JOHN T MATHER MEMORIAL HOSPITAL T C U

Nursing Home Inspector

75 NORTH COUNTRY ROAD
PORT JEFFERSON, NY 11777
Suffolk County
Phone: 631-473-1320
Provider Number: 335853
Last Inspection: 03/17/2017

About the Nursing Home

Number of Beds: 16
Number of Residents: 13
Beds Available: 3
Percent Occupancy: 81%
Insurance Accepted: Medicare
Types of Councils: None
Ownership: Non profit - Corporation
Within Hospital?: YES

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

0

Facility
12

County
14

NY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

0

2017
6

2016
12

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

2/25/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 4/22/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/22/2016
 

3/6/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 5/5/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 5/5/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 5/5/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 5/5/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NY State Avg
Number of Residents 13 181.19 167.28
Registered Nurses 3.12 0.81 0.74
Licensed Practical / Vocational Nurses 0.00 0.81 0.84
Certified Nursing Assistants 4.07 2.28 2.30
Total Staff Hours 7.18 3.90 3.88

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NY State Avg%
of short-stay residents assessed and appropriately given the pneumococcal vaccine 99 5 6
of short-stay residents who had an outpatient emergency department visit 8 98 95
of short-stay residents who made improvements in function 51 98 96
of short-stay residents who newly received an antipsychotic medication 0 3 2
of short-stay residents who self-report moderate to severe pain 13 8 8
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 99 6 6
of short-stay residents who were rehospitalized after a nursing home admission 22 19 15
of short-stay residents who were successfully discharged to the community 70 11 13
of short-stay residents with pressure ulcers that are new or worsened 0 1 3