Cycle 1
Health 2025-04-16 · Fire 2025-04-16
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Jaffrey, NH
Jaffrey Rehabilitation And Nursing Center
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
20 Plantation Drive, Jaffrey, NH
(603) 532-8762
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ephram Lahasky
Operator or chain grouping
Approved since
1996-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
28 facilities
Chain averages 2 overall / 2 health / 2 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
0.77
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,987
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.08
Performance 18.15% · Measure score 7.08 · Achievement 7.08 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.61
Baseline 6.10% · Performance 7.05% · Measure score 2.61 · Achievement 2.61 · Improvement 0
Total nurse turnover
0
Baseline 48.53% · Performance 64.52% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.57
Baseline 4.01 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.53% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 14.46% · Lower 95% interval 8.58% |
| Discharge to community | 47.23% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 43.66% · Lower 95% interval 39.69% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 56 · Denominator 56 |
| Falls with major injury | 7.14% |
0.77%
6.4 pts worse
|
Numerator 4 · Denominator 56 |
| Discharge self-care score | 48.65% |
53.69%
5 pts worse
|
Numerator 18 · Denominator 37 |
| Discharge mobility score | 48.65% |
50.94%
2.3 pts worse
|
Numerator 18 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 2 · Denominator 56 · Adjusted rate 3.17% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 8.14% |
8.2%
0.1 pts worse
|
Numerator 7 · Denominator 86 |
| Staff flu vaccination coverage | 40.95% |
42%
1 pts worse
|
Numerator 43 · Denominator 105 |
| Discharge function score | 40.54% |
56.45%
15.9 pts worse
|
Numerator 15 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 14 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.6
0.7 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.3 |
1.9
2.4 pts worse
|
1.8
2.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.2% |
96.4%
23.2 pts worse
|
93.4%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.4% · Q2 72.7% · Q3 85.0% · Q4 92.1% · 4Q avg 73.2% |
| 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 | 6.0% |
4.5%
1.5 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.3% · Q3 5.0% · Q4 6.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 32.0% |
9.7%
22.3 pts worse
|
11.4%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.4% · Q3 35.3% · Q4 70.7% · 4Q avg 32.0% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.5%
2.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 4.2% · Q3 13.0% · Q4 0.0% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.5% |
18.9%
12.6 pts worse
|
19.6%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 26.0% · Q3 36.4% · Q4 33.9% · 4Q avg 31.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
18.7%
1.1 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 19.4% · Q3 13.3% · Q4 20.8% · 4Q avg 17.6% · 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 | 22.7% |
19.2%
3.5 pts worse
|
16.3%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 38.9% · Q3 18.9% · Q4 2.7% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
21.9%
0.4 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 29.2% · Q3 17.0% · Q4 10.9% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.3%
0.9 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.4%
0.6 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.7% · Q3 3.3% · Q4 1.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
26.7%
0.3 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 39.8% · Q3 19.0% · Q4 29.0% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.4%
1.5 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 4.1% · Q3 5.5% · Q4 3.6% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.9% |
85.6%
32.7 pts worse
|
81.7%
28.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 44.9% · Q3 65.3% · Q4 69.6% · 4Q avg 52.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 28.1% |
14.1%
14 pts worse
|
12.0%
16.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 24.6% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.7%
1.1 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 3.0% · Q4 3.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.8% |
83.0%
10.2 pts worse
|
79.7%
6.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
22.1%
4.1 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 22.8% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-26 · Fire 2024-04-26
5 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-04-13 · Fire 2023-04-13
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-01
E · Potential for more than minimal harm
2024-04-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-11
C · Minimal harm
2024-04-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-11
C · Minimal harm
2024-04-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-11
D · Potential for more than minimal harm
2023-04-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-16
C · Minimal harm
2023-04-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-16
C · Minimal harm
2023-04-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-16
C · Minimal harm
2023-04-13
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-05-16
C · Minimal harm
2023-04-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-04-16
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-04-16
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-04-16
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 2025-05-07
D · Potential for more than minimal harm
2025-04-16
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 2025-05-12
D · Potential for more than minimal harm
2025-04-16
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 2025-05-11
D · Potential for more than minimal harm
2025-04-16
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 2025-04-16
B · Minimal harm
2025-04-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-08
E · Potential for more than minimal harm
2024-04-26
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 2024-05-24
E · Potential for more than minimal harm
2024-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-29
E · Potential for more than minimal harm
2024-04-26
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-26
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-05-17
E · Potential for more than minimal harm
2023-04-13
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 2023-04-28
E · Potential for more than minimal harm
2023-04-13
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 2023-05-01
E · Potential for more than minimal harm
2023-04-13
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-14
B · Minimal harm
2023-04-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-25
Penalties and ownership
What sits behind the stars
Ownership
Lahasky, Ephram
5% Or Greater Direct Ownership Interest · Individual
Lahasky, Ephram
Operational/Managerial Control · Individual
Wilkins, Barbara
W-2 Managing Employee · Individual
Nearby options
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2-star overall rating with 2-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
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Baldwinville, MA
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Alpine Healthcare Center
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1-star overall rating with 1-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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