Cycle 1
Health 2025-06-13 · Fire 2025-06-13
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Peterborough, NH
Pheasant Wood Center
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
50 Pheasant Road, Peterborough, NH
(603) 924-7267
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1996-08-20
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
0.45
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.29
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
2.89
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.32
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,050
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9908
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.16
Baseline 16.87% · Performance 20.43% · Measure score 2.16 · Achievement 2.16 · Improvement 0
Healthcare-associated infections
4.43
Baseline 6.17% · Performance 6.51% · Measure score 4.43 · Achievement 4.43 · Improvement 0
Total nurse turnover
8.44
Baseline 44.30% · Performance 29.17% · Measure score 8.44 · Achievement 8.44 · Improvement 7.28
Adjusted total nurse staffing
0
Baseline 3.15 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.42% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 11.69% · Lower 95% interval 7.22% |
| Discharge to community | 51.5% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 48.61% · Lower 95% interval 41.41% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.55% |
95.27%
0.7 pts worse
|
Numerator 52 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 60.42% |
53.69%
6.7 pts better
|
Numerator 29 · Denominator 48 |
| Discharge mobility score | 64.58% |
50.94%
13.6 pts better
|
Numerator 31 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 2.2% |
| Healthcare-associated infections requiring hospitalization | 6.51% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 3.7% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 1.08% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 93 |
| Staff flu vaccination coverage | 58.77% |
42%
16.8 pts better
|
Numerator 67 · Denominator 114 |
| Discharge function score | 68.75% |
56.45%
12.3 pts better
|
Numerator 33 · Denominator 48 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 38.46% |
25.2%
13.3 pts better
|
Numerator 10 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.9
1 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
96.4%
2.3 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 97.3% · Q4 98.6% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
98.0%
0.9 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
4.5%
1.3 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 1.2% · Q3 4.0% · Q4 2.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.3% |
9.7%
11.6 pts worse
|
11.4%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 22.4% · Q3 23.9% · Q4 10.9% · 4Q avg 21.3% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.5%
1.1 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 4.7% · Q4 9.4% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
18.9%
1.6 pts better
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 16.7% · Q3 16.2% · Q4 14.3% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
18.7%
2 pts better
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 16.0% · Q3 15.2% · Q4 16.7% · 4Q avg 16.7% · 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 | 19.8% |
19.2%
0.6 pts worse
|
16.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 21.6% · Q3 23.1% · Q4 22.0% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.3% |
21.9%
7.4 pts worse
|
14.9%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 16.9% · Q3 50.8% · Q4 34.3% · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.4%
2.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
26.7%
3.4 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 16.0% · Q3 27.0% · Q4 19.3% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.4%
1.9 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 3.3% · Q3 2.3% · Q4 2.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
85.6%
7.9 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 95.7% · Q3 94.1% · Q4 93.2% · 4Q avg 93.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
14.1%
0.1 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 13.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 | 23.0% |
22.1%
0.9 pts worse
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 19.4% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-04-14 · Fire 2023-04-14
9 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-05
D · Potential for more than minimal harm
2025-06-13
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 2025-08-05
D · Potential for more than minimal harm
2025-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-05
C · Minimal harm
2024-06-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-16
B · Minimal harm
2024-06-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-16
C · Minimal harm
2023-04-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-13
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 2025-08-06
D · Potential for more than minimal harm
2025-06-13
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-06-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-06-13
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 2025-08-06
D · Potential for more than minimal harm
2025-06-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-06-13
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 2025-08-06
B · Minimal harm
2025-06-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-06
E · Potential for more than minimal harm
2024-06-27
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 2024-07-31
D · Potential for more than minimal harm
2024-06-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-18
D · Potential for more than minimal harm
2024-06-27
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 2024-08-06
D · Potential for more than minimal harm
2024-06-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-08-08
B · Minimal harm
2024-06-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-16
D · Potential for more than minimal harm
2023-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-11-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-17
D · Potential for more than minimal harm
2023-04-14
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 2023-05-25
D · Potential for more than minimal harm
2023-04-14
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 2023-05-25
D · Potential for more than minimal harm
2023-04-14
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 2023-05-25
D · Potential for more than minimal harm
2023-04-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-05-25
B · Minimal harm
2023-04-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-25
B · Minimal harm
2023-04-14
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 2023-05-25
B · Minimal harm
2023-04-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-05-25
Penalties and ownership
What sits behind the stars
Ownership
Harborside New Hampshire Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Bilal, Haris
Operational/Managerial Control · Individual
Bridgeford, Laura
Corporate Officer · 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
Harborside Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Harborside Toledo Business LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Labrie, Nicholas
Operational/Managerial Control · Individual
Mendelson, Avi
Corporate Officer · Individual
Morris, Diane
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sunbridge Healthcare LLC
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
Jaffrey Rehabilitation And Nursing Center
Jaffrey, NH
1-star overall rating with 1-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Crestwood Center
Milford, NH
4-star overall rating with 3-star inspections with $15,646 in total fines with 3 recent health deficiencies
#3
The Elms Center
Milford, NH
1-star overall rating with 1-star inspections with $9,770 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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