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
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing
LPN hours / resident day
0.69
Licensed practical nurse staffing
Aide hours / resident day
2.07
Nurse aide staffing
Weekend hours
2.86
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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