Wolfeboro Bay Center
39 Clipper Drive, Wolfeboro, NH 03894 · For profit - Limited Liability company · 104 certified beds · (603) 569-3950 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 14.4% | 22.7% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.1% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 1.1% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.2% | 2.1% | 2.0% | better |
| Long-stay residents with depressive symptoms | 22.0% | 13.7% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.1% | 4.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.9% | 17.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.6% | 19.0% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.6% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.0% | 4.2% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.5% | 25.7% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.7% | 17.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.9% | 1.3% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.5% | 83.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 33.9% | 22.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.8% | 13.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 0.83 | 1.64 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.44 | 1.87 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 20.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.3%CMS range 49.9–69.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.3–15.0 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 20.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 8.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 25.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.0–13.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 104 beds and averages 72.7 residents a day — about 70% occupied, or roughly 31 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.31 hrs/resident/day on weekends vs 3.65 on weekdays — 9% thinner on weekends. RN hours go from 0.79 to 0.66 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · D2026-04-16 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility failed to ensure PRN (as needed) orders for antipsychotic drugs are limited to 14 days in 1 of 5 residents reviewed for unnecessary medications (Resident identifier is #11). Findings include:Review on 4/15/26 of Resident #11's medical record revealed an order for Olanzapine 5mg (milligrams) 1 tablet by mouth every 12 hours as needed for vascular dementia, moderate, with agitation for 60 days with a start date of 2/26/26. Further review revealed that Resident #11 received the PRN dose on April 1, 3, 4, 6, 14, and 15, 2026. Review on 4/15/26 of Resident #11's Medication Regime Review, dated 3/12/26 revealed a recommendation for, Currently has an active order for Olanzapine prn (as needed) with a duration of 60 days. Please note that CMS guidelines do not allow maintaining orders for PRN antipsychotics for greater than 14 days on medication profiles . Prescriber responded: disagree, already documented need for over 14 days. Interview on 4/15/26 at approximately 2:15 p.m. with Staff C (Clinical Consultant)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure medications were administered in accordance with physician orders. This failure resulted in multiple insulin administration errors for 1 of 1 resident reviewed for insulin. (Resident identifier is #33.)Findings include: Resident #33 Record review on 4/14/26 showed a physician's order dated 1/16/26 for NovoLog Flex Pen Subcutaneous Solution Pen-inject 100 unit/ml (Insulin Aspart). Inject 20 units subcutaneously before meals for DM2(Diabetes Mellitus type 2) Hold for BS (blood sugar) under 110. Review of the Medication Administration Record (MAR) on 04/14/2026 revealed insulin was administrated outside ordered parameters on: On January 21st Insulin was administered when the BS was 96 at 7:00 a.m.On January 28th Insulin was administered when the BS was 99 at 5:00 p.m. On February 11th Insulin was administered when the BS was 99 at 5:00 p.m.On February 12th Insulin was administered when the BS was 106 at 11:30 a.m., and at 5:00 p.m. one MAR entry for this date was left blank with no documentation of a BS level and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-02-21 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate was less than 5 percent (%) for 11 of 35 medication administrations observed. (Resident identifiers are #38) Findings include: Resident #38 Observation on 2/21/25 at approximately 8:45 a.m. of Staff B (Licensed Practical Nurse) revealed Staff B prepared the following 11 medications for Resident #1: Aspirin 81 mg (milligram) enteric coated, Magnesium Oxide 400 mg, Vitamin D3 1000 iu (units), Senna 8.6 mg, Miralax 17gm (grams), Buspirone 15 mg, Olanzapine 15 mg (3), Paroxetine 50 mg, Metformin 1000 mg, Carvedolil 25 mg, and Lisinopril 20 mg. Further observation revealed Staff B entered the wrong residents room. Staff B introduced themselves to Resident #38 and was prepared to administer the medications. The surveyor intervened. Interview on 2/21/25 at approximately 8:45 a.m. with Staff B confirmed he/she was going to administer Resident #1's medications to Resident #38. Review on 2/21/25 of facility policy titled Medication Administration reviewed/revised…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-21 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, it was determined that the facility failed to meet professional standards for 1 of 4 nursing staff observed for medication administration and 1 of 2 residents reviewed for pain in a final sample of 16 residents (Resident identifiers are #164 and #214). