Cycle 1
Health 2024-02-19 · Fire 2024-02-19
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Port Jervis, NY
St Josephs Place
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
160 East Main Street, Port Jervis, NY
(845) 856-5351
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
38
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-04-11
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
0.95
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
22%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,416
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9975
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.00% · Performance 21.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.40
Baseline 5.61% · Performance 7.12% · Measure score 2.40 · Achievement 2.40 · Improvement 0
Total nurse turnover
9.46
Baseline 28.57% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 9
Adjusted total nurse staffing
5.90
Baseline 4.53 hours · Performance 4.76 hours · Measure score 5.90 · Achievement 5.90 · Improvement 1.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 8.05% · Lower 95% interval 7.19% |
| Discharge to community | 58.82% |
50.57%
8.2 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 55.81% · Lower 95% interval 50.12% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 43 · Denominator 43 |
| Falls with major injury | 2.33% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 43 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 12 · Denominator 30 |
| Discharge mobility score | 23.33% |
50.94%
27.6 pts worse
|
Numerator 7 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 1 · Denominator 43 · Adjusted rate 2.24% |
| Healthcare-associated infections requiring hospitalization | 7.12% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 5.48% |
8.2%
2.7 pts worse
|
Numerator 4 · Denominator 73 |
| Staff flu vaccination coverage | 67.65% |
42%
25.7 pts better
|
Numerator 92 · Denominator 136 |
| Discharge function score | 36.67% |
56.45%
19.8 pts worse
|
Numerator 11 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 3 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
91.2%
About the same
|
93.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 92.0% · Q3 94.1% · Q4 90.6% · 4Q avg 91.2% |
| 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 | 1.8% |
3.0%
1.2 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 3.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 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 who lose too much weight | 2.8% |
6.1%
3.3 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 6.5% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
13.5%
6 pts worse
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 16.7% · Q3 20.6% · Q4 18.8% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
14.8%
9.2 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 18.2% · Q3 28.6% · Q4 23.1% · 4Q avg 24.0% · 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 | 12.8% |
15.1%
2.3 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
15.5%
2.5 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 14.3% · Q3 3.2% · Q4 25.0% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.6%
1.4 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 2.3% · Q4 2.4% · 4Q avg 2.0% · 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 4.3% · Q3 3.0% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.7% |
20.8%
6.9 pts worse
|
19.8%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 20.1% · Q3 38.9% · Q4 20.7% · 4Q avg 27.7% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
6.9%
3.2 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.2% · Q3 3.0% · Q4 3.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
76.7%
0.6 pts worse
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.0% · Q2 72.1% · Q3 81.5% · Q4 75.0% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
9.7%
2.6 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 11.1% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 3.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
78.8%
9.3 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
20.6%
6.2 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 24.4% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-04 · Fire 2021-08-04
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-06-07 · Fire 2019-06-07
4 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-02-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-11
E · Potential for more than minimal harm
2021-08-04
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-04
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-04
K381 · Smoke Deficiencies
Fire Safety
Provide outside doors or windows in every resident room.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-30
C · Minimal harm
2021-08-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2021-09-30
C · Minimal harm
2021-08-04
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2021-09-30
E · Potential for more than minimal harm
2019-06-07
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-08-05
D · Potential for more than minimal harm
2019-06-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-08-05
C · Minimal harm
2019-06-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2019-08-05
C · Minimal harm
2019-06-07
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2019-08-05
C · Minimal harm
2019-06-07
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2019-08-05
B · Minimal harm
2019-06-07
K381 · Smoke Deficiencies
Fire Safety
Provide outside doors or windows in every resident room.
Corrected 2019-08-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2019-06-07
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2019-08-05
D · Potential for more than minimal harm
2019-06-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-08-05
D · Potential for more than minimal harm
2019-06-07
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2019-08-05
B · Minimal harm
2019-06-07
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 2019-08-05
Penalties and ownership
What sits behind the stars
Ownership
Bon Secours Charity Health System, Inc.
5% Or Greater Direct Ownership Interest · Organization
Baker, Patrick
Corporate Director · Individual
Bon Secours Mercy Health Inc
5% Or Greater Indirect Ownership Interest · Organization
Costello, Anthony
Corporate Director · Individual
Difiglia, Mario
Corporate Director · Individual
El-Rayess, Tamer
Corporate Director · Individual
Gevertz, Susan
Corporate Director · Individual
Grannum, Sandra
Corporate Director · Individual
Lubarsky, David
Corporate Director · Individual
Lubarsky, David
Corporate Officer · Individual
Madis, Mark
Corporate Director · Individual
Pickens, Andrew
Corporate Officer · Individual
Ratner, Joshua
Corporate Director · Individual
Rogowsky, Martin
Corporate Director · Individual
Rosenblut, Michael
Corporate Director · Individual
Weitzman, Jonas
Corporate Director · Individual
Westchester Medical Center Health Network
5% Or Greater Indirect Ownership Interest · Organization
Yezzo, Marie
Operational/Managerial Control · Individual
Yezzo, Marie
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Delaware Valley Skilled Nursing & Rehabilitation C
Matamoras, PA
3-star overall rating with 3-star inspections with $8,190 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Milford Rehabilitation And Healthcare Center
Milford, PA
2-star overall rating with 2-star inspections with $61,593 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Highland Rehabilitation And Nursing Center
Middletown, NY
1-star overall rating with 1-star inspections with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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