Cycle 1
Health 2025-05-23 · Fire 2025-05-23
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Port Jefferson, NY
John T Mather Memorial Hosp T C U
5-star overall rating with 3-star inspections with 7 recent health deficiencies
75 North Country Road, Port Jefferson, NY
(631) 473-1320
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
16
Certified beds
Average residents
13
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-04-04
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
5.33
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
3.42
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
8.75
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
5.33
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
7.37
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
4.10
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.31
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
4.79
CMS adjusted RN staffing hours
Adjusted total hours
7.86
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
19%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
149
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
81.35
Composite VBP score used to determine payment impact.
Payment multiplier
1.0261
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.47
Baseline 21.81% · Performance 18.48% · Measure score 6.47 · Achievement 6.37 · Improvement 6.47
Healthcare-associated infections
10
Baseline 4.49% · Performance 3.79% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
7.93
Baseline 19.23% · Performance 31.25% · Measure score 7.93 · Achievement 7.93 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.88% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 617 · Observed rate 10.7% · Lower 95% interval 9.48% |
| Discharge to community | 80.52% |
50.57%
29.9 pts better
|
Better than the National Rate · Eligible stays 533 · Observed rate 80.86% · Lower 95% interval 76.99% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.39% |
95.27%
4.1 pts better
|
Numerator 325 · Denominator 327 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 327 |
| Discharge self-care score | 44.79% |
53.69%
8.9 pts worse
|
Numerator 129 · Denominator 288 |
| Discharge mobility score | 67.71% |
50.94%
16.8 pts better
|
Numerator 195 · Denominator 288 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 327 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 3.79% |
7.12%
3.3 pts better
|
Better than the National Rate · Eligible stays 301 · Observed rate 1% · Lower 95% interval 1.98% |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 1 · Denominator 32 |
| Staff flu vaccination coverage | 87.88% |
42%
45.9 pts better
|
Numerator 29 · Denominator 33 |
| Discharge function score | 64.24% |
56.45%
7.8 pts better
|
Numerator 185 · Denominator 288 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 66 · Denominator 66 |
| Transfer of health information to patient | 99.62% |
96.28%
3.3 pts better
|
Numerator 260 · Denominator 261 |
| Resident COVID-19 vaccinations up to date | 18.86% |
25.2%
6.3 pts worse
|
Numerator 33 · Denominator 175 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
76.7%
22.1 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.6% · Q3 99.5% · Q4 99.0% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
9.7%
5.4 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
78.8%
20.8 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
20.6%
0.1 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 18.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-10-05 · Fire 2022-10-05
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 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
2024-06-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-05
D · Potential for more than minimal harm
2022-10-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-11-02
D · Potential for more than minimal harm
2022-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-05-23
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-05-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-05-23
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-07-18
C · Minimal harm
2025-05-23
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-07-18
D · Potential for more than minimal harm
2024-06-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-06-20
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-15
E · Potential for more than minimal harm
2022-10-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-21
C · Minimal harm
2022-10-05
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-11-21
Penalties and ownership
What sits behind the stars
Ownership
Northwell Healthcare Inc
5% Or Greater Direct Ownership Interest · Organization
Bello, Stephen
Corporate Director · Individual
Blumencranz, Roger
Operational/Managerial Control · Individual
Blumencranz, Roger
Corporate Director · Individual
Blumencranz, Roger
Corporate Officer · Individual
Britton, Betsy
Operational/Managerial Control · Individual
Britton, Betsy
Corporate Director · Individual
Britton, Betsy
Corporate Officer · Individual
Colson, Marvin
Corporate Director · Individual
Craig, Nicholas
Operational/Managerial Control · Individual
Craig, Nicholas
Corporate Director · Individual
Craig, Nicholas
Corporate Officer · Individual
Cusack, Michele
Corporate Officer · Individual
Danowski, James
Operational/Managerial Control · Individual
Danowski, James
Corporate Director · Individual
Danowski, James
Corporate Officer · Individual
Diaz, Sylvia
Corporate Director · Individual
Diviney, John
Operational/Managerial Control · Individual
Diviney, John
Corporate Director · Individual
Diviney, John
Corporate Officer · Individual
Donnelly, Sharon
Operational/Managerial Control · Individual
Donnelly, Sharon
Corporate Director · Individual
Donnelly, Sharon
W-2 Managing Employee · Individual
Engelhardt, Debra
Corporate Director · Individual
Engelhardt, Debra
Corporate Officer · Individual
Frey, Kathryn
Operational/Managerial Control · Individual
Frey, Kathryn
Corporate Director · Individual
Frey, Kathryn
Corporate Officer · Individual
Glynn, Timothy
Operational/Managerial Control · Individual
Glynn, Timothy
Corporate Director · Individual
Iadanza, Christina
Operational/Managerial Control · Individual
Iadanza, Christina
Corporate Director · Individual
Iadanza, Christina
W-2 Managing Employee · Individual
Kuhn, Konrad
Operational/Managerial Control · Individual
Kuhn, Konrad
Corporate Director · Individual
Kuhn, Konrad
Corporate Officer · Individual
Lippencott, Donald
Corporate Director · Individual
Livreri, Christine
Operational/Managerial Control · Individual
Livreri, Christine
Corporate Director · Individual
Livreri, Christine
W-2 Managing Employee · Individual
Mader, William
W-2 Managing Employee · Individual
Nappi, Ralph
Operational/Managerial Control · Individual
Nappi, Ralph
Corporate Director · Individual
Nappi, Ralph
Corporate Officer · Individual
Ng, Joseph
W-2 Managing Employee · Individual
Roberts, Kenneth
Operational/Managerial Control · Individual
Roberts, Kenneth
Corporate Director · Individual
Roberts, Kenneth
Corporate Officer · Individual
Roberts, Kenneth
W-2 Managing Employee · Individual
Ruggiero, Christine
Corporate Director · Individual
Sini, John
Operational/Managerial Control · Individual
Sini, John
Corporate Director · Individual
Sini, John
Corporate Officer · Individual
Sternlicht, Leo
Operational/Managerial Control · Individual
Sternlicht, Leo
Corporate Director · Individual
Sternlicht, Leo
Corporate Officer · Individual
Tranchon, Harold
Operational/Managerial Control · Individual
Tranchon, Harold
Corporate Director · Individual
Tranchon, Harold
Corporate Officer · Individual
Weiss, Edward
Operational/Managerial Control · Individual
Weiss, Edward
Corporate Director · Individual
Weiss, Edward
Corporate Officer · Individual
Wisnoski, Joseph
Operational/Managerial Control · Individual
Wisnoski, Joseph
Corporate Director · Individual
Wisnoski, Joseph
W-2 Managing Employee · Individual
Yu, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Waters Edge At Port Jefferson For Rehab And Nrsg
Port Jefferson, NY
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
#2
Allegria Nursing & Rehab Center Of Port Jefferson
Port Jefferson Stati, NY
2-star overall rating with 1-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Jefferson's Ferry
South Setauket, NY
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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