5 Star Analysis - Nursing Home

Nursing Home Five Star Analysis

Extract Date: January 1, 2025

Woodland Pond At New Paltz, New Paltz, NY

Overall 5 Star Rating:

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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:

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3 Months Prior:

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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	2023-03-03	2020-02-28	2018-04-25
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	0	0	0
Nursing and Physician Services	0	0	0
Resident Rights	0	0	0
Nutrition and Dietary	0	1	1
Pharmacy Service	0	1	0
Environmental	0	1	0
Administration	0	1	0
Infection Control	0	1	1
Standard Inspection
Number of Standard Inspection Health Deficiencies	0	5	2
Scope of most Severe Standard Inspection Health Deficiency		Many	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	0	5	2
Health Deficiency Score	0	48	16
Number of Health Revisits	0	1	1
Health Revisit Score	0	0	0
Total Health Score	0	48	16
Survey Weighting	1/2	1/3	1/6
Weighted Total Health Score	0	16	3
Total Weighted Health Survey Score	19 View Cut Points
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Staffing 5 Star Rating:

Previous Month: only updated quarterly

3 Months Prior:

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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	5.49	50	Full points are currently being attained for this measure, but decreasing this rate by -18.7% or by approximately -1.026 could result in losing 5 points.	4.464	24
Adjusted Total Nurse Hours Per Day View Trend	6.131	100	Full points are currently being attained for this measure, but decreasing this rate by -17.3% or by approximately -1.061 could result in losing 10 points.	5.07	Or Higher
Adjusted RN Hours Per Day View Trend	1.246	100	Potential To Lose Points Full points are currently being attained for this measure, but decreasing this rate by -3.5% or by approximately -0.044 could result in losing 10 points.	1.202	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
RN Turnover Percentage View Trend	33.3	40	Increasing the rate for this measure by 7.2% or by approximately 2.414 could result in losing 5 points.	28.752	35.714
Total Nurse Turnover Percentage View Trend	52.6	25	Increasing the rate for this measure by 1.6% or by approximately 0.825 could result in losing 5 points.	49.255	53.425
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	345	380	380	1	345
Gain	345				345
Lose	330				330
Gain and lose	330				330

Staffing Stars

Interpretation

This facility currently has a 5 star staffing rating of 5.
The value of 'Adjusted RN Hours Per Day' is close to a cut point and has the potential to result in losing 10 points.
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:

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Long Stay Quality Measure 5 Star Rating:

Short Stay Quality Measure 5 Star Rating:

View Quality Measure 5 Star Trend

Quality Measure	Rate	Points	Interpretation	Bottom Cut Point	Top Cut Point
Higher Rate is Better
Successful community discharge (short-stay) View Trend	40.16	30	Increasing this QM rate by 6.1% or by approximately 2.45 points could result in gaining 15 points.	37.63	42.61
D/C Function Score View Trend	79.17	150	Full points are currently being attained for this QM, but decreasing this rate by 10.6% or by approximately 8.43 points could result in losing 15 points.	70.74	100
Lower Rate is Better
Urinary Tract Infection (long-stay) View Trend	5.31	20	Potential To Gain Points Decreasing this QM rate by 14.7% or by approximately 0.78 points could result in gaining 20 points.	4.53	100
Injurious Falls (long-stay) View Trend	7.563	20	Decreasing this QM rate by 31.9% or by approximately 2.413 points could result in gaining 20 points.	5.15	100
Ambulation Decline (long-stay) View Trend	41.891	15	Potential To Gain Points Decreasing this QM rate by 6.8% or by approximately 2.841 points could result in gaining 15 points.	39.05	100
ADL Decline (long-stay) View Trend	14.925	90	Potential To Gain Points Decreasing this QM rate by 1.9% or by approximately 0.285 points could result in gaining 15 points.	14.64	17.02
Number of outpatient emergency department (ED) visits per 1,000 resident days (long-stay) View Trend	2.069	30	Decreasing this QM rate by 4.8% or by approximately 0.098 points could result in gaining 15 points.	1.97	2.551
ED Visits (short-stay) View Trend	13.94	30	Decreasing this QM rate by 3.8% or by approximately 0.53 points could result in gaining 15 points.	13.41	15.92
Catheter (long-stay) View Trend	2.581	40	Decreasing this QM rate by 15.5% or by approximately 0.401 points could result in gaining 20 points.	2.18	3.56
Hospital readmission (short-stay) View Trend	20.023	90	Decreasing this QM rate by 2.2% or by approximately 0.443 points could result in gaining 15 points.	19.58	20.93
Antipsychotic Medications (short-stay) View Trend	1.205	60	Decreasing this QM rate by 19.5% or by approximately 0.235 points could result in gaining 20 points.	0.97	1.68
Pressure Ulcers (long-stay) View Trend	6.763	40	Decreasing this QM rate by 11.6% or by approximately 0.783 points could result in gaining 20 points.	5.98	7.97
Number of hospitalizations per 1,000 resident days (long-stay) View Trend	1.5	75	Decreasing this QM rate by 4.2% or by approximately 0.062 points could result in gaining 15 points.	1.438	1.59
New or Worsening Pressure Ulcers (short-stay) View Trend	3.4	60	Increasing this QM rate by 16.2% or by approximately 0.55 points could result in losing 20 points.	2.2	3.95
Antipsychotic Medications (long-stay) View Trend	9.244	120	Increasing this QM rate by 3.9% or by approximately 0.356 points could result in losing 15 points.	7.5	9.6
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.

Total Points	Overall	Long-Stay	Short-Stay
Current	1054	450	604
Gain	1104	500	604
Lose	1054	450	604
Gain and lose	1104	500	604

Overall

Long-Stay

Short-Stay

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:

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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.	3	3	3
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		4	4	4
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.