Cycle 1
Health 2024-12-18 · Fire 2024-12-18
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Berlin, NH
Coos County Nursing Home
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
364 Cates Hill Rd Po Box 416, Berlin, NH
(603) 752-2343
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
77
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-04-30
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
0.88
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
3.07
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.67
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
96%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
92%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,142
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9990
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.34
Performance 18.49% · Measure score 6.34 · Achievement 6.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.81
Baseline 5.83% · Performance 6.69% · Measure score 3.81 · Achievement 3.81 · Improvement 0
Total nurse turnover
2.27
Baseline 44.66% · Performance 54.40% · Measure score 2.27 · Achievement 2.27 · Improvement 0
Adjusted total nurse staffing
5.88
Baseline 5.34 hours · Performance 4.75 hours · Measure score 5.88 · Achievement 5.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.55% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 7.69% · Lower 95% interval 6.52% |
| Discharge to community | 70.55% |
50.57%
20 pts better
|
Better than the National Rate · Eligible stays 61 · Observed rate 72.13% · Lower 95% interval 55.78% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 37.14% |
53.69%
16.5 pts worse
|
Numerator 13 · Denominator 35 |
| Discharge mobility score | 51.43% |
50.94%
0.5 pts better
|
Numerator 18 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 4.88% |
2.29%
2.6 pts worse
|
Numerator 2 · Denominator 41 · Adjusted rate 4.38% |
| Healthcare-associated infections requiring hospitalization | 6.7% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 22.14% |
8.2%
13.9 pts better
|
Numerator 31 · Denominator 140 |
| Staff flu vaccination coverage | 53.5% |
42%
11.5 pts better
|
Numerator 107 · Denominator 200 |
| Discharge function score | 51.43% |
56.45%
5 pts worse
|
Numerator 18 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.36% |
25.2%
11.2 pts better
|
Numerator 8 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.9
1.2 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
96.4%
3.3 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 8.2% |
4.5%
3.7 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 10.4% · Q3 9.3% · Q4 4.1% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
9.7%
6.1 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 7.7% · Q4 4.3% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
5.5%
4 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 8.5% · Q3 12.0% · Q4 6.8% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.2% |
18.9%
11.3 pts worse
|
19.6%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 26.3% · Q3 32.0% · Q4 32.4% · 4Q avg 30.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.3% |
18.7%
6.6 pts worse
|
16.7%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 23.4% · Q3 25.8% · Q4 26.6% · 4Q avg 25.3% · 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 | 22.9% |
19.2%
3.7 pts worse
|
16.3%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 22.5% · Q3 20.6% · Q4 27.2% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
21.9%
3.1 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 38.1% · Q3 16.1% · Q4 23.0% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.3%
0.3 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 0.0% · Q4 1.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
2.4%
3.6 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 4.2% · Q3 5.3% · Q4 5.4% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
26.7%
4.9 pts better
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 21.8% · Q3 27.9% · Q4 14.5% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
4.4%
3.1 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.2% · Q3 4.6% · Q4 11.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
85.6%
12.9 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
14.1%
1.4 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
22.1%
4.1 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 15.6% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-08 · Fire 2023-12-08
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-10
C · Minimal harm
2022-11-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-09
C · Minimal harm
2022-11-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-18
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-27
D · Potential for more than minimal harm
2024-12-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-29
D · Potential for more than minimal harm
2023-12-08
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-12-08
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
2022-11-03
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-11-22
D · Potential for more than minimal harm
2022-11-03
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 2022-11-25
D · Potential for more than minimal harm
2022-11-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-11-29
Penalties and ownership
What sits behind the stars
Ownership
Beede, Lynn
Operational/Managerial Control · Individual
Brady, Thomas
Operational/Managerial Control · Individual
Fish, Jennifer
Operational/Managerial Control · Individual
Gorman, Raymond
Operational/Managerial Control · Individual
Theberge, Robert
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Saint Vincent Rehabilitation & Nursing Center
Berlin, NH
1-star overall rating with 1-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Country Village Center, Genesis Healthcare
Lancaster, NH
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Morrison Nursing Home
Whitefield, NH
1-star overall rating with 1-star inspections with $73,340 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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