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Resident #214 Observation on 2/20/25 at approximately 9:00 a.m. of Staff E (Medication Nursing Assistant (MNA)) revealed that Staff E administered medications to Resident #214 including Fluticasone Propionate Diskus Inhalation Powder 250mcg/ACT. Further observation revealed that Staff E did not have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-19 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to ensure that long term care residents were seen face to face by a physician at least once every 60 days for 2 out of 2 residents reviewed for physician visits in a final sample of 22 residents (Resident Identifiers are #22 and #42). Finding include: Resident #22 Interview on 1/17/24 at 1:13 p.m. with Resident #22 revealed that he/she has seen the nurse practitioner but has not seen the physician. Review on 1/18/24 of Resident #22's medical record revealed he/she was initially admitted to the facility for long term care on 1/23. Further review of the medical record revealed the following face to face provider visits: APRN [Advanced Practice Registered Nurse] saw the resident on 2/13/23, 3/13/23, 6/20/23, 11/20/23, and 1/12/24. Review on 1/18/24 of Resident #22's physician progress notes revealed that there were no face to face visits performed by a physician. Interview on 1/18/24 at 3:00 p.m. with Staff A (Director of Nursing) revealed that Staff A was unable to find any documentation in Resident #22's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-19 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs for 12 of 30 days reviewed (Resident Identifiers are #3, #10, #13, #15, #19, #21, #22, #29 #43, #46, and #211). Findings include: Review on 1/17/24 of the facility assessment staffing ratios revealed: Solona Unit Licensed Nursing Assistant (LNA) ratios = 1:12 for 7:00 a.m. - 3:00 p.m., 2:16 for 3:00 p.m. - 11:00 p.m. and 1:24 for 11:00 p.m. - 7:00 a.m. Granite Unit LNA ratios = 1:13 for the 7:00 a.m. - 3:00 p.m., 1:13 3:00 p.m. - 11:00 p.m. and 1:19 for 11:00 p.m. - 7:00 a.m. Review on 1/16/24 at 11:00 a.m. of the Facilities Nursing Staffing Scheduled for the past 30 days revealed that the staffing ratios for the LNAs did not meet the established ratios in the above Facility Assessment on the following days: 12/18/23: Granite Unit 3:00 p.m. - 11:00 p.m. shift had 2 full shift LNAs and one other LNA for 4 hours for 35 residents. 12/25/23: Solona Unit 7:00 a.m. - 3:00 p.m. shift had 1 LNA for 23 residents. The 3:00 p.m. - 11:00 p.m. shift had 1 LNA for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-19 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that the facility failed to monitor medication temperatures to ensure safe temperature controls in 3 out of 4 medication room refrigerators observed. Findings include: Review on 1/16/24 of the Temperature Refrigerator Log in the Bay Unit medication room for January 2024 revealed missing temperatures on 3 of 15 days (1/2/24, 1/4/24, and 1/5/24). Interview on 1/16/24 at 10:59 a.m. with Staff E (Licensed Practical Nurse, Unit Manager) confirmed above findings. Interview on 1/16/24 at 10:43 a.m. with Staff F (Medication Nursing Assistant) revealed that he/she was unable to provide temperature logs for Granite Unit medication room refrigerator. Review on 1/19/24 of the January 2024 Temperature Refrigerator Logs For Vaccines revealed missing temperatures on 4 out of 18 days (1/6/24, 1/7/24, 1/13/24, 1/14/24). Interview on 1/19/24 at 11:20 a.m. with Staff D (Infection Preventionist) confirmed the above findings. Review on 1/19/24 of the facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to monitor food temperatures to ensure proper preparation. Findings include: Interview on 1/16/24 at 1:00 p.m. with Staff I (Food Service Director) revealed that food temperatures had not been taken for the morning breakfast food service or during the lunch meal service and that he/she was unable to provide any documentation of meal temperature monitoring. Observation on 1/16/24 at 1:30 p.m. of the Meal Temperature Logs revealed the most current log with temperatures were from August of 2023. Interview on 1/16/24 at 1:32 p.m. with Staff I (Food Service Director) confirmed that they had not been taking the temperature of the food prior to service.
