Acute Care Hospital

St John's Episcopal Hospital at South Shore

327 Beach 19th Street, Far Rockaway, NY 11691
24/7 Emergency Services Nonprofit
1 out of 5 Stars Why 1 stars? St John's Episcopal Hospital at South Shore's 1-star rating reflects below-average performance on Mortality, Readmissions, Patient Experience, and Timely Care.

CMS Overall Hospital Quality Star Rating · St John's Episcopal Hospital at South Shore

How was St John's Episcopal Hospital at South Shore's 1-star rating calculated?

The CMS Overall Hospital Quality Star Rating applies to acute care hospitals like St John's Episcopal Hospital at South Shore. CMS standardizes every underlying measure against the national rate, computes a weighted score for each of five domains, sums them by the fixed weights below, and assigns 1–5 stars using k-means clustering across all reporting hospitals.

Domains that fed St John's Episcopal Hospital at South Shore's rating
Domain Weight Measures reported Hospital performance vs. national
Mortality 22% 6 of 7 0 better 4 same 2 worse
Safety of Care 22% 13 of 19 0 better 12 same 1 worse
Readmissions 22% 3 of 6 0 better 0 same 3 worse
Timely & Effective Care 12% 15 of 22 3 better 4 same 8 worse
Patient Experience 22% HCAHPS See HCAHPS detail below

How star meaning varies by hospital type. This CMS Overall Star Rating only applies to acute care hospitals. Children's hospitals (Pediatric Quality), psychiatric hospitals (IPFQR), inpatient rehabilitation facilities (IRF QRP), long-term acute care hospitals (LTACH QRP), and VA medical centers each use separate quality programs designed for their patient populations. Comparing star ratings across these facility types isn't meaningful — see the methodology page for the full mapping of which program applies to which facility.

How CareRanks computes ratings → · CMS official methodology ↗

Emergency & urgent care

How this emergency department performs on the measures that matter most when you need care fast.

229 min Typical ER visit before heading home Worse than ~75% of hospitals · national median 148 min
2% Walked out before being seen Worse than ~75% of hospitals · national median 1%
57% Recommended sepsis care given Near the national median of 64%

From CMS Timely & Effective Care reporting.

Quality measures

Mortality

Below National Average

Measures the rate at which patients die within 30 days of hospital admission for specific conditions. A lower mortality rate indicates better outcomes.

Underlying measures: Death rate for COPD patients No Different Than the National Rate Hospital score: 10.60 95% interval: 6.80 – 15.90 Sample size: 69 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_COPD Death rate for heart attack patients No Different Than the National Rate Hospital score: 11.80 95% interval: 9.00 – 15.30 Sample size: 42 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_AMI Death rate for heart failure patients No Different Than the National Rate Hospital score: 10.70 95% interval: 7.30 – 15.50 Sample size: 81 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_HF Death rate for stroke patients No Different Than the National Rate Hospital score: 17.60 95% interval: 12.60 – 24.80 Sample size: 76 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_STK Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate Worse Than the National Rate Hospital score: 5.90 95% interval: 5.00 – 7.00 Sample size: 669 Reporting period: 07/01/2023 – 06/30/2024 CMS measure id: Hybrid_HWM Death rate for pneumonia patients Worse Than the National Rate Hospital score: 26.50 95% interval: 22.80 – 30.50 Sample size: 306 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_PN Death rate for CABG surgery patients Not Available Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: MORT_30_CABG

Safety of Care

Same as National Average

Tracks hospital-acquired infections, surgical complications, and other patient safety indicators. Lower rates indicate better safety practices.

