St John'S Episcopal Hospital at South Shore

Hospital in Far Rockaway, NY, Medicare certification number 330395. CMS publishes 55 quality measures for it.

Medicare certification

Provider of Services

CCN: 330395The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Voluntary non-profit - Private
Control type: Private (not for profit)
Participating since: Jan 1, 1982
Last certification: Jun 24, 2022
Beds: 257
Overall star rating: 1 of 5Care Compare
Address: 327 Beach 19TH Street
Far Rockaway, NY 11691
(718) 869-7000

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Better4 of 5
- State average 3.04 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Worse2 of 5
- State average 2.27 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Worse2 of 5
- State average 2.9 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Worse2 of 5
- State average 2.67 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Worse1 of 5
- State average 2.89 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Worse2 of 5
- State average 2.81 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Worse2 of 5
- State average 2.3 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Worse2 of 5
- State average 3.1 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Worse2 of 5
- State average 2.8 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 16

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected0.97
- State average 1.05 (computed here)
- National average 1.06
- No different than the national rate
- 545 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected1.26
- State average 1.1 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate among surgical inpatients with serious treatable complications As expected177.83
- State average 183.97 (computed here)
- National average 173.3
- No different than the national rate
- 27 patients
- Period from 07/01/2022
Death rate for COPD patients As expected9.8
- State average 8.32 (computed here)
- National average 8.6
- No different than the national rate
- 84 patients
- Period from 07/01/2022
Death rate for heart attack patients As expected11.6
- State average 11.31 (computed here)
- National average 11.9
- No different than the national rate
- 39 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected9.6
- State average 10.43 (computed here)
- National average 11.1
- No different than the national rate
- 85 patients
- Period from 07/01/2022
Death rate for pneumonia patients Worse25.8
- State average 14.6 (computed here)
- National average 15.2
- Worse than the national rate
- 349 patients
- Period from 07/01/2022
Death rate for stroke patients As expected14.9
- State average 11.03 (computed here)
- National average 11.9
- No different than the national rate
- 85 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate Worse5.3
- State average 3.71 (computed here)
- National average 3.9
- Worse than the national rate
- 1,636 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.18
- State average 0.21 (computed here)
- National average 0.21
- No different than the national rate
- 4,042 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.28
- State average 0.29 (computed here)
- National average 0.27
- No different than the national rate
- 4,031 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.9
- State average 3.69 (computed here)
- National average 3.52
- No different than the national rate
- 281 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.18
- State average 2.43 (computed here)
- National average 2.34
- No different than the national rate
- 314 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected2.07
- State average 1.73 (computed here)
- National average 1.77
- No different than the national rate
- 63 patients
- Period from 07/01/2022
Pressure ulcer rate Worse1.53
- State average 0.91 (computed here)
- National average 0.63
- Worse than the national rate
- 3,342 patients
- Period from 07/01/2022
Rate of complications for hip/knee replacement patients As expected6.5
- State average 3.95 (computed here)
- National average 4.1
- No different than the national rate
- 40 patients
- Period from 04/01/2023

Measures CMS does not publish for this facility (4)

Death rate for CABG surgery patients — 5
Postoperative acute kidney injury requiring dialysis rate — 1
Postoperative respiratory failure rate — 1
Postoperative sepsis rate — 1

Infections 4

Medicare Care Compare

Catheter Associated Urinary Tract Infections (ICU + select Wards) As expected1.38
- State average 0.44
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Central Line Associated Bloodstream Infection (ICU + select Wards) As expected1.29
- State average 0.55
- National average 1
- No different than national benchmark
- Period from 10/01/2024
Clostridium Difficile (C.Diff) Better0.47
- State average 0.33
- National average 1
- Better than the national benchmark
- Period from 10/01/2024
MRSA Bacteremia Better0
- State average 0.68
- National average 1
- Better than the national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (2)

SSI - Abdominal Hysterectomy — 13
SSI - Colon Surgery — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 4
- State average 5.23 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 42
- State average 23.75 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 1.16
- State average 0.99
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 15

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 51
- State average 60
- National average 65
- 843 patients
- Period from 10/01/2024
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better 241
- State average 200
- National average 168
- 384 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better 233
- State average 194
- National average 162
- 345 patients
- Period from 10/01/2024
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 461
- State average 294
- National average 257
- 31 patients
- Period from 10/01/2024
Discharged on Antithrombotic Therapy 96
- State average 96.71 (computed here)
- National average 96.1 (computed here)
- 93 patients
- Period from 01/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 100
- State average 92
- National average 93
- 21 patients
- Period from 01/01/2024
Healthcare workers given influenza vaccination 60
- State average 72
- National average 78
- 2,415 patients
- Period from 10/01/2024
Hospital Harm - Opioid Related Adverse Events 0
- State average 0.24 (computed here)
- National average 0.18 (computed here)
- 2,894 patients
- Period from 01/01/2024
Intensive Care Unit Venous Thromboembolism Prophylaxis 96
- State average 94.43 (computed here)
- National average 93.49 (computed here)
- 780 patients
- Period from 01/01/2024
Left before being seen 2
- State average 2
- National average 2
- 49,536 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 12
- State average 14
- National average 15
- 1,112 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 63
- State average 74
- National average 73
- 224 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 79
- State average 86
- National average 87
- 116 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 77
- State average 78
- National average 81
- 844 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 83
- State average 88
- National average 93
- 465 patients
- Period from 10/01/2024

Measures CMS does not publish for this facility (15)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 5
Antithrombotic Therapy by End of Hospital Day 2 — 5
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better — 1
Emergency department volume — high
Global Malnutrition Composite Score — 5
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
Global Malnutrition Composite Score: Nutrition Assessment — 5
Global Malnutrition Composite Score: Nutritional Care Plan — 5
Head CT results — 1
Hospital Harm - Severe Hyperglycemia — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
ST-Segment Elevation Myocardial Infarction (STEMI) — 5
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 8

Medicare Care Compare

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate As expected14.3
- State average 14.47 (computed here)
- National average 14.4
- No different than the national rate
- 30 patients
- Period from 07/01/2023
Heart failure (HF) 30-Day Readmission Rate As expected23.3
- State average 21.89 (computed here)
- National average 21.3
- No different than the national rate
- 235 patients
- Period from 07/01/2023
Hospital return days for heart failure patients 109.7
- State average 26.25 (computed here)
- National average 4.02 (computed here)
- More days than average per 100 discharges
- 91 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients 123.2
- State average 27.98 (computed here)
- National average 5.65 (computed here)
- More days than average per 100 discharges
- 305 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected20.3
- State average 17.78 (computed here)
- National average 17.3
- No different than the national rate
- 382 patients
- Period from 07/01/2023
Rate of readmission after hip/knee replacement As expected6.7
- State average 5.59 (computed here)
- National average 5.8
- No different than the national rate
- 42 patients
- Period from 07/01/2023
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected22.5
- State average 20.27 (computed here)
- National average 20
- No different than the national rate
- 235 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12.6
- State average 12.82 (computed here)
- National average 13
- No different than the national rate
- 73 patients
- Period from 01/01/2022

Measures CMS does not publish for this facility (6)

Hospital return days for heart attack patients — 1
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy — 1
Rate of inpatient admissions for patients receiving outpatient chemotherapy — 1
Rate of readmission for CABG — 5
Ratio of unplanned hospital visits after hospital outpatient surgery — 1

Community Hospital of Smithtown CCN 330309, Smithtown, NY

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them.

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.