BETHLEHEM COMMONS CARE CENTER - DELMAR, NY

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Addresss:

125 ROCKEFELLER ROAD
DELMAR, NY, 12054

Phone (make sure to verify first before calling): (518) 439-8116

Number of Certified Beds: 120
Total Number of Residents: 119
Percent of Occupied Beds: 99%
Sprinkler Status: Partially Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: Non profit - Corporation
Located Within a Hospital?: No
Multi Nursing Home Ownership?: No
Resident and Family Councils: Both
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No
Type: Skilled Nursing Facilities

Overall Star Rating: 2 Stars
Health Inspections Star Rating: 1 Star
Nurse Staffing Star Rating: 4 Stars
Quality Measures Star Rating: 5 Stars
RN Only Star Rating: 3 Stars

Other nearby hospitals and nursing homes

ALBANY MEDICAL CENTER / SOUTH CLINICAL CAMPUS (ALBANY, 1.74 miles)
CATHOLIC CHARITIES OF THE DIOCESE OF ALBANY, INC (ALBANY, 2.04 miles)
CHILDS NURSING HOME COMPANY INC (ALBANY, 1.74 miles)
FMS-ALBANY REGIONAL KIDNEY CENTER (ALBANY, 2.14 miles)
LIVING RESOURCES CORPORATION, INC (ALBANY, 2.02 miles)
ST MARGARETS CENTER (ALBANY, 1.74 miles)
ST PETERS NURSING AND REHABILITATION CENTER (ALBANY, 2.05 miles)

Employment Full-Time Equivalent

Administrative Staff - Full Time: 12.33

Administrative Staff - Part Time: 1.71

Certified Nurse Aides - Full Time: 35.24

Certified Nurse Aides - Part Time: 14.76

Dietitians - Under Contract: 0.27

Food Service Personnel - Full Time: 12.06

Food Service Personnel - Part Time: 7.11

Housekeeping Personnel - Full Time: 9.64

Licensed Practical/ Vocational Nurses - Full Time: 17.80

Licensed Practical/ Vocational Nurses - Part Time: 7.00

Medical Directors - Under Contract: 0.26

Mental Health Services Personnel - Under Contract: 0.57

Nurses With Administrative Duties - Full Time: 2.14

Persons Not Included In Any Other Categories - Full Time: 6.01

Registered Nurses - Full Time: 3.21

Rn Director Of Nursing - Full Time: 0.64

Social Workers - Full Time: 0.97

Activities Professionals - Full Time: 0.96

Occupational Therapists - Part Time: 0.53

Pharmacists - Under Contract: 0.07

Physical Therapists - Part Time: 0.81

Podiatrists - Under Contract: 0.04

Speech Pathologists - Under Contract: 0.24

Other Physicians - Under Contract: 0.21

Physician Extenders - Under Contract: 0.20

Dietitians - Full Time: 1.07

Persons Not Included In Any Other Categories - Part Time: 2.96

Registered Nurses - Part Time: 4.16

Social Workers - Part Time: 0.69

Housekeeping Personnel - Part Time: 3.63

Physical Therapists - Full Time: 1.07

Occupational Therapy Assistants - Part Time: 0.81

Number Of Beds

Total: 120

Total Certified: 120

Provided Services

Activities Services Are Provided Onsite To Residents

Administration And Storage Of Blood Services Are Provided Offsite To Residents

Clinical Laboratory Services Are Provided Offsite To Residents

Clinical Laboratory Services Are Provided Onsite To Residents

Dental Services Are Provided Onsite To Residents

Diagnostic Xray Services Are Provided Offsite To Residents

Diagnostic Xray Services Are Provided Onsite To Residents

Dietary Services Are Provided Onsite To Residents

Housekeeping Services Are Provided Onsite To Residents

Mental Health Services Are Provided Onsite To Residents

Nursing Services Are Provided Onsite To Residents

Occupational Therapy Services Are Provided Onsite To Residents

Pharmacy Services Are Provided Onsite To Residents

Physical Therapy Services Are Provided Onsite To Residents

Physician Extender Services Are Provided Onsite To Residents

Physician Services Are Provided Offsite To Residents

Physician Services Are Provided Onsite To Residents

Podiatry Services Are Provided Onsite To Residents

Social Work Services Are Provided Onsite To Residents

Speech/Language Pathology Services Are Provided Onsite To Residents

Complaint Deficiency

Properly constructed piped-in oxygen systems
- Harm: Potential for minimal harm
- Scope: Some
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Signs that state that exit doors are to be kept closed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Protected exits that allow the resident to escape the building
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Back-up procedures in place for a faulty automatic sprinkler system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly maintained smoke detectors
- Harm: Potential for minimal harm
- Scope: Many
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Potential for minimal harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide medically-related social services to help each resident achieve the highest possible quality of life
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Potential for minimal harm
- Scope: Many
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Try to resolve each resident's complaints quickly
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide medically-related social services to help each resident achieve the highest possible quality of life
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.470
State:	0.637

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

This Nursing Home:	1.100
State:	0.790

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.570
New York:	1.425

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.080
State:	0.080

Number Therapy Hours Per Resident Per Day

Here:	0.080
New York:	0.081

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	7.5%
State:	15.6%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	4.3%
State:	8.4%

Percent of long-stay residents who lose too much weight

This Nursing Home:	3.8%
State:	6.4%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	6.7%
New York:	3.1%

Percent of long-stay residents with a urinary tract infection

Here:	2.5%
New York:	6.8%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	1.3%
State:	12.6%

Percent of long-stay residents who were physically restrained

This Nursing Home:	9.8%
State:	2.3%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	2.4%
State:	2.9%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	100.0%
New York:	96.7%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	100.0%
State:	97.3%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	4.5%
State:	16.9%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	1.0%
New York:	1.8%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	98.8%
State:	86.9%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	99.0%
New York:	85.0%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	1.4%
State:	3.1%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	30.8%
State:	20.8%

BETHLEHEM COMMONS CARE CENTER - DELMAR, NY

Complaint Deficiency

Staff Information

Quality Measures

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