5 Star Analysis - Nursing Home

Nursing Home Five Star Analysis

Extract Date: January 1, 2025

Queen Of Peace Residence, Queens Village, NY

Overall 5 Star Rating:

Previous Month:

3 Months Prior:

Follow the sections below to see how your current rating is calculated and 2 scenarios that could possibly change your overall 5 star rating. View Overall 5 Star Trend

Growing Importance of Nursing Home Ratings

Receiving a better than average 5-star rating has never been more important to nursing homes.

These ratings are increasingly used by consumers, regulators, insurers and other payers, and provider networks to select which facilities they will consider having relationships with. Nursing homes may not even be able to obtain sufficient referrals or receive Medicare and Medicaid funding in the future if they do not have at least a 3-star rating.

Health Inspection 5 Star Rating:

Previous Month:

3 Months Prior:

Help

The health inspection rating is based on the number, scope, and severity of deficiencies identified during the 3 or 2 most recent annual inspection surveys and 36 months of complaint investigations and focused infection control surveys. More than one revisit will have a negative impact on the score for a survey cycle. The total score from each survey cycle is weighted so that the more recent survey cycles have more impact on the overall total score as compared to the older survey cycle. View Health Inspection 5 Star Trend

Inspection Cycle	1	2	3
Health Survey Date	2023-06-20	2021-11-22	2019-11-07
Count of Health Deficiencies
Freedom from Abuse, Neglect, and Exploitation	0	0	0
Quality of Life and Care	0	0	0
Resident Assessment and Care Planning	1	0	0
Nursing and Physician Services	0	0	0
Resident Rights	1	0	0
Nutrition and Dietary	0	0	0
Pharmacy Service	1	0	0
Environmental	0	0	0
Administration	0	0	0
Infection Control	0	1	0
Standard Inspection
Number of Standard Inspection Health Deficiencies	3	1	0
Scope of most Severe Standard Inspection Health Deficiency	Few	Many
Severity of most Severe Standard Inspection Health Deficiency	Minimal harm or potential for actual harm	Minimal harm or potential for actual harm
Complaint Inspection
Number of Complaint Inspection Health Deficiencies	0	0	0
Scope of most Severe Complaint Inspection Health Deficiency
Severity of most Severe Complaint Inspection Health Deficiency
Infection Control Inspection
Number of Infection Control Inspection Health Deficiencies	0	0	0
Scope of most Severe Infection Control Inspection Health Deficiency
Severity of most Severe Infection Control Inspection Health Deficiency
Total Number of Health Deficiencies	3	1	0
Health Deficiency Score	12	16	0
Number of Health Revisits	1	1	0
Health Revisit Score	0	0	0
Total Health Score	12	16	0
Survey Weighting	1/2	1/3	1/6
Weighted Total Health Score	6	5	0
Total Weighted Health Survey Score	11 View Cut Points
Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your inspection ratings to your peers.

Staffing 5 Star Rating:

Previous Month: only updated quarterly

3 Months Prior:

Help

View Staffing 5 Star Trend

Staffing Measure	Rate	Points	Interpretation	Bottom Cut Point	Top Cut Point
Adjusted Weekend Total Nurse Hours Per Day View Trend	6.045	50	Full points are currently being attained for this measure, but decreasing this rate by -26.2% or by approximately -1.581 could result in losing 5 points.	4.464	24
Adjusted RN Hours Per Day View Trend	1.973	100	Full points are currently being attained for this measure, but decreasing this rate by -39.1% or by approximately -0.771 could result in losing 10 points.	1.202	Or Higher
Adjusted Total Nurse Hours Per Day View Trend	6.549	100	Full points are currently being attained for this measure, but decreasing this rate by -22.6% or by approximately -1.479 could result in losing 10 points.	5.07	Or Higher
Administrator Turnover Count View Trend	0	30	Potential To Lose Points Although full points are currently being attained for this measure, increasing the count by 1 would result in losing 5 points.	0	0
Total Nurse Turnover Percentage View Trend	40	40	Increasing the rate for this measure by 4.3% or by approximately 1.739 could result in losing 5 points.	37.501	41.739
RN Turnover Percentage View Trend	35.3	40	Increasing the rate for this measure by 1.2% or by approximately 0.414 could result in losing 5 points.	28.752	35.714
Note: The staffing measures and points in this table have been rounded to either one, two, or three decimal places due to space constraints. However, the full value has been used to calculate facility scores and rankings. To view the full staffing cut point tables, click here .

Total Points	Unscaled	Maximum	Available	Scaling Factor	Re-Scaled
Current	360	380	380	1	360
Gain	360				360
Lose	355				355
Gain and lose	355				355

Staffing Stars

Interpretation

This facility currently has a 5 star staffing rating of 5.
The value of 'Administrator Turnover Count' is close to a cut point and has the potential to result in losing 5 points.
Although the scores are close to a cut point, there is a possibility that the change in cut point groups could result in the staffing rating remaining constant.

Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your staffing to your peers.

View Cut Points

Quality Measure 5 Star Rating:

Previous Month: only updated quarterly

3 Months Prior:

Help

Long Stay Quality Measure 5 Star Rating:

View Quality Measure 5 Star Trend

Disclaimer:

Based on this provider having missing short-stay QM data, possibly due to a low number of residents or stays, the Overall Quality Measure 5 Star Rating is based on the rating of the long-stay QMs only.

