Cycle 1
Health 2025-08-21 · Fire 2025-08-21
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bedford, NH
Bedford Hills Center
3-star overall rating with 4-star inspections with $16,452 in total fines with 1 fire-safety deficiencies in the latest cycle
30 Colby Court, Bedford, NH
(603) 625-6462
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
147
Certified beds
Average residents
137
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
603 Healthcare
Operator or chain grouping
Approved since
1996-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.30
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,440
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.58% · Performance 22.88% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.31% · Performance 8.76% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.09
Baseline 60.78% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 4.49
Adjusted total nurse staffing
1.61
Baseline 3.43 hours · Performance 3.54 hours · Measure score 1.61 · Achievement 1.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.32% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 202 · Observed rate 11.88% · Lower 95% interval 8.88% |
| Discharge to community | 46.35% |
50.57%
4.2 pts worse
|
No Different than the National Rate · Eligible stays 159 · Observed rate 39.62% · Lower 95% interval 40.16% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 90.76% |
95.27%
4.5 pts worse
|
Numerator 108 · Denominator 119 |
| Falls with major injury | 1.68% |
0.77%
0.9 pts worse
|
Numerator 2 · Denominator 119 |
| Discharge self-care score | 31.51% |
53.69%
22.2 pts worse
|
Numerator 23 · Denominator 73 |
| Discharge mobility score | 38.36% |
50.94%
12.6 pts worse
|
Numerator 28 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 4.2% |
2.29%
1.9 pts worse
|
Numerator 5 · Denominator 119 · Adjusted rate 4.09% |
| Healthcare-associated infections requiring hospitalization | 8.76% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 117 · Observed rate 10.26% · Lower 95% interval 5.73% |
| Staff COVID-19 vaccination coverage | 24.86% |
8.2%
16.7 pts better
|
Numerator 43 · Denominator 173 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 47.95% |
56.45%
8.5 pts worse
|
Numerator 35 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 51.52% |
25.2%
26.3 pts better
|
Numerator 34 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
96.4%
0.1 pts worse
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 94.4% · Q3 97.5% · Q4 99.1% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
98.0%
1.3 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
4.5%
0.8 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.3% · Q3 6.6% · Q4 5.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
9.7%
2.7 pts better
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.4% · Q3 6.4% · Q4 5.3% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.5%
1.6 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 7.2% · Q3 3.3% · Q4 2.2% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.0% |
18.9%
9.1 pts worse
|
19.6%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 26.7% · Q3 27.6% · Q4 33.7% · 4Q avg 28.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.8% |
18.7%
7.1 pts worse
|
16.7%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 29.3% · Q3 22.8% · Q4 24.1% · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.6% |
19.2%
1.4 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 15.0% · Q3 24.0% · Q4 20.0% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
21.9%
3.2 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 25.7% · Q3 21.9% · Q4 24.5% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.3%
1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
2.4%
2.1 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 7.6% · Q3 1.7% · Q4 4.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
26.7%
0.5 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 26.6% · Q3 22.7% · Q4 27.7% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.4%
0.1 pts better
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.8% · Q3 3.2% · Q4 3.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.5% |
85.6%
15.1 pts worse
|
81.7%
11.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.5% · Q2 77.8% · Q3 84.5% · Q4 66.1% · 4Q avg 70.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
14.1%
1.5 pts better
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 13.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.7%
2.2 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.8% · Q3 1.8% · Q4 3.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
83.0%
3.4 pts worse
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
22.1%
0.1 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 21.2% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-31 · Fire 2024-07-31
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2025-08-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-05
D · Potential for more than minimal harm
2023-06-29
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-27
C · Minimal harm
2023-06-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-27
C · Minimal harm
2023-06-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-27
C · Minimal harm
2023-06-29
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-07-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-09
D · Potential for more than minimal harm
2024-07-31
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-07-31
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2024-08-28
B · Minimal harm
2024-07-31
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-16
B · Minimal harm
2024-07-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-21
J · Immediate jeopardy
2024-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-02
D · Potential for more than minimal harm
2023-06-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-06-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-26
Penalties and ownership
What sits behind the stars
$16,452
2024-05-22
Fine
Fine · fine $16,452
Fine
Ownership
Black Mountain Peak Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
603 Healthcare LLC
Operational/Managerial Control · Organization
Forrence, Heidi
Operational/Managerial Control · Individual
Ojutalayo, Ayobami
Operational/Managerial Control · Individual
Pr Nh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Rausman, Philip
5% Or Greater Indirect Ownership Interest · Individual
Rausman, Robert
5% Or Greater Indirect Ownership Interest · Individual
Rr Nh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Stevenson, Sean
5% Or Greater Indirect Ownership Interest · Individual
Stevenson, Sean
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Ridgewood Center, Genesis HealthCare
Bedford, NH
2-star overall rating with 2-star inspections with $15,646 in total fines with 5 recent health deficiencies
#2
Bedford Nursing & Rehabilitation Center
Bedford, NH
2-star overall rating with 1-star inspections with Special Focus status with $24,850 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Maple Leaf Health Care Center
Manchester, NH
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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