Cycle 1
Health 2025-03-13 · Fire 2025-03-13
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Manchester, NH
Hackett Hill Healthcare Center
2-star overall rating with 1-star inspections with $12,735 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
191 Hackett Hill Road, Manchester, NH
(603) 668-8161
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1989-10-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
1.20
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.59
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.79
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.06
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,227
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.75
Baseline 21.15% · Performance 20.62% · Measure score 1.75 · Achievement 1.75 · Improvement 0.79
Healthcare-associated infections
1.70
Baseline 7.80% · Performance 7.33% · Measure score 1.70 · Achievement 1.70 · Improvement 1.18
Total nurse turnover
6.3
Baseline 28.07% · Performance 37.93% · Measure score 6.3 · Achievement 6.3 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.45 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 165 · Observed rate 13.33% · Lower 95% interval 8.16% |
| Discharge to community | 55.98% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 170 · Observed rate 47.65% · Lower 95% interval 47.19% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 145 · Denominator 145 |
| Falls with major injury | 1.38% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 145 |
| Discharge self-care score | 68% |
53.69%
14.3 pts better
|
Numerator 68 · Denominator 100 |
| Discharge mobility score | 59% |
50.94%
8.1 pts better
|
Numerator 59 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 1.38% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 145 · Adjusted rate 1.59% |
| Healthcare-associated infections requiring hospitalization | 7.33% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 8% · Lower 95% interval 4.82% |
| Staff COVID-19 vaccination coverage | 5.15% |
8.2%
3 pts worse
|
Numerator 5 · Denominator 97 |
| Staff flu vaccination coverage | 49.03% |
42%
7 pts better
|
Numerator 76 · Denominator 155 |
| Discharge function score | 66% |
56.45%
9.5 pts better
|
Numerator 66 · Denominator 100 |
| Transfer of health information to provider | 98.99% |
95.95%
3 pts better
|
Numerator 98 · Denominator 99 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 73.75% |
25.2%
48.5 pts better
|
Numerator 59 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.9
0.9 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · 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 | 5.6% |
4.5%
1.1 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.5% · Q3 4.4% · Q4 2.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.2% |
9.7%
3.5 pts worse
|
11.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.9% · Q3 18.2% · Q4 17.9% · 4Q avg 13.2% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.5%
1.3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.1% · Q3 4.8% · Q4 0.0% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
18.9%
9.9 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 30.4% · Q3 28.9% · Q4 28.6% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
18.7%
7.2 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 17.2% · Q3 6.9% · Q4 12.5% · 4Q avg 11.5% · 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 | 2.3% |
19.2%
16.9 pts better
|
16.3%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.6% · Q3 0.0% · Q4 4.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
21.9%
16.8 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.3% · Q3 6.7% · Q4 4.8% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.3%
0.6 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.4%
1.2 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.7% |
26.7%
22 pts better
|
19.8%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 11.0% · Q3 2.5% · Q4 2.6% · 4Q avg 4.7% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.4%
0.8 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.1% · Q3 5.4% · Q4 2.4% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
85.6%
13.3 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.4% · Q3 98.9% · Q4 98.3% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
14.1%
1.1 pts better
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 14.2% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.7%
1.3 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.0% |
83.0%
3 pts better
|
79.7%
6.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
22.1%
3.7 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 18.6% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-02 · Fire 2024-04-02
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-10 · Fire 2023-03-10
4 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-02
E · Potential for more than minimal harm
2023-03-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-10
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 2023-04-21
D · Potential for more than minimal harm
2023-03-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-21
C · Minimal harm
2023-03-10
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-04-21
Inspection history
Recent health citations
G · Actual harm
2025-12-17
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-11-14
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 2026-02-09
D · Potential for more than minimal harm
2025-03-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-22
D · Potential for more than minimal harm
2025-03-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-04-22
B · Minimal harm
2025-03-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-15
D · Potential for more than minimal harm
2024-04-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-04-02
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 2024-04-19
B · Minimal harm
2024-04-02
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-04-29
B · Minimal harm
2024-01-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-05-04
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-05-04
F560 · Resident Rights Deficiencies
Health
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-03-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-04-07
Penalties and ownership
What sits behind the stars
$12,735
2025-12-17
Fine
Fine · fine $12,735
Fine
Ownership
191 Hackett Hill Road Operations LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bridgeford, Laura
Corporate Officer · Individual
Cullerot, Elizabeth
Operational/Managerial Control · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Nh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Operations LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mendelson, Avi
Corporate Officer · Individual
Ojutalayo, Ayobami
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Courville At Manchester
Manchester, NH
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Mount Carmel Rehabilitation And Nursing Center
Manchester, NH
4-star overall rating with 4-star inspections with 2 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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