Cycle 1
Health 2025-01-14 · Fire 2025-01-14
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
St James, NY
Luxor Nursing And Rehabilitation At Mills Pond
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
273 Moriches Road, St James, NY
(631) 862-8990
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
252
Certified beds
Average residents
239
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Carerite Centers
Operator or chain grouping
Approved since
1991-08-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
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
0.31
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
2.68
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,456
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0037
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.03
Baseline 18.95% · Performance 18.17% · Measure score 7.03 · Achievement 7.03 · Improvement 3.54
Healthcare-associated infections
3.07
Baseline 6.77% · Performance 6.92% · Measure score 3.07 · Achievement 3.07 · Improvement 0
Total nurse turnover
8.88
Baseline 48.53% · Performance 27.37% · Measure score 8.88 · Achievement 8.88 · Improvement 8.43
Adjusted total nurse staffing
0.89
Baseline 2.69 hours · Performance 3.12 hours · Measure score 0.89 · Achievement 0 · Improvement 0.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 667 · Observed rate 8.55% · Lower 95% interval 7.42% |
| Discharge to community | 58.11% |
50.57%
7.5 pts better
|
Better than the National Rate · Eligible stays 727 · Observed rate 51.17% · Lower 95% interval 54.03% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 613 · Denominator 613 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 4 · Denominator 613 |
| Discharge self-care score | 55.07% |
53.69%
1.4 pts better
|
Numerator 250 · Denominator 454 |
| Discharge mobility score | 68.5% |
50.94%
17.6 pts better
|
Numerator 311 · Denominator 454 |
| Pressure ulcers or injuries, new or worsened | 0.82% |
2.29%
1.5 pts better
|
Numerator 5 · Denominator 613 · Adjusted rate 0.7% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 533 · Observed rate 6.57% · Lower 95% interval 5.35% |
| Staff COVID-19 vaccination coverage | 3.77% |
8.2%
4.4 pts worse
|
Numerator 8 · Denominator 212 |
| Staff flu vaccination coverage | 58.74% |
42%
16.7 pts better
|
Numerator 158 · Denominator 269 |
| Discharge function score | 52.64% |
56.45%
3.8 pts worse
|
Numerator 239 · Denominator 454 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 148 · Denominator 148 |
| Transfer of health information to patient | 99.73% |
96.28%
3.5 pts better
|
Numerator 366 · Denominator 367 |
| Resident COVID-19 vaccinations up to date | 20.8% |
25.2%
4.4 pts worse
|
Numerator 73 · Denominator 351 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.2%
8.5 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.4% · Q4 99.4% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
95.3%
2.3 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.0%
1.1 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.9% · Q3 4.5% · Q4 4.4% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.5% |
18.5%
32 pts worse
|
11.4%
39.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.0% · Q2 53.2% · Q3 48.3% · Q4 49.6% · 4Q avg 50.5% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.1%
1.4 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 5.2% · Q3 5.5% · Q4 4.5% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.0% |
13.5%
7.5 pts better
|
19.6%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.3% · Q3 6.2% · Q4 7.7% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
14.8%
6.4 pts better
|
16.7%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 7.9% · Q3 7.4% · Q4 8.8% · 4Q avg 8.4% · 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 | 11.0% |
15.1%
4.1 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 16.0% · Q3 10.3% · Q4 10.6% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
15.5%
0.1 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 21.1% · Q3 12.8% · Q4 13.1% · 4Q avg 15.4% · 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 | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 20.2% |
20.8%
0.6 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 19.5% · Q3 28.2% · Q4 16.1% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
6.9%
3.1 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.8% · Q3 3.2% · Q4 3.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
76.7%
22.9 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.8% · Q3 99.8% · Q4 99.2% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.6% |
9.7%
5.1 pts better
|
12.0%
7.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.6% · Observed 4.0% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.2%
1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 0.0% · Q3 0.0% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
78.8%
9.1 pts better
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.4% |
20.6%
1.8 pts worse
|
23.9%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 20.8% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-13 · Fire 2023-07-13
4 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-05-13 · Fire 2021-05-13
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-01-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-15
E · Potential for more than minimal harm
2025-01-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-01-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-15
D · Potential for more than minimal harm
2025-01-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-25
D · Potential for more than minimal harm
2023-07-13
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-15
D · Potential for more than minimal harm
2023-07-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-23
D · Potential for more than minimal harm
2023-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-08
E · Potential for more than minimal harm
2021-05-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-07-12
D · Potential for more than minimal harm
2021-05-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-01-14
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 2025-02-25
D · Potential for more than minimal harm
2025-01-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-25
D · Potential for more than minimal harm
2023-07-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-13
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 2023-08-11
D · Potential for more than minimal harm
2023-07-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
D · Potential for more than minimal harm
2021-05-13
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-05-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-05-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-07-10
D · Potential for more than minimal harm
2021-05-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-10
Penalties and ownership
What sits behind the stars
Ownership
Bernath, Shaya
5% Or Greater Direct Ownership Interest · Individual
Hager, Jacob
5% Or Greater Direct Ownership Interest · Individual
Rozenberg, Kenneth
5% Or Greater Direct Ownership Interest · Individual
Hagar, Chaim
5% Or Greater Direct Ownership Interest · Individual
Hager, Shifra
5% Or Greater Direct Ownership Interest · Individual
Kahan, Elliot
5% Or Greater Direct Ownership Interest · Individual
Oberlander, Zalmen
5% Or Greater Direct Ownership Interest · Individual
Lewis, Steven
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
St James Rehabilitation & Healthcare Center
St James, NY
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Smithtown Center For Rehabilitation & Nursing Care
Smithtown, NY
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Hamlet Rehabilitation And Healthcare Center At
Nesconset, NY
5-star overall rating with 4-star inspections with $92,770 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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