735
Form Approved OMB
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
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.
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.
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
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.
335735
Form Approved OMB
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
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 .
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F-F695 as it pertains to the facility's failure to ensure respiratory care services provided met professional standards.
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F-F725 as it pertains to the facility's failure to ensure sufficient staffing services provided met professional standards.
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F-F726 as it pertains to the facility's failure to ensure competent nursing services provided met professional standards.
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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.
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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.
335735
Form Approved OMB
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
F-F812 as it pertains to the facility's failure to store, prepare, distribute, and serve food met professional food service safety standards.
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.
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)
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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
335735
Form Approved OMB
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