Brentwood, NH

Rockingham County Nursing Home

4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

117 North Road, Brentwood, NH

(603) 679-5335

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

226

Certified beds

Average residents

135

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1995-11-11

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

0.70

Registered nurse staffing · state 0.74 · national 0.68

LPN hours / resident day

1.27

Licensed practical nurse staffing · state 0.76 · national 0.87

Aide hours / resident day

3.14

Nurse aide staffing · state 2.39 · national 2.35

Total nurse hours

5.11

All reported nurse hours · state 3.88 · national 3.89

Licensed hours

1.97

RN + LPN hours · state 1.49 · national 1.54

Weekend hours

4.49

Weekend nurse staffing · state 3.44 · national 3.43

Weekend RN hours

0.51

Weekend registered nurse coverage · state 0.51 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.82

CMS adjusted RN staffing hours

Adjusted total hours

5.99

CMS adjusted total nurse staffing hours

Case-mix index

1.17

Higher values indicate more complex resident acuity

RN turnover

58%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

61%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,516

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

56.03

Composite VBP score used to determine payment impact.

Payment multiplier

1.0111

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

10

Baseline 21.09% · Performance 16.97% · Measure score 10 · Achievement 10 · Improvement 9

Healthcare-associated infections

3.82

Baseline 7.04% · Performance 6.69% · Measure score 3.82 · Achievement 3.82 · Improvement 1.19

Total nurse turnover

0

Baseline 45.10% · Performance 63.09% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

8.59

Baseline 5.26 hours · Performance 5.52 hours · Measure score 8.59 · Achievement 8.59 · Improvement 4.55

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.97%	10.72% 1.8 pts better	No Different than the National Rate · Eligible stays 208 · Observed rate 6.25% · Lower 95% interval 6.42%
Discharge to community	53.67%	50.57% 3.1 pts better	No Different than the National Rate · Eligible stays 167 · Observed rate 50.3% · Lower 95% interval 45.69%
Medicare spending per beneficiary	0.83	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 112 · Denominator 112
Falls with major injury	0.89%	0.77% 0.1 pts worse	Numerator 1 · Denominator 112
Discharge self-care score	33.33%	53.69% 20.4 pts worse	Numerator 32 · Denominator 96
Discharge mobility score	50%	50.94% 0.9 pts worse	Numerator 48 · Denominator 96
Pressure ulcers or injuries, new or worsened	5.36%	2.29% 3.1 pts worse	Numerator 6 · Denominator 112 · Adjusted rate 5.37%
Healthcare-associated infections requiring hospitalization	6.69%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 122 · Observed rate 4.92% · Lower 95% interval 4.07%
Staff COVID-19 vaccination coverage	10.04%	8.2% 1.8 pts better	Numerator 27 · Denominator 269
Staff flu vaccination coverage	46.04%	42% 4 pts better	Numerator 122 · Denominator 265
Discharge function score	44.79%	56.45% 11.7 pts worse	Numerator 43 · Denominator 96
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 13 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	55.17%	25.2% 30 pts better	Numerator 32 · Denominator 58

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.4	1.6 0.8 pts worse	1.9 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.8 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.9 1.1 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.2%	96.4% 2.8 pts better	93.4% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.2% · Q3 99.2% · Q4 99.2% · 4Q avg 99.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.2%	98.0% 1.2 pts better	95.5% 3.7 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.2%
Percentage of long-stay residents experiencing one or more falls with major injury	4.4%	4.5% 0.1 pts better	3.3% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.8% · Q3 3.3% · Q4 4.7% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.9%	9.7% 7.8 pts better	11.4% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.7% · Q3 0.9% · Q4 1.6% · 4Q avg 1.9%
Percentage of long-stay residents who lose too much weight	6.0%	5.5% 0.5 pts worse	5.4% 0.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 8.9% · Q3 7.6% · Q4 4.2% · 4Q avg 6.0%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	26.0%	18.9% 7.1 pts worse	19.6% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 26.9% · Q3 28.9% · Q4 23.2% · 4Q avg 26.0%
Percentage of long-stay residents who received an antipsychotic medication	21.5%	18.7% 2.8 pts worse	16.7% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 24.1% · Q3 21.5% · Q4 21.8% · 4Q avg 21.5% · 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	20.7%	19.2% 1.5 pts worse	16.3% 4.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 21.1% · Q3 27.5% · Q4 14.1% · 4Q avg 20.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	23.9%	21.9% 2 pts worse	14.9% 9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 26.3% · Q3 27.5% · Q4 18.1% · 4Q avg 23.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	1.3% 1.1 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.4%	2.4% 1 pts better	1.7% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.5% · Q3 0.9% · Q4 0.8% · 4Q avg 1.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	34.1%	26.7% 7.4 pts worse	19.8% 14.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 37.8% · Q3 33.6% · Q4 30.7% · 4Q avg 34.1%
Percentage of long-stay residents with pressure ulcers	3.2%	4.4% 1.2 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.8% · Q3 3.0% · Q4 3.8% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.4%	85.6% 4.8 pts better	81.7% 8.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 94.5% · Q3 90.6% · Q4 90.0% · 4Q avg 90.4%
Percentage of short-stay residents who had an outpatient emergency department visit	19.6%	14.1% 5.5 pts worse	12.0% 7.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 17.7% · Expected 10.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.1%	1.7% 0.4 pts worse	1.6% 0.5 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 5.4% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	59.6%	83.0% 23.4 pts worse	79.7% 20.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 59.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.8%	22.1% 3.3 pts better	23.9% 5.1 pts better	Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 14.6% · Expected 18.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-28 · Fire 2025-08-28

4 health deficiencies

Top issue: Infection Control (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-08-22 · Fire 2024-08-22

0 health deficiencies

No concentrated health issue counts in this cycle.

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-07-12 · Fire 2023-07-12

0 health deficiencies

No concentrated health issue counts in this cycle.

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-08-28

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 2025-10-20

D · Potential for more than minimal harm 2025-08-28

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 2025-10-20

C · Minimal harm 2025-08-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-10-20

D · Potential for more than minimal harm 2023-07-12

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-07-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-28

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-10-20

D · Potential for more than minimal harm 2025-08-28

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 2025-10-20

D · Potential for more than minimal harm 2025-08-28

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 2025-10-20

D · Potential for more than minimal harm 2025-08-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-20

Penalties and ownership

What sits behind the stars

Ownership

County Of Rockingham

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 1970-01-01

Bourbeau, Bruce