Cycle 1
Health 2025-08-07 · Fire 2025-08-07
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
North Conway, NH
Mineral Springs
1-star overall rating with 2-star inspections with $32,148 in total fines with 1 recent health deficiencies
1251 White Mountain Highway, North Conway, NH
(603) 356-7294
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
603 Healthcare
Operator or chain grouping
Approved since
1997-02-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 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
1.13
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
4.35
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.79
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
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
60%
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
12,822
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.99% · Performance 22.56% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.7
Baseline 8.15% · Performance 7.14% · Measure score 2.7 · Achievement 2.33 · Improvement 2.7
Total nurse turnover
0
Baseline 58.33% · Performance 69.70% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.41
Baseline 3.20 hours · Performance 3.48 hours · Measure score 1.41 · Achievement 1.41 · Improvement 0.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.18% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 107 · Observed rate 11.21% · Lower 95% interval 8.15% |
| Discharge to community | 48.82% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 45.35% · Lower 95% interval 39.02% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 50 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 38.89% |
53.69%
14.8 pts worse
|
Numerator 14 · Denominator 36 |
| Discharge mobility score | 25% |
50.94%
25.9 pts worse
|
Numerator 9 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 3 · Denominator 54 · Adjusted rate 6.93% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 42.47% |
8.2%
34.3 pts better
|
Numerator 31 · Denominator 73 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 36.11% |
56.45%
20.3 pts worse
|
Numerator 13 · Denominator 36 |
| Transfer of health information to provider | 85.19% |
95.95%
10.8 pts worse
|
Numerator 23 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.21% |
25.2%
3 pts better
|
Numerator 11 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.9
0.8 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.3 · Expected 1.4 · 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 | 95.9% |
98.0%
2.1 pts worse
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
4.5%
0.1 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.7% · Q3 4.7% · Q4 7.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.9% |
9.7%
11.2 pts worse
|
11.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 20.5% · Q3 32.4% · Q4 26.8% · 4Q avg 20.9% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.5%
1.4 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.6% · Q3 5.4% · Q4 2.8% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.4% |
18.9%
0.5 pts better
|
19.6%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 23.7% · Q3 13.5% · Q4 8.3% · 4Q avg 18.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.2% |
18.7%
9.5 pts worse
|
16.7%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 37.5% · Q3 33.3% · Q4 18.2% · 4Q avg 28.2% · 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 | 24.4% |
19.2%
5.2 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 30.8% · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.8% |
21.9%
4.9 pts worse
|
14.9%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 25.0% · Q3 17.6% · Q4 30.3% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
1.3%
0.1 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.4%
0.5 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 2.3% · Q3 0.0% · Q4 2.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
26.7%
2.1 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 41.5% · Q3 23.0% · Q4 32.9% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.4%
0.6 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.7% · Q3 3.6% · Q4 2.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
85.6%
1.7 pts better
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 52.9% · Q2 85.7% · Q3 98.1% · Q4 98.3% · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
14.1%
2.2 pts better
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.7% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.7%
About the same
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 2.8% · Q4 3.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.0% |
83.0%
7 pts better
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
22.1%
3.7 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 23.3% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-21 · Fire 2025-02-21
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2024-09-12 · Fire 2024-09-12
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-08
D · Potential for more than minimal harm
2025-02-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-08
F · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-09-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-09-12
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 2024-11-05
C · Minimal harm
2024-09-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-05
C · Minimal harm
2024-09-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-05
C · Minimal harm
2024-09-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-05
C · Minimal harm
2024-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-16
D · Potential for more than minimal harm
2025-02-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-04-05
D · Potential for more than minimal harm
2025-02-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-21
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 2025-03-18
D · Potential for more than minimal harm
2025-02-21
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 2025-03-28
D · Potential for more than minimal harm
2025-02-21
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 2025-03-27
F · Potential for more than minimal harm
2024-09-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-09-12
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-12
E · Potential for more than minimal harm
2024-09-12
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-10-05
E · Potential for more than minimal harm
2024-09-12
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 2024-11-04
D · Potential for more than minimal harm
2024-09-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-12
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 2024-11-01
D · Potential for more than minimal harm
2024-09-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-07
D · Potential for more than minimal harm
2024-09-12
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-09-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-09-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-10-12
D · Potential for more than minimal harm
2024-09-12
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 2024-10-25
C · Minimal harm
2024-09-12
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-10-23
J · Immediate jeopardy
2024-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-02-01
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-02-28
E · Potential for more than minimal harm
2023-11-08
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-08
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 2023-12-04
D · Potential for more than minimal harm
2023-11-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-04
D · Potential for more than minimal harm
2023-11-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-09
Penalties and ownership
What sits behind the stars
$16,801
2024-05-30
Fine
Fine · fine $16,801
Fine
$15,347
2023-09-13
Fine
Fine · fine $15,347
Fine
Ownership
Black Mountain Peak Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
603 Healthcare LLC
Operational/Managerial Control · Organization
Hernandez, Amanda
Operational/Managerial Control · Individual
Martin, Chris
Operational/Managerial Control · Individual
Pr Nh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Rausman, Philip
5% Or Greater Indirect Ownership Interest · Individual
Rausman, Robert
5% Or Greater Indirect Ownership Interest · Individual
Rr Nh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Stevenson, Sean
5% Or Greater Indirect Ownership Interest · Individual
Stevenson, Sean
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Merriman House
North Conway, NH
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Mountain View Community
Ossipee, NH
2-star overall rating with 2-star inspections with $101,192 in total fines with 3 recent health deficiencies
#3
Wolfeboro Bay Center
Wolfeboro, NH
2-star overall rating with 2-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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