10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Freeport, NY
2-star overall rating with 2-star inspections with 10 recent health deficiencies
275 W Merrick Road, Freeport, NY
(516) 623-4000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
100
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sapphire Care Group
Operator or chain grouping
Approved since
1979-09-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 2 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
RN hours / resident day
0.92
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.73
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
2.85
CMS adjusted total nurse staffing hours
Case-mix index
1.94
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
4,948
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9911
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
8.29
Baseline 19.80% · Performance 17.59% · Measure score 8.29 · Achievement 8.29 · Improvement 7.48
Healthcare-associated infections
0
Baseline 8.96% · Performance 11.35% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.12
Baseline 31.87% · Performance 38.68% · Measure score 6.12 · Achievement 6.12 · Improvement 0
Adjusted total nurse staffing
0.79
Baseline 2.26 hours · Performance 2.71 hours · Measure score 0.79 · Achievement 0 · Improvement 0.79
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 116 · Observed rate 16.38% · Lower 95% interval 8.48% |
| Discharge to community | 45.73% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 32.39% · Lower 95% interval 36.99% |
| Medicare spending per beneficiary | 1.48 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 96.99% |
95.27%
1.7 pts better
|
Numerator 161 · Denominator 166 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 166 |
| Discharge self-care score | 53.25% |
53.69%
0.4 pts worse
|
Numerator 41 · Denominator 77 |
| Discharge mobility score | 55.84% |
50.94%
4.9 pts better
|
Numerator 43 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 9.64% |
2.29%
7.4 pts worse
|
Numerator 16 · Denominator 166 · Adjusted rate 6.81% |
| Healthcare-associated infections requiring hospitalization | 11.35% |
7.12%
4.2 pts worse
|
Worse than the National Rate · Eligible stays 108 · Observed rate 26.85% · Lower 95% interval 7.72% |
| Staff COVID-19 vaccination coverage | 1.72% |
8.2%
6.5 pts worse
|
Numerator 3 · Denominator 174 |
| Staff flu vaccination coverage | 50.6% |
42%
8.6 pts better
|
Numerator 85 · Denominator 168 |
| Discharge function score | 55.84% |
56.45%
0.6 pts worse
|
Numerator 43 · Denominator 77 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 85 · Denominator 85 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 42 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 1.03% |
25.2%
24.2 pts worse
|
Numerator 1 · Denominator 97 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 3.6 · Expected 3.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 1.1 · Expected 2.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
91.2%
3 pts worse
|
93.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.3% · Q2 85.3% · Q3 93.2% · Q4 98.6% · 4Q avg 88.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
95.3%
2.3 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.0%
2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.4% · Q4 1.4% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
18.5%
11.1 pts better
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.1% · Q3 8.2% · Q4 7.8% · 4Q avg 7.4% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.1%
1.9 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.8% · Q3 1.4% · Q4 1.4% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
13.5%
4.7 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.0% · Q3 9.7% · Q4 8.3% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
14.8%
4.9 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.8% · Q3 7.5% · Q4 16.7% · 4Q avg 9.9% · 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 | 22.6% |
15.1%
7.5 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 26.0% · Q3 26.3% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 33.3% |
15.5%
17.8 pts worse
|
14.9%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 40.4% · Q3 20.5% · Q4 34.8% · 4Q avg 33.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.6%
0.4 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.4%
About the same
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 1.4% · Q4 0.0% · 4Q avg 1.4% · 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 9.8% · Q2 17.4% · Q3 19.4% · Q4 8.5% · 4Q avg 13.8% |
| Percentage of long-stay residents with pressure ulcers | 11.0% |
6.9%
4.1 pts worse
|
5.1%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 14.0% · Q3 10.7% · Q4 10.8% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.2% |
76.7%
5.5 pts worse
|
81.7%
10.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.0% · Q2 60.3% · Q3 73.5% · Q4 89.9% · 4Q avg 71.2% |
| 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 6.3% · Expected 14.6% · 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 | 68.9% |
78.8%
9.9 pts worse
|
79.7%
10.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
20.6%
3.8 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 28.6% · Expected 40.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2024-06-05
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-05
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-05
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-05
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-06-05
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-10-13
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-31
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-10-13
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 2022-10-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-13
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-13
Fire Safety
Have a properly installed medical gas master alarm panel.
Corrected 2022-10-13
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-13
Inspection history
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-09-30
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 2025-09-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-30
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-09-30
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-04
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-30
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-04
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-09-30
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 2024-05-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-27
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-27
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-27
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 2024-05-27
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-27
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-05-27
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-27
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-27
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-07-17
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-02
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-05
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-02
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
W-2 Managing Employee · Individual
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