Underlying measures: Abdominopelvic accidental puncture or laceration rate No Different Than the National Rate Hospital score: 0.97 95% interval: 0.00 – 2.02 Sample size: 545 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_15 Clostridium Difficile (C.Diff) No Different than National Benchmark Hospital score: 0.72 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_6_SIR Catheter Associated Urinary Tract Infections (ICU + select Wards) No Different than National Benchmark Hospital score: 1.64 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_2_SIR Central Line Associated Bloodstream Infection (ICU + select Wards) No Different than National Benchmark Hospital score: 1.44 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_1_SIR Iatrogenic pneumothorax rate No Different Than the National Rate Hospital score: 0.18 95% interval: 0.00 – 0.40 Sample size: 4,042 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_06 In-hospital fall-associated fracture rate No Different Than the National Rate Hospital score: 0.28 95% interval: 0.07 – 0.48 Sample size: 4,031 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_08 MRSA Bacteremia No Different than National Benchmark Hospital score: 0.31 SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_5_SIR Postoperative hemorrhage or hematoma rate No Different Than the National Rate Hospital score: 2.18 95% interval: 0.50 – 3.85 Sample size: 314 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_09 Perioperative pulmonary embolism or deep vein thrombosis rate No Different Than the National Rate Hospital score: 3.90 95% interval: 1.45 – 6.35 Sample size: 281 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_12 CMS Medicare PSI 90: Patient safety and adverse events composite No Different Than the National Value Hospital score: 1.26 95% interval: 0.87 – 1.66 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_90 Death rate among surgical inpatients with serious treatable complications No Different Than the National Rate Hospital score: 177.83 95% interval: 120.89 – 234.77 Sample size: 27 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_04 Postoperative wound dehiscence rate No Different Than the National Rate Hospital score: 2.07 95% interval: 0.55 – 3.59 Sample size: 63 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_14 Pressure ulcer rate Worse Than the National Rate Hospital score: 1.53 95% interval: 0.80 – 2.27 Sample size: 3,342 Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_03 Rate of complications for hip/knee replacement patients Number of Cases Too Small Hospital score: — Reporting period: 04/01/2021 – 03/31/2024 CMS measure id: COMP_HIP_KNEE Postoperative acute kidney injury requiring dialysis rate Number of Cases Too Small Hospital score: — Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_10 Postoperative respiratory failure rate Number of Cases Too Small Hospital score: — Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_11 Postoperative sepsis rate Number of Cases Too Small Hospital score: — Reporting period: 07/01/2022 – 06/30/2024 CMS measure id: PSI_13 SSI - Abdominal Hysterectomy Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_4_SIR SSI - Colon Surgery Not Available Hospital score: — SIR Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: HAI_3_SIR

Readmissions

Below National Average

Measures how often patients return to the hospital within 30 days of discharge. Lower readmission rates suggest effective treatment and discharge planning.

Underlying measures: 30-day Readmission, COPD Worse than expected Hospital score: 1.08 Sample size: 77 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-COPD-HRRP 30-day Readmission, Heart Failure Worse than expected Hospital score: 1.08 Sample size: 86 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HF-HRRP 30-day Readmission, Pneumonia Worse than expected Hospital score: 1.33 Sample size: 263 Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-PN-HRRP 30-day Readmission, Bypass Surgery Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-CABG-HRRP 30-day Readmission, Heart Attack Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-AMI-HRRP 30-day Readmission, Hip/Knee Replacement Hospital score: — Reporting period: 07/01/2021 – 06/30/2024 CMS measure id: READM-30-HIP-KNEE-HRRP

Patient Experience

Below National Average

Based on the HCAHPS survey — patient satisfaction with communication, cleanliness, pain management, and discharge information.

Patient survey detail — the questions feeding the Patient Experience domain above expand ↓

CMS computes the Patient Experience domain from the federal HCAHPS survey. Each bar below is one survey question; the percentage is the share of St's recent patients who gave the most positive response. HCAHPS percentages aren't directly comparable across all measures — see the methodology page for how CMS weights them.

  • Communication with Nurses 66%
  • Communication with Doctors 72%
  • Hospital Cleanliness 73%
  • Hospital Quietness 43%
  • Staff Responsiveness N/A
  • Discharge Information 80%
  • Overall Hospital Rating (9 or 10) 50%
  • Would Recommend Hospital 51%

Percentages represent patients who gave the most positive response. Survey conducted by CMS through the HCAHPS program.

Timely & Effective Care

Below National Average

Measures how quickly the hospital provides important treatments such as antibiotics for pneumonia or interventions for heart attacks.