Quality Measure	Rate	Points	Interpretation	Bottom Cut Point	Top Cut Point
Higher Rate is Better
D/C Function Score View Trend	State Average Due to Missing Data 57.229	Excluded 105	Although this QM is excluded based on missing data in either/both the long-stay or short-stay QMs, here is the interpretation based on the data for this QM: The facilty rate is missing for this QM, possibly due to a low number of residents or stays. The state average is possibly used with a non-published rate to impute a rate used for your rating. Here is the interpretation based on the state average: Decreasing this QM rate by 1.1% or by approximately 0.619 points could result in losing 15 points.	56.61	60.34
Successful community discharge (short-stay) View Trend	State Average Due to Missing Data 46.233	Excluded 60	Potential To Lose Points Although this QM is excluded based on missing data in either/both the long-stay or short-stay QMs, here is the interpretation based on the data for this QM: This QM is not publically reported possible due to a low number of stays. Thus the following is the interpretation based on the state average: Decreasing this QM rate by 0.3% or by approximately 0.143 points could result in losing 15 points.	46.09	49.16
Lower Rate is Better
Catheter (long-stay) View Trend	0	100	Full points are currently being attained for this QM, but increasing this rate by approximately 0.5 points could result in losing 20 points.	0	0.5
Number of hospitalizations per 1,000 resident days (long-stay) View Trend	2.917	15	Decreasing this QM rate by 20% or by approximately 0.583 points could result in gaining 15 points.	2.333	1000
Injurious Falls (long-stay) View Trend	9.804	20	Decreasing this QM rate by 47.5% or by approximately 4.654 points could result in gaining 20 points.	5.15	100
ED Visits (short-stay) View Trend	20.868	Excluded 15	Although this QM is excluded based on missing data in either/both the long-stay or short-stay QMs, here is the interpretation based on the data for this QM: Decreasing this QM rate by 23.7% or by approximately 4.938 points could result in gaining 15 points.	15.93	100
New or Worsening Pressure Ulcers (short-stay) View Trend	State Average Due to Missing Data 2.551	Excluded 60	Although this QM is excluded based on missing data in either/both the long-stay or short-stay QMs, here is the interpretation based on the data for this QM: The facilty rate is missing for this QM, possibly due to a low number of residents or stays. The state average is possibly used with a non-published rate to impute a rate used for your rating. Here is the interpretation based on the state average: Decreasing this QM rate by 13.7% or by approximately 0.351 points could result in gaining 20 points.	2.2	3.95
Antipsychotic Medications (short-stay) View Trend	State Average Due to Missing Data 1.287	Excluded 60	Although this QM is excluded based on missing data in either/both the long-stay or short-stay QMs, here is the interpretation based on the data for this QM: The facilty rate is missing for this QM, possibly due to a low number of residents or stays. The state average is possibly used with a non-published rate to impute a rate used for your rating. Here is the interpretation based on the state average: Decreasing this QM rate by 24.6% or by approximately 0.317 points could result in gaining 20 points.	0.97	1.68
Antipsychotic Medications (long-stay) View Trend	8.497	120	Decreasing this QM rate by 11.7% or by approximately 0.997 points could result in gaining 15 points.	7.5	9.6
Ambulation Decline (long-stay) View Trend	14.842	120	Increasing this QM rate by 5% or by approximately 0.748 points could result in losing 15 points.	12.36	15.59
Number of outpatient emergency department (ED) visits per 1,000 resident days (long-stay) View Trend	1.356	75	Increasing this QM rate by 3.6% or by approximately 0.049 points could result in losing 15 points.	1.193	1.405
ADL Decline (long-stay) View Trend	25	45	Increasing this QM rate by 3% or by approximately 0.74 points could result in losing 15 points.	22.46	25.74
Urinary Tract Infection (long-stay) View Trend	4.167	40	Increasing this QM rate by 8.5% or by approximately 0.353 points could result in losing 20 points.	2.73	4.52
Hospital readmission (short-stay) View Trend	11.09	Excluded 150	Although this QM is excluded based on missing data in either/both the long-stay or short-stay QMs, here is the interpretation based on the data for this QM: Full points are currently being attained for this QM, but increasing this rate by 24.3% or by approximately 2.69 points could result in losing 15 points.	0	13.78
Pressure Ulcers (long-stay) View Trend	2.867	100	Potential To Lose Points Full points are currently being attained for this QM, but increasing this rate by 0.4% or by approximately 0.013 points could result in losing 20 points.	0	2.88
Note: The QM rates and points in this table have been rounded to either one, two, or three decimal places due to space constraints. However, the full QM value has been used to calculate facility scores and rankings. To view the full QM cut point tables, click here.

Disclaimer:

Based on this provider having missing short-stay QM data, possibly due to a low number of residents or stays, the Overall Quality Measure 5 Star Rating is based on the rating of the long-stay QMs only.

Total Points	Overall	Long-Stay
Current	635	635
Gain	635	635
Lose	615	615
Gain and lose	615	615

Long-Stay (and Overall)

Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your QMs to your peers or to see how your QMs are trending.

View Cut Points

Overall 5 Star Rating:

Previous Month:

3 Months Prior:

Help

Follow the steps below to see how your current rating is calculated and 2 scenarios could possibly change your overall 5 star rating.

Step	Instruction	Current	Likely to Gain	Likely to Lose
1	Start with the health inspection rating.	4	4	4
2	Add one star to the Step 1 result if the staffing rating is five stars; subtract one star if the staffing rating is one star. The overall rating cannot be more than five stars or less than one star.	+ 1	+ 1	+ 1
3	Add one star to the Step 2 result if quality measure rating is five stars; subtract one star if quality measure rating is one star. The overall rating cannot be more than five stars or less than one star.	+ 0	+ 0	+ 0
Note	If the health inspection rating is one star, then the overall quality rating cannot be upgraded by more than one star based on the staffing and quality measure ratings.	- 0	- 0	- 0
Final Overall Star Rating		5	5	5
Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your 5 Star Ratings to your peers.