- Potential for harm · D2024-01-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure that residents' needs were timely addressed for 1 of 3 closed records reviewed (Resident Identifier is #111). Findings include: Review on 1/19/24 of Staff N (Licensed Nursing Assistant (LNA)) written witness statement dated 8/12/23 revealed .I worked from 11-11PM [11 a.m. to 11:00 p.m.] .At 11am I was assigned [Resident #111's name omitted]/ Between 11-11:30am I went in to check and change [pronoun omitted]. [pronoun omitted] breathing seems slightly labored . When I laid [pronoun omitted] flat it appeared [pronoun omitted] had periods of apnea so I raised [pronoun omitted] head again. The PT [Physical Therapy] therapist arrived and told me that we needed to get [pronoun omitted] up in the chair. I was surprised, but [pronoun omitted] went on to say [pronoun omitted] was up yesterday and did well. However when [pronoun omitted] went to help me get [pronoun omitted] up [pronoun omitted] commented that there was a decline. I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, it was determined that the facility failed to complete a performance review of nurse aides at least every 12 months for 1 of 1 Licensed Nursing Assistant (LNA) reviewed for annual performances. Findings include: Review on 1/18/24 at 12:00 p.m. of Staff F's (LNA) employee record revealed they were hired on 8/18/22 and there was no documentation of a performance review. Interview on 1/18/24 at 2:00 p.m. with Staff A (Director of Nursing) confirmed that they had not been doing performance reviews every 12 months for LNAs.
Show the remaining 6 citations
- Potential for harm · D2024-01-19 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to ensure that any irregularities reported in residents' drug regimen review were acted upon by the attending physician for 1 of 5 residents reviewed for unnecessary medications (Resident Identifier is #40). Findings include: Review on 1/19/24 of Resident #40's pharmacy consultation report [drug regimen review], dated 12/6/23, revealed that Resident #40 was on Seroquel [antipsychotic] 75 mg [milligrams] by mouth once a day, Seroquel 100 mg by mouth in the evening, and Escitalopram 10 mg one time a day. Further review revealed a comment that CMS [Centers for Medicare & Medicaid Services] guidelines require periodic assessment for need and dose reduction to ensure the lowest effective dose and to decrease the chance of adverse effects. Review also revealed a recommendation that if this therapy is to continue with no changes, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual. There was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-19 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to ensure that the required 12 hours of in-service training was completed for 1of 1 (Licensed Nursing Assistant (LNA)) reviewed for required in-service training. Findings include: Review on 1/19/24 at 11:30 a.m. of Staff S's (LNA) Online Education Transcript Report revealed that Staff S did not contain the required education related to Dementia, Abuse Training, or a minimum of 12 hours of continuing competences for nurse aides. Interview on 1/19/24 at 12:00 with Staff A (Director of Nursing) confirmed the above findings. Review on 1/18/24 at 2:00 p.m. of the facility's policy titled Assessment, dated 2023, section B.2.Acuity-Care Requirements .4. Staff Competency: .3 .Required in-service training for nurse aides, which must be sufficient to ensure that continuing competence of nurse aides, but must be no less than 12 hours per year. Nurse aide training includes dementia management training and resident abuse prevention training. It also addresses areas of weakness as determined in nurse aide performance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-01-19 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility failed to provide the resident or the resident's representative with a written notice of transfer/discharge and also failed to send a copy of the written notice of transfer/discharge to the Long-Term Care (LTC) Ombudsman for 3 of 3 resident discharged records reviewed in a final sample of 22 residents (Resident identifiers are #28, #59, and #161). Findings include: Resident #59 Review on 1/19/24 of Resident #59's medical record revealed that Resident #59 was discharged from the facility on 11/2/23. There was no documentation of a written notice of transfer/discharge for the 11/2/23 discharge. Interview on 1/19/24 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that he/she was not aware that residents or residents' representatives are to be provided with written notice of transfer/discharge. Staff A also stated that there were no copies of written notice of transfer/discharge