Underlying measures: Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients Better than ~75% of hospitals Hospital score: 100.00 % National median: 97.00 % (higher is better) Sample size: 21 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_29 Safe Use of Opioids - Concurrent Prescribing Better than ~75% of hospitals Hospital score: 12.00 % National median: 15.00 % (lower is better) Sample size: 1,112 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: SAFE_USE_OF_OPIOIDS Hospital Harm - Opioid Related Adverse Events Better than ~75% of hospitals Hospital score: 0.00 % National median: 0.00 % (lower is better) Sample size: 2,894 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: HH_ORAE Intensive Care Unit Venous Thromboembolism Prophylaxis Near the national median Hospital score: 96.00 % National median: 97.00 % (higher is better) Sample size: 780 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: VTE_2 Appropriate care for severe sepsis and septic shock Near the national median Hospital score: 57.00 % National median: 64.00 % (higher is better) Sample size: 746 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_1 Septic Shock 3-Hour Bundle Near the national median Hospital score: 79.00 % National median: 72.00 % (higher is better) Sample size: 157 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_3HR Severe Sepsis 3-Hour Bundle Near the national median Hospital score: 76.00 % National median: 81.00 % (higher is better) Sample size: 747 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_3HR Discharged on Antithrombotic Therapy Worse than ~75% of hospitals Hospital score: 96.00 % National median: 98.00 % (higher is better) Sample size: 93 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: STK_02 Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better Worse than ~75% of hospitals Hospital score: 451.00 min National median: 248.00 min (lower is better) Sample size: 36 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18c 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 Worse than ~75% of hospitals Hospital score: 229.00 min National median: 148.00 min (lower is better) Sample size: 334 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18b 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 Worse than ~75% of hospitals Hospital score: 245.00 min National median: 154.00 min (lower is better) Sample size: 379 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: OP_18a Left before being seen Worse than ~75% of hospitals Hospital score: 2.00 % National median: 1.00 % (lower is better) Sample size: 49,536 Reporting period: 01/01/2024 – 12/31/2024 CMS measure id: OP_22 Septic Shock 6-Hour Bundle Worse than ~75% of hospitals Hospital score: 80.00 % National median: 89.00 % (higher is better) Sample size: 94 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEP_SH_6HR Severe Sepsis 6-Hour Bundle Worse than ~75% of hospitals Hospital score: 84.00 % National median: 94.00 % (higher is better) Sample size: 431 Reporting period: 07/01/2024 – 06/30/2025 CMS measure id: SEV_SEP_6HR Healthcare workers given influenza vaccination Worse than ~75% of hospitals Hospital score: 60.00 % National median: 79.00 % (higher is better) Sample size: 2,415 Reporting period: 10/01/2024 – 03/31/2025 CMS measure id: IMM_3

Psychiatric Unit Quality (IPFQR)

St John's Episcopal Hospital at South Shore operates a Medicare-certified inpatient psychiatric unit that reports under the federal IPFQR program. The measures are specific to that unit — not the hospital as a whole. They cover restraint and seclusion use, screening for medication side effects, substance-use and tobacco treatment, transitions of care, follow-up after discharge, and readmissions.

Show the psychiatric unit's 10 reported measures expand ↓
Physical Restraint Use 0.0 hours per 1,000 patient-hours
National median: 0.1 hours Near national median

HBIPS-2 — hours of physical restraint use per 1,000 patient-hours. Lower is better; restraints carry physical and psychological risks.

Seclusion Use 0.9 hours per 1,000 patient-hours
National median: 0.0 hours Worse than national median

HBIPS-3 — hours of seclusion per 1,000 patient-hours. Lower is better; seclusion is used only when no other intervention works.

Metabolic Screening (SMD) 94.0 %
National median: 92.0 % Near national median

SMD — % of patients on antipsychotics screened for metabolic side effects (BMI, blood glucose, cholesterol). Antipsychotics raise metabolic-syndrome risk; screening catches it early.

Substance-Use Treatment Provided 62.0 %
National median: 74.0 % Worse than national median

SUB-2 — % of patients with alcohol/drug use referred for treatment during admission.

Substance-Use Treatment at Discharge 10.0 %
National median: 77.0 % Worse than national median

SUB-3 — % of patients with substance-use disorder offered or referred to treatment at discharge.

Tobacco-Use Treatment at Discharge 0.0 %
National median: 64.0 % Worse than national median

TOB-3 — % of patients using tobacco who received counseling and/or medication at discharge.

Transition Record Completed 98.0 %
National median: 77.0 % Better than national median

TR-1 — % of discharges with a completed transition record including medications, follow-up plan, and crisis instructions.

Medication Continuation 84.4 %
National median: 78.2 % Near national median

MedCont — % of discharged patients with continued antipsychotic / antidepressant medication post-discharge.

30-Day Readmission Rate 21.8 %
National median: 19.1 % Worse than national median

READM-30-IPF — risk-standardized 30-day readmission rate. No Different Than the National Rate

Influenza Immunization 7.0 %
National median: 87.0 % Worse than national median

IMM-2 — % of patients given a flu vaccine during the inpatient stay.

Source: CMS Inpatient Psychiatric Facility Quality Reporting Program. Reporting period ending 12/31/2024.

