Cycle 1
Health 2025-07-02 · Fire 2025-07-02
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
West Islip, NY
Our Lady Of Consolation Nursing And Rehab Care Ctr
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
111 Beach Drive, West Islip, NY
(631) 587-1600
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
450
Certified beds
Average residents
277
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-06-12
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
0.91
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,147
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9880
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.30
Baseline 18.52% · Performance 20.37% · Measure score 2.30 · Achievement 2.30 · Improvement 0
Healthcare-associated infections
1.89
Baseline 6.62% · Performance 7.27% · Measure score 1.89 · Achievement 1.89 · Improvement 0
Total nurse turnover
9.36
Baseline 28.51% · Performance 25.44% · Measure score 9.36 · Achievement 9.36 · Improvement 7.89
Adjusted total nurse staffing
0
Baseline 3.23 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.83% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 777 · Observed rate 10.55% · Lower 95% interval 10.14% |
| Discharge to community | 53.11% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 949 · Observed rate 47.95% · Lower 95% interval 49.99% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 548 · Denominator 548 |
| Falls with major injury | 0.18% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 548 |
| Discharge self-care score | 45.38% |
53.69%
8.3 pts worse
|
Numerator 172 · Denominator 379 |
| Discharge mobility score | 51.98% |
50.94%
1 pts better
|
Numerator 197 · Denominator 379 |
| Pressure ulcers or injuries, new or worsened | 0.91% |
2.29%
1.4 pts better
|
Numerator 5 · Denominator 548 · Adjusted rate 0.88% |
| Healthcare-associated infections requiring hospitalization | 7.27% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 545 · Observed rate 6.61% · Lower 95% interval 5.24% |
| Staff COVID-19 vaccination coverage | 2.22% |
8.2%
6 pts worse
|
Numerator 11 · Denominator 496 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50.66% |
56.45%
5.8 pts worse
|
Numerator 192 · Denominator 379 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 150 · Denominator 150 |
| Transfer of health information to patient | 99.68% |
96.28%
3.4 pts better
|
Numerator 308 · Denominator 309 |
| Resident COVID-19 vaccinations up to date | 24.24% |
25.2%
1 pts worse
|
Numerator 72 · Denominator 297 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.8 · 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 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.2%
8.3 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.0% · Q3 99.5% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.2% |
95.3%
3.9 pts better
|
95.5%
3.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.0%
1.3 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.4% · Q3 1.4% · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
18.5%
18.1 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.1%
0.1 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.0% · Q3 7.4% · Q4 3.5% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
13.5%
0.1 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 13.5% · Q3 13.0% · Q4 17.5% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
14.8%
0.6 pts better
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 16.1% · Q3 16.7% · Q4 13.8% · 4Q avg 14.2% · 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 | 18.2% |
15.1%
3.1 pts worse
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 22.7% · Q3 18.3% · Q4 17.2% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
15.5%
1.4 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 22.0% · Q3 12.7% · Q4 19.1% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.6%
0.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.0% · Q4 0.8% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.4%
0.4 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 1.0% · Q4 3.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.8% |
20.8%
7 pts better
|
19.8%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 14.8% · Q3 14.5% · Q4 15.6% · 4Q avg 13.8% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
6.9%
4 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.3% · Q3 2.8% · Q4 3.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
76.7%
22.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 99.4% · Q4 99.6% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
9.7%
4.8 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.5% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.4% · Q3 1.6% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.8% |
78.8%
20 pts better
|
79.7%
19.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
20.6%
3.3 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 22.5% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-03-18 · Fire 2022-03-18
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-07-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-07-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-07-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-25
E · Potential for more than minimal harm
2024-04-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-04-12
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-04-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-12
D · Potential for more than minimal harm
2024-04-12
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2024-05-31
C · Minimal harm
2023-07-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-11
F · Potential for more than minimal harm
2022-03-18
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-05-13
E · Potential for more than minimal harm
2022-03-18
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-05-13
E · Potential for more than minimal harm
2022-03-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-18
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-05-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-07-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-08-25
E · Potential for more than minimal harm
2025-07-02
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 2025-08-25
E · Potential for more than minimal harm
2025-07-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-02
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-02
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 2025-08-25
D · Potential for more than minimal harm
2025-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-02
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-07-02
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 2025-08-25
F · Potential for more than minimal harm
2024-04-12
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-04-12
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 2024-06-01
D · Potential for more than minimal harm
2024-04-12
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 2024-06-01
D · Potential for more than minimal harm
2024-04-12
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-06-01
D · Potential for more than minimal harm
2024-04-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-01
D · Potential for more than minimal harm
2022-03-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-05-13
D · Potential for more than minimal harm
2022-03-18
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 2022-05-13
Penalties and ownership
What sits behind the stars
Ownership
Celiberti, Douglas
Corporate Director · Individual
Christman, Thomas
Corporate Director · Individual
Dagher, Peter
Corporate Director · Individual
Haight, John
Corporate Director · Individual
Hoffman, Jennifer
Corporate Director · Individual
Lambert, Michael
Corporate Director · Individual
Mccarthy, Justin
Corporate Director · Individual
O'brien, John
Corporate Director · Individual
Pietrowski, Stephen
Corporate Director · Individual
Ryan, James
W-2 Managing Employee · Individual
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#2
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#3
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3-star overall rating with 3-star inspections with 5 recent health deficiencies
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