Cycle 1
Health 2024-11-21 · Fire 2024-11-21
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Derry, NH
Pleasant Valley Nursing and Rehab Center
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
8 Peabody Road, Derry, NH
(603) 434-1566
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.99
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
1.71
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,403
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9931
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.61
Baseline 21.18% · Performance 19.29% · Measure score 4.61 · Achievement 4.61 · Improvement 4.05
Healthcare-associated infections
5.68
Baseline 6.78% · Performance 6.14% · Measure score 5.68 · Achievement 5.68 · Improvement 3.10
Total nurse turnover
3.22
Performance 50.53% · Measure score 3.22 · Achievement 3.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.54
Baseline 3.47 hours · Performance 3.80 hours · Measure score 2.54 · Achievement 2.54 · Improvement 0.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.18% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 10.56% · Lower 95% interval 7.41% |
| Discharge to community | 59.1% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 122 · Observed rate 52.46% · Lower 95% interval 50.61% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 91 · Denominator 91 |
| Falls with major injury | 3.3% |
0.77%
2.5 pts worse
|
Numerator 3 · Denominator 91 |
| Discharge self-care score | 35.71% |
53.69%
18 pts worse
|
Numerator 25 · Denominator 70 |
| Discharge mobility score | 32.86% |
50.94%
18.1 pts worse
|
Numerator 23 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 2.2% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 91 · Adjusted rate 2.68% |
| Healthcare-associated infections requiring hospitalization | 6.14% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 3.66% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 2.42% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 124 |
| Staff flu vaccination coverage | 59.33% |
42%
17.3 pts better
|
Numerator 89 · Denominator 150 |
| Discharge function score | 27.14% |
56.45%
29.3 pts worse
|
Numerator 19 · Denominator 70 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 51 · Denominator 51 |
| 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 | 51.06% |
25.2%
25.9 pts better
|
Numerator 24 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.9
0.4 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 62.5% |
96.4%
33.9 pts worse
|
93.4%
30.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 62.9% · Q3 62.1% · Q4 58.1% · 4Q avg 62.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
98.0%
7.5 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
4.5%
0.5 pts better
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.6% · Q3 2.3% · Q4 3.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
9.7%
1.6 pts better
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.5% · Q3 15.2% · Q4 1.2% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.5%
0.6 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 6.0% · Q3 7.7% · Q4 1.6% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
18.9%
1.2 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 17.6% · Q3 21.5% · Q4 21.9% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.4% |
18.7%
8.7 pts worse
|
16.7%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 29.6% · Q3 26.4% · Q4 23.2% · 4Q avg 27.4% · 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 | 19.2% |
19.2%
About the same
|
16.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 16.9% · Q3 14.8% · Q4 18.1% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.9% |
21.9%
1 pts better
|
14.9%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.6% · Q2 25.8% · Q3 9.4% · Q4 7.9% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.3%
About the same
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.9% · Q3 1.2% · Q4 1.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.4%
1.1 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 2.3% · Q3 2.3% · Q4 2.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
26.7%
1.5 pts better
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 29.4% · Q3 19.2% · Q4 24.6% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.4%
1 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 2.2% · Q3 2.1% · Q4 4.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.7% |
85.6%
19.9 pts worse
|
81.7%
16 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.5% · Q2 74.3% · Q3 74.2% · Q4 65.1% · 4Q avg 65.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.8% |
14.1%
11.7 pts worse
|
12.0%
13.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 25.4% · Expected 11.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 3.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.1% |
83.0%
10.9 pts worse
|
79.7%
7.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.7% |
22.1%
4.6 pts worse
|
23.9%
2.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 22.4% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
12 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-02 · Fire 2022-12-02
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-12
E · Potential for more than minimal harm
2023-12-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-01
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-23
C · Minimal harm
2023-12-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-23
F · Potential for more than minimal harm
2022-12-02
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 2023-02-02
F · Potential for more than minimal harm
2022-12-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-02
E · Potential for more than minimal harm
2022-12-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-02
E · Potential for more than minimal harm
2022-12-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-02
D · Potential for more than minimal harm
2022-12-02
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 2023-02-02
D · Potential for more than minimal harm
2022-12-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-02
D · Potential for more than minimal harm
2022-12-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-02
D · Potential for more than minimal harm
2022-12-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-02
D · Potential for more than minimal harm
2022-12-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-02
C · Minimal harm
2022-12-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-02
C · Minimal harm
2022-12-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-02
C · Minimal harm
2022-12-02
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-02
B · Minimal harm
2022-12-02
K379 · Smoke Deficiencies
Fire Safety
Have proper openings in smoke barrier doors.
Corrected 2023-02-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-30
E · Potential for more than minimal harm
2023-12-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-12-21
E · Potential for more than minimal harm
2023-12-01
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-01-23
E · Potential for more than minimal harm
2023-12-01
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-12-28
E · Potential for more than minimal harm
2023-12-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-12-01
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-12-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-12-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-12-01
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-12-01
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 2023-12-21
D · Potential for more than minimal harm
2023-12-01
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 2023-12-21
D · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-22
B · Minimal harm
2023-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-21
E · Potential for more than minimal harm
2022-12-02
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-01-18
D · Potential for more than minimal harm
2022-12-02
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-02
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 2023-01-20
D · Potential for more than minimal harm
2022-12-02
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 2023-01-20
D · Potential for more than minimal harm
2022-12-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-01-20
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
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Derry Center For Rehabilitation And Healthcare
Derry, NH
1-star overall rating with 1-star inspections with Special Focus status with $69,219 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Warde Health Center
Windham, NH
5-star overall rating with 5-star inspections
#3
Holy Cross Health Center
Manchester, NH
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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