Clinical Staff

St John's Episcopal Hospital at South Shore has 241 CMS-affiliated clinicians on its roster — physicians, advanced practice providers, and other Medicare-enrolled professionals who list this hospital as an affiliated facility.

Top specialties

  • Internal Medicine 62
  • Diagnostic Radiology 26
  • Emergency Medicine 17
  • Psychiatry 13
  • Hospitalist 12
  • Nurse Practitioner 11
  • Family Practice 10
  • Obstetrics/Gynecology 8

Self-reported primary specialty in the CMS Doctors & Clinicians dataset. Many clinicians serve multiple facilities.

Practice characteristics

Accept Medicare assignment
230 (95%)

Bill Medicare directly at the approved rate — patients only owe co-insurance/deductible.

Offer telehealth
44 (18%)

Indicated by the clinician in their CMS profile as routinely providing virtual visits.

Medicare quality scoring (MIPS)

119 of these clinicians have a published Merit-based Incentive Payment System (MIPS) final score. Of those, 37 (31%) score above the national median of 85.5.

MIPS scoring is heavily compressed at the top of the 0–100 range, so individual scores are not a reliable consumer signal. We surface roster-level coverage and the share above the national median instead.

Source: CMS Doctors and Clinicians (Care Compare) national downloadable file and MIPS Performance Year final scores, as of 2026-07-18. Affiliations from the CMS Facility Affiliations dataset. About 16% of small facilities (critical access, rural emergency, freestanding psych, IRF/LTCH) do not appear in the affiliations file and therefore have no panel.

Find a Doctor

Search the 241 clinicians affiliated with St John's Episcopal Hospital at South Shore. Each name links to that clinician's official Medicare Care Compare profile, where you can see their credentials, secondary specialties, group affiliations, and (when applicable) MIPS quality scores.

Showing 30 of 241 clinicians (alphabetical)

Roster from CMS Doctors and Clinicians (Care Compare), updated 2026-07-18. A clinician may also practice at other facilities; "affiliated" means this hospital is on their CMS profile, not that they exclusively work here. Procedure volumes are Medicare fee-for-service counts from the CMS clinician utilization file (all practice locations, not just this hospital). Industry payment totals are from CMS Open Payments, program year 2024, and include meals, travel, consulting, and speaking fees; payments are legal and common — we show them for transparency, not as a quality judgment.

Pricing & Costs

Facility Information

Licensed beds
257
Facility type
Acute Care Hospitals
Ownership
Voluntary non-profit - Private
Emergency services
Yes — 24/7

Ownership & Finances

Ownership
Nonprofit
Charity care spend (FY2023)
$1.6M
List prices vs. actual cost
≈ 2.7× actual cost

From the hospital's FY2023 Medicare cost report (HCRIS).

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How St John's Episcopal Hospital at South Shore compares nearby

Compared with the 8 other acute-care hospitals within 25 miles — 9 facilities in all, CMS data only.

Among the 9 acute-care hospitals within 25 miles, St John's Episcopal Hospital at South Shore's overall star rating is 1★; the median among the 8 peers reporting it is 1★.

Measure This facility Nearby median Best nearby
Overall star rating reported by 8 of 8 nearby peers 1★ 1★ 3★
Patient experience (HCAHPS) star reported by 8 of 8 nearby peers 2★ 2★ 3★
Mortality reported by 8 of 8 nearby peers Below National Average Same as National Average Better than National Average
Safety of Care reported by 8 of 8 nearby peers Same as National Average Same as National Average Better than National Average
Readmissions reported by 8 of 8 nearby peers Below National Average Same as National Average Same as National Average

The comparison group

Cohort: within 25 miles · CMS data period 2026-06 · method cohort-v1 · comparisons are never affected by claiming or payment. How nearby comparisons work

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Skilled nursing facilities nearby

For planning care after discharge — CMS five-star ratings shown; always confirm availability and coverage with the facility and your insurer.

About this data

Quality and ratings data are sourced from the U.S. Centers for Medicare & Medicaid Services (CMS) Hospital Compare program. Star ratings are CMS's own calculation; CareRanks does not modify or re-weight them. Facility-level details (address, beds, ownership, teaching status) come from CMS provider files and the CMS Provider of Services file.

Pricing data, where shown, is drawn from the hospital's own Machine-Readable File (MRF) published under the federal Hospital Price Transparency Rule. See our methodology for the full update cadence and limitations.

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