being sent to the LTC Ombudsman. Staff A was unable to provide evidence that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-01-19 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility failed to ensure that residents' records were complete and accurate for 2 residents in a final sample of 22 residents (Resident Identifiers are #59 and #111). Findings include: Resident #59 Review on 1/19/24 of Resident #59's medical record revealed that Resident #59 was discharged out of the facility on 11/2/23. Further review also revealed no documentation from staff or providers of Resident #59's discharge information or situation. Interview on 1/19/24 at approximately 12:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that Resident #59 went out with a friend, he/she did not come back from an outing, and after talking to the previous administrator on the phone, Resident #59 decided not to come back to the facility and left AMA [Against Medical Advice]. Review on 1/19/24 of Resident #59's progress notes revealed that there was no documentation of Resident #59's AMA. Interview on 1/19/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-11-01 · tag F0567 — failed to protect residents' money held by the home — patternHonor the resident's right to manage his or her financial affairs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility failed to ensure that residents had access to their funds on an ongoing basis for 1 of 4 residents reviewed for Resident Funds (Resident identifier is #1). Findings include: Review on 11/1/23 of the facility reported incident #45974 dated 10/9/23 revealed that Resident #1 on 10/9/23 was angry and frustrated with not being able to get access to his/her money prior to the staff person who buys cigarettes going on vacation. Resident #1 left the building with the intent to go to the store, but was agreeable to return to the facility and have another staff person purchase cigarettes. Review on 11/1/23 of the facilities policy titled RFMS [Resident Fund Management Service] Petty Cash Box revised December 2022 revealed, .Federal regulations . require residents to have access to petty cash on an ongoing basis and be able to arrange for access to larger funds (those in excess of $100). To be in compliance, each center will maintain an RFMS resident petty cash box and an after hours RFMS resident cash box . Recommended…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-11-01 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflect the resident's smoking status for 4 of 4 residents reviewed for smoking (Resident Identifiers are: #1, #2, #3, #4). Finding Include: Interview on 11/1/23 at 9:20 a.m. with Staff A (Unit Manager) revealed that Residents #1, #2, #3, and #4 were smokers. Resident #2 Interview on 11/1/23 at 9:45 a.m. with Resident #2 revealed that Resident #2 has been a smoker since his admission to the facility 11/25/21. Review on 11/1/23 of Resident #2's care plan dated 2/14/22 with a target date of 11/20/23 revealed a smoking plan of care. Review on 11/1/23 of Resident #2's Annual MDS with an Assessment Reference Date (ARD) of 11/30/22 revealed that under Section J1300 Current Tobacco Use was coded as 0 or No. Interview on 11/1/23 at 11:00 a.m. with Staff D (Director of Nursing) revealed that the MDS was coded incorrectly. Interview on 11/1/23 at 2:46 p.m. with Staff G (MDS Coordinator) confirmed that the above MDS was incorrectly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to 603 HEALTHCARE — 7 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.6 | +0.4 vs chain |
| Health inspection | 4 of 5 | 3.6 | +0.4 vs chain |
| Staffing | 4 of 5 | 3.6 | +0.4 vs chain |
| Quality measures | 2 of 5 | 3.0 | -1.0 vs chain |
The other 6 homes this chain runs (chain average 3.6★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BLACK MOUNTAIN PEAK HEALTHCARE, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 01/25/2024 |
| PR NH HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | since 02/19/2024 |
| RR NH HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 48% | since 02/19/2024 |
| 603 HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/29/2024 |
| AWEH, NELSON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2024 |
| SLATTERY, JESSICA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/01/2024 |
| STEVENSON, SEAN | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/29/2024 |
CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.
4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 77% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NH
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the New Hampshire Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 305083. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.