Berlin, NH

Saint Vincent Rehabilitation & Nursing Center

1-star overall rating with 1-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

29 Providence Avenue, Berlin, NH

(603) 752-1820

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Catholic Charities New Hampshire

Operator or chain grouping

Approved since

1996-04-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

6 facilities

Chain averages 4 overall / 4 health / 4 staffing / 3 quality stars

Changed ownership

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

0.57

Registered nurse staffing · state 0.74 · national 0.68

LPN hours / resident day

0.59

Licensed practical nurse staffing · state 0.76 · national 0.87

Aide hours / resident day

2.44

Nurse aide staffing · state 2.39 · national 2.35

Total nurse hours

3.60

All reported nurse hours · state 3.88 · national 3.89

Licensed hours

1.16

RN + LPN hours · state 1.49 · national 1.54

Weekend hours

3.15

Weekend nurse staffing · state 3.44 · national 3.43

Weekend RN hours

0.49

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

0.74

CMS adjusted RN staffing hours

Adjusted total hours

4.66

CMS adjusted total nurse staffing hours

Case-mix index

1.06

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 45% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,585

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

Performance score

23.21

Composite VBP score used to determine payment impact.

Payment multiplier

0.9831

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

Baseline 58.21% · Performance 65.15% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

4.64

Baseline 4.97 hours · Performance 4.40 hours · Measure score 4.64 · Achievement 4.64 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.46%	10.72% 1.3 pts better	No Different than the National Rate · Eligible stays 49 · Observed rate 2.04% · Lower 95% interval 6.18%
Discharge to community	40.61%	50.57% 10 pts worse	No Different than the National Rate · Eligible stays 35 · Observed rate 31.43% · Lower 95% interval 28.57%
Medicare spending per beneficiary	1.22	1.02 0.2 pts worse
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	100%	8.2% 91.8 pts better	Numerator 122 · Denominator 122
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	1.6 0.2 pts worse	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.1 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.0	1.9 1.1 pts worse	1.8 1.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.2 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	97.5%	96.4% 1.1 pts better	93.4% 4.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 97.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.3%	98.0% 0.3 pts better	95.5% 2.8 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3%
Percentage of long-stay residents experiencing one or more falls with major injury	6.2%	4.5% 1.7 pts worse	3.3% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.2% · Q3 9.7% · Q4 6.5% · 4Q avg 6.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.4%	9.7% 9.3 pts better	11.4% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who lose too much weight	8.4%	5.5% 2.9 pts worse	5.4% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 9.4% · Q3 15.8% · Q4 6.8% · 4Q avg 8.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.8%	18.9% 0.9 pts worse	19.6% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 15.8% · Q3 19.7% · Q4 24.2% · 4Q avg 19.8%
Percentage of long-stay residents who received an antipsychotic medication	5.3%	18.7% 13.4 pts better	16.7% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.2% · Q3 5.3% · Q4 1.9% · 4Q avg 5.3% · 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	12.5%	19.2% 6.7 pts better	16.3% 3.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 13.9% · Q3 8.9% · Q4 9.7% · 4Q avg 12.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.2%	21.9% 2.7 pts better	14.9% 4.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 19.2% · Q3 16.4% · Q4 10.9% · 4Q avg 19.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.8%	1.3% 0.5 pts worse	1.0% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.7% · Q3 1.4% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.9%	2.4% 1.5 pts worse	1.7% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 5.5% · Q3 6.9% · Q4 1.7% · 4Q avg 3.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.9%	26.7% 7.8 pts better	19.8% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 12.9% · Q3 20.6% · Q4 21.2% · 4Q avg 18.9%
Percentage of long-stay residents with pressure ulcers	4.7%	4.4% 0.3 pts worse	5.1% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.1% · Q3 4.2% · Q4 4.1% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	67.4%	85.6% 18.2 pts worse	81.7% 14.3 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 67.4%
Percentage of short-stay residents who had an outpatient emergency department visit	33.6%	14.1% 19.5 pts worse	12.0% 21.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 33.6% · Observed 28.0% · Expected 9.3% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	10.5%	22.1% 11.6 pts better	23.9% 13.4 pts better	Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 8.0% · Expected 18.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-19 · Fire 2025-06-19

6 health deficiencies

Top issue: Infection Control (2 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-05-07 · Fire 2024-05-07

6 health deficiencies

Top issue: Infection Control (2 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 3 Health 2023-06-13 · Fire 2023-06-13

12 health deficiencies

Top issue: Nursing and Physician Services (4 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-06-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-06-19

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-08-15

D · Potential for more than minimal harm 2025-06-19

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-08-15

C · Minimal harm 2025-06-19

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-08-15

F · Potential for more than minimal harm 2024-05-07

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-07-01

F · Potential for more than minimal harm 2024-05-07

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-07-01

D · Potential for more than minimal harm 2024-05-07

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-07-01

D · Potential for more than minimal harm 2024-05-07

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-07-01

C · Minimal harm 2024-05-07

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-07-01

C · Minimal harm 2024-05-07

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-07-01

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-19

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 2025-07-25

D · Potential for more than minimal harm 2025-06-19

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-07-23

D · Potential for more than minimal harm 2025-06-19

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-06-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-25

D · Potential for more than minimal harm 2025-06-19

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-07-21

B · Minimal harm 2025-06-19

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2025-07-25

E · Potential for more than minimal harm 2024-05-07

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 2024-06-16

E · Potential for more than minimal harm 2024-05-07

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-07-08

D · Potential for more than minimal harm 2024-05-07

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-06-26

D · Potential for more than minimal harm 2024-05-07

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-05-30

B · Minimal harm 2024-05-07

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-06-21

B · Minimal harm 2024-05-07

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2024-06-18

E · Potential for more than minimal harm 2023-11-29

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 2023-12-21

E · Potential for more than minimal harm 2023-11-29

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 2023-11-30

D · Potential for more than minimal harm 2023-11-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-29

C · Minimal harm 2023-11-29

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-01-12

E · Potential for more than minimal harm 2023-09-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-29

D · Potential for more than minimal harm 2023-08-08

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 2023-09-19

D · Potential for more than minimal harm 2023-08-08

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-09-19

E · Potential for more than minimal harm 2023-06-13

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 2023-07-14

E · Potential for more than minimal harm 2023-06-13

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 2023-07-10

D · Potential for more than minimal harm 2023-06-13

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-07-10

D · Potential for more than minimal harm 2023-06-13

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-07-14

C · Minimal harm 2023-06-13

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2023-07-10

Penalties and ownership

What sits behind the stars

Ownership

Nh Catholic Charities Inc

5% Or Greater Direct Ownership Interest · Organization

100% 7 facilities 1990-01-01

Barrett, Kevin