Cycle 1
Health 2025-05-29 · Fire 2025-05-29
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
South Setauket, NY
Jefferson's Ferry
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
500 Mather Drive, South Setauket, NY
(631) 650-2700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-11-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.03
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
3.45
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.50
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
2.05
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
5.02
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
5.04
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
52%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,119
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9941
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 18.17% · Performance 16.94% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
0.71
Baseline 5.81% · Performance 7.62% · Measure score 0.71 · Achievement 0.71 · Improvement 0
Total nurse turnover
0
Baseline 39.73% · Performance 62.50% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.77
Baseline 4.14 hours · Performance 4.72 hours · Measure score 5.77 · Achievement 5.77 · Improvement 3.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.04% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 344 · Observed rate 9.59% · Lower 95% interval 9.59% |
| Discharge to community | 58.32% |
50.57%
7.8 pts better
|
Better than the National Rate · Eligible stays 345 · Observed rate 58.55% · Lower 95% interval 53.4% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 212 · Denominator 212 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 212 |
| Discharge self-care score | 68.26% |
53.69%
14.6 pts better
|
Numerator 114 · Denominator 167 |
| Discharge mobility score | 70.66% |
50.94%
19.7 pts better
|
Numerator 118 · Denominator 167 |
| Pressure ulcers or injuries, new or worsened | 2.36% |
2.29%
0.1 pts worse
|
Numerator 5 · Denominator 212 · Adjusted rate 2.44% |
| Healthcare-associated infections requiring hospitalization | 7.62% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 226 · Observed rate 5.75% · Lower 95% interval 5.08% |
| Staff COVID-19 vaccination coverage | 1.13% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 177 |
| Staff flu vaccination coverage | 88.5% |
42%
46.5 pts better
|
Numerator 177 · Denominator 200 |
| Discharge function score | 69.46% |
56.45%
13 pts better
|
Numerator 116 · Denominator 167 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 141 · Denominator 141 |
| Resident COVID-19 vaccinations up to date | 41.35% |
25.2%
16.2 pts better
|
Numerator 43 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.2%
8.8 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.0%
1 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.1% · Q3 3.2% · Q4 3.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
18.5%
13.4 pts better
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.3% · Q3 6.9% · Q4 6.7% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
6.1%
4.2 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 13.0% · Q3 14.8% · Q4 9.1% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.4% |
13.5%
3.9 pts worse
|
19.6%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 13.8% · Q3 20.0% · Q4 20.7% · 4Q avg 17.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
14.8%
3.9 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 20.0% · Q3 15.4% · Q4 16.7% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.2% |
15.1%
11.1 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
15.5%
2.8 pts worse
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.9% · Q3 18.5% · Q4 20.0% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.1% |
1.4%
4.7 pts worse
|
1.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 6.9% · Q3 6.5% · Q4 0.0% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.7% |
20.8%
5.1 pts better
|
19.8%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 13.6% · Q3 25.3% · Q4 15.6% · 4Q avg 15.7% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.9%
1.1 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 0.0% · Q3 8.4% · Q4 3.5% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
76.7%
23 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.3% |
9.7%
0.4 pts better
|
12.0%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 8.1% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.2%
1.5 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.2% · Q3 4.1% · Q4 1.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.8%
21.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
20.6%
2.7 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 15.7% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2024-05-31
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-08-30 · Fire 2022-08-30
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-29
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-07-15
D · Potential for more than minimal harm
2024-05-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-15
F · Potential for more than minimal harm
2022-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-11-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-17
E · Potential for more than minimal harm
2024-05-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-07-01
C · Minimal harm
2022-08-30
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-10-25
Penalties and ownership
What sits behind the stars
Ownership
Amtmann, Brian
Corporate Officer · Individual
Caulfield, Robert
Corporate Officer · Individual
Comerford, Anthony
Operational/Managerial Control · Individual
Danowski, James
Corporate Director · Individual
Darwell, Wendy
Corporate Director · Individual
Davidow, Lawrence
Corporate Director · Individual
Engelhardt, Debra
Corporate Director · Individual
Kubasek-Shemitz, Kim
Corporate Director · Individual
Roberts, Kenneth
Corporate Director · Individual
Shattes, Wayne
Corporate Director · Individual
Sini, John
Corporate Director · Individual
Snyder, Gloria
Corporate Director · Individual
Nearby options
Other facilities in reach
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#2
Allegria Nursing & Rehab Center Of Port Jefferson
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2-star overall rating with 1-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Waters Edge At Port Jefferson For Rehab And Nrsg
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2-star overall rating with 1-star inspections with $153,911 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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