Cycle 1
Health 2025-12-17 · Fire 2025-12-17
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bedford, NH
Bedford Nursing & Rehabilitation Center
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
480 Donald Street, Bedford, NH
(603) 627-4147
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.53
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,603
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9966
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.01
Baseline 19.38% · Performance 18.18% · Measure score 7.01 · Achievement 7.01 · Improvement 4.59
Healthcare-associated infections
6.23
Baseline 5.96% · Performance 5.97% · Measure score 6.23 · Achievement 6.23 · Improvement 0
Total nurse turnover
3.35
Baseline 35.13% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
0.84
Baseline 4.78 hours · Performance 3.32 hours · Measure score 0.84 · Achievement 0.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 162 · Observed rate 9.88% · Lower 95% interval 7.54% |
| Discharge to community | 54.02% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 157 · Observed rate 50.32% · Lower 95% interval 46.52% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 107 · Denominator 107 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 107 |
| Discharge self-care score | 49.4% |
53.69%
4.3 pts worse
|
Numerator 41 · Denominator 83 |
| Discharge mobility score | 53.01% |
50.94%
2.1 pts better
|
Numerator 44 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 2.8% |
2.29%
0.5 pts worse
|
Numerator 3 · Denominator 107 · Adjusted rate 2.77% |
| Healthcare-associated infections requiring hospitalization | 5.97% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 3.74% · Lower 95% interval 3.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 34.26% |
42%
7.7 pts worse
|
Numerator 37 · Denominator 108 |
| Discharge function score | 61.45% |
56.45%
5 pts better
|
Numerator 51 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 77 · Denominator 77 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 19.4% |
25.2%
5.8 pts worse
|
Numerator 13 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.9
1 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.4%
3.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
4.5%
2.3 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.0% · Q3 1.4% · Q4 3.1% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
9.7%
7 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.1% · Q3 2.9% · Q4 3.4% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.5%
3.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 1.8% · Q4 3.5% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
18.9%
2.1 pts better
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 18.3% · Q3 18.3% · Q4 15.0% · 4Q avg 16.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
18.7%
12.7 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 6.1% · Q3 5.7% · Q4 6.0% · 4Q avg 6.0% · 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 | 14.5% |
19.2%
4.7 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 18.4% · Q3 12.9% · Q4 15.7% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
21.9%
13.9 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.0% · Q3 3.4% · Q4 14.5% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.4%
2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.2% |
26.7%
2.5 pts better
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 23.4% · Q3 25.6% · Q4 19.6% · 4Q avg 24.2% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.4%
About the same
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.9% · Q3 6.3% · Q4 5.6% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
85.6%
13.4 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.6% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
14.1%
4.4 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 8.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.7%
1.4 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
83.0%
17 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
22.1%
2.9 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 16.8% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-03 · Fire 2024-10-03
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-12-15 · Fire 2023-12-15
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-09
D · Potential for more than minimal harm
2024-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-22
C · Minimal harm
2024-10-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-22
D · Potential for more than minimal harm
2023-12-15
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 2024-01-15
C · Minimal harm
2023-12-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-15
C · Minimal harm
2023-12-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-15
Inspection history
Recent health citations
J · Immediate jeopardy
2025-12-17
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-12-17
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-12-17
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 2026-01-02
D · Potential for more than minimal harm
2025-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-07
D · Potential for more than minimal harm
2024-10-03
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 2024-10-28
D · Potential for more than minimal harm
2024-10-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-28
B · Minimal harm
2024-10-03
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-10-28
D · Potential for more than minimal harm
2023-12-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-01-09
D · Potential for more than minimal harm
2023-12-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-15
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 2024-01-10
D · Potential for more than minimal harm
2023-12-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-15
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-05
Penalties and ownership
What sits behind the stars
$24,850
2025-12-17
Fine
Fine · fine $24,850
Fine
Ownership
Woh LLC
5% Or Greater Direct Ownership Interest · Organization
603 Healthcare LLC
Operational/Managerial Control · Organization
Aggcp LLC
5% Or Greater Indirect Ownership Interest · Organization
Auletto, Amy
Operational/Managerial Control · Individual
Black Mountain Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Goldstein, Avrohom
5% Or Greater Indirect Ownership Interest · Individual
Mad Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Natr Trust
5% Or Greater Indirect Ownership Interest · Organization
Pasha, Muhammad
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
Zmry LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Bedford Hills Center
Bedford, NH
3-star overall rating with 4-star inspections with $16,452 in total fines with 1 fire-safety deficiencies in the latest cycle
#2
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
#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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