Cycle 1
Health 2025-02-04 · Fire 2025-02-04
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Epsom, NH
Epsom Healthcare Center
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
901 Suncook Valley Highway, Epsom, NH
(603) 736-4772
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-02-01
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
0.52
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.45
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
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,297
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9900
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.25
Baseline 19.10% · Performance 19.46% · Measure score 4.25 · Achievement 4.25 · Improvement 0
Healthcare-associated infections
3.50
Baseline 7.61% · Performance 6.79% · Measure score 3.50 · Achievement 3.50 · Improvement 2.65
Total nurse turnover
6.93
Baseline 35.48% · Performance 35.37% · Measure score 6.93 · Achievement 6.93 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.42 hours · Performance 3.2 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.29% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 7.98% · Lower 95% interval 7.05% |
| Discharge to community | 43.46% |
50.57%
7.1 pts worse
|
Worse than the National Rate · Eligible stays 150 · Observed rate 38.67% · Lower 95% interval 36.38% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 135 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 48.15% |
53.69%
5.5 pts worse
|
Numerator 52 · Denominator 108 |
| Discharge mobility score | 48.15% |
50.94%
2.8 pts worse
|
Numerator 52 · Denominator 108 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 3 · Denominator 135 · Adjusted rate 2.17% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 4.9% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 2.55% |
8.2%
5.6 pts worse
|
Numerator 4 · Denominator 157 |
| Staff flu vaccination coverage | 37.27% |
42%
4.7 pts worse
|
Numerator 41 · Denominator 110 |
| Discharge function score | 50.93% |
56.45%
5.5 pts worse
|
Numerator 55 · Denominator 108 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 59 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 20 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
96.4%
2.2 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 98.9% · Q4 97.8% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
98.0%
2.3 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
4.5%
2.6 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 9.3% · Q3 5.6% · Q4 6.7% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
9.7%
8.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 1.3% · Q4 1.3% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
5.5%
3.6 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.1% · Q3 9.6% · Q4 6.5% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
18.9%
8.6 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 11.1% · Q3 12.0% · Q4 9.1% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
18.7%
7.6 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.3% · Q3 8.3% · Q4 8.3% · 4Q avg 11.1% · 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 | 13.5% |
19.2%
5.7 pts better
|
16.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 12.8% · Q3 11.0% · Q4 7.4% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
21.9%
4.6 pts better
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 18.3% · Q3 15.3% · Q4 14.7% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
1.3%
0.9 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.7% · Q3 1.2% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.4%
0.4 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 2.3% · Q4 1.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
26.7%
2.6 pts better
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 26.7% · Q3 19.6% · Q4 24.8% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.4%
1.4 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.9% · Q3 3.0% · Q4 4.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
85.6%
8.4 pts worse
|
81.7%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 71.7% · Q3 72.3% · Q4 84.4% · 4Q avg 77.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
14.1%
0.3 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 13.5% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.7%
0.6 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.6% |
83.0%
11.4 pts worse
|
79.7%
8.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.1%
2.2 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 22.5% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-02-17 · Fire 2023-02-17
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-02-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-25
C · Minimal harm
2025-02-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-25
C · Minimal harm
2025-02-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-25
E · Potential for more than minimal harm
2024-03-07
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 2024-05-30
E · Potential for more than minimal harm
2024-03-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-30
D · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-30
C · Minimal harm
2024-03-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-30
E · Potential for more than minimal harm
2023-02-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-20
E · Potential for more than minimal harm
2023-02-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-02-17
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-04-20
D · Potential for more than minimal harm
2023-02-17
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 2023-04-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-13
D · Potential for more than minimal harm
2024-03-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-03-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-07
D · Potential for more than minimal harm
2023-06-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-02-17
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-02-19
E · Potential for more than minimal harm
2023-02-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-17
E · Potential for more than minimal harm
2023-02-17
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-02-19
D · Potential for more than minimal harm
2023-02-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-28
B · Minimal harm
2023-02-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-02-22
Penalties and ownership
What sits behind the stars
Ownership
Nh3 Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Bishop, Tammy
W-2 Managing Employee · Individual
Dwight Mortgage Trust LLC
5% Or Greater Security Interest · Organization
Esnh LLC
5% Or Greater Indirect Ownership Interest · Organization
Jpnh LLC
5% Or Greater Indirect Ownership Interest · Organization
Matera Health LLC
Operational/Managerial Control · Organization
Pepper, Yehuda
5% Or Greater Indirect Ownership Interest · Individual
Pepper, Yehuda
Operational/Managerial Control · Individual
Schwarcz, Elliot
5% Or Greater Indirect Ownership Interest · Individual
Schwarcz, Elliot
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Havenwood-Heritage Heights
Concord, NH
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Harris Hill Center, Genesis HealthCare
Concord, NH
2-star overall rating with 2-star inspections with $15,646 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Presidential Oaks
Concord, NH
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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