4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Westhampton, NY
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
78 Old Country Road, Westhampton, NY
(631) 288-0101
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
Beds
180
Certified beds
Average residents
170
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Center Management Group
Operator or chain grouping
Approved since
1995-03-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.55
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.23
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
0.12
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
2.90
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
6,373
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.94
Baseline 21.91% · Performance 20.23% · Measure score 2.94 · Achievement 2.60 · Improvement 2.94
Healthcare-associated infections
4.22
Baseline 7.04% · Performance 6.57% · Measure score 4.22 · Achievement 4.22 · Improvement 1.79
Total nurse turnover
6.08
Baseline 42.69% · Performance 38.82% · Measure score 6.08 · Achievement 6.08 · Improvement 1.67
Adjusted total nurse staffing
0
Baseline 2.81 hours · Performance 2.71 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.89% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 755 · Observed rate 9.27% · Lower 95% interval 9.25% |
| Discharge to community | 60% |
50.57%
9.4 pts better
|
Better than the National Rate · Eligible stays 817 · Observed rate 55.81% · Lower 95% interval 57.02% |
| Medicare spending per beneficiary | 1.39 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 563 · Denominator 563 |
| Falls with major injury | 1.24% |
0.77%
0.5 pts worse
|
Numerator 7 · Denominator 563 |
| Discharge self-care score | 59.43% |
53.69%
5.7 pts better
|
Numerator 230 · Denominator 387 |
| Discharge mobility score | 70.8% |
50.94%
19.9 pts better
|
Numerator 274 · Denominator 387 |
| Pressure ulcers or injuries, new or worsened | 0.36% |
2.29%
1.9 pts better
|
Numerator 2 · Denominator 563 · Adjusted rate 0.31% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 526 · Observed rate 5.7% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 0.41% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 241 |
| Staff flu vaccination coverage | 81.99% |
42%
40 pts better
|
Numerator 264 · Denominator 322 |
| Discharge function score | 57.62% |
56.45%
1.2 pts better
|
Numerator 223 · Denominator 387 |
| Transfer of health information to provider | 99.32% |
95.95%
3.4 pts better
|
Numerator 146 · Denominator 147 |
| Transfer of health information to patient | 97.31% |
96.28%
1 pts better
|
Numerator 325 · Denominator 334 |
| Resident COVID-19 vaccinations up to date | 47.75% |
25.2%
22.6 pts better
|
Numerator 138 · Denominator 289 |
Quality measures
| 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 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.2%
8.4 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.2% · Q4 99.2% · 4Q avg 99.6% |
| 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 | 2.8% |
3.0%
0.2 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.8% · Q3 2.5% · Q4 4.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.3% |
18.5%
80.8 pts worse
|
11.4%
87.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 99.1% · Q4 99.1% · 4Q avg 99.3% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
6.1%
0.4 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 6.4% · Q3 1.7% · Q4 7.1% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.6% |
13.5%
10.1 pts worse
|
19.6%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 22.8% · Q3 21.7% · Q4 23.7% · 4Q avg 23.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
14.8%
2.6 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 11.1% · Q3 10.5% · Q4 11.1% · 4Q avg 12.2% · 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 | 7.5% |
15.1%
7.6 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 6.8% · Q3 6.8% · Q4 6.4% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
15.5%
6 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 9.2% · Q3 7.5% · Q4 8.6% · 4Q avg 9.5% · 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 | 29.4% |
20.8%
8.6 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 25.8% · Q3 31.5% · Q4 31.5% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.9%
2.5 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.9% · Q3 5.9% · Q4 4.1% · 4Q avg 4.4% · 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 99.7% · Q2 99.3% · Q3 99.3% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
9.7%
2.8 pts worse
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 11.8% · Expected 10.5% · 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 0.5% · Q2 0.5% · Q3 1.5% · Q4 1.5% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
78.8%
15.8 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
20.6%
1.2 pts worse
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 21.5% · Expected 23.4% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-18
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-08
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-08
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-04
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-03-04
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-03-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-04
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-03-04
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-04
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-03-04
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-03-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-04
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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