Cycle 1
Health 2025-08-14 · Fire 2025-08-14
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Salem, NH
Salemhaven
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
23 Geremonty Drive, Salem, NH
(603) 893-5586
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
110
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-01-01
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
0.75
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
2.43
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.47
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,043
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9996
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.63
Baseline 18.49% · Performance 19.75% · Measure score 3.63 · Achievement 3.63 · Improvement 0
Healthcare-associated infections
3.81
Baseline 7.20% · Performance 6.69% · Measure score 3.81 · Achievement 3.81 · Improvement 1.79
Total nurse turnover
6.34
Baseline 48.89% · Performance 37.76% · Measure score 6.34 · Achievement 6.34 · Improvement 4.13
Adjusted total nurse staffing
4.72
Baseline 4.83 hours · Performance 4.42 hours · Measure score 4.72 · Achievement 4.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.25% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 400 · Observed rate 11% · Lower 95% interval 8.63% |
| Discharge to community | 63.7% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 377 · Observed rate 57.29% · Lower 95% interval 57.19% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.21% |
95.27%
3.9 pts better
|
Numerator 251 · Denominator 253 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 253 |
| Discharge self-care score | 34.73% |
53.69%
19 pts worse
|
Numerator 58 · Denominator 167 |
| Discharge mobility score | 38.92% |
50.94%
12 pts worse
|
Numerator 65 · Denominator 167 |
| Pressure ulcers or injuries, new or worsened | 3.95% |
2.29%
1.7 pts worse
|
Numerator 10 · Denominator 253 · Adjusted rate 3.59% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 267 · Observed rate 5.62% · Lower 95% interval 4.33% |
| Staff COVID-19 vaccination coverage | 4.46% |
8.2%
3.7 pts worse
|
Numerator 7 · Denominator 157 |
| Staff flu vaccination coverage | 70.25% |
42%
28.2 pts better
|
Numerator 111 · Denominator 158 |
| Discharge function score | 45.51% |
56.45%
10.9 pts worse
|
Numerator 76 · Denominator 167 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 152 · Denominator 152 |
| Resident COVID-19 vaccinations up to date | 49.15% |
25.2%
23.9 pts better
|
Numerator 58 · Denominator 118 |
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 1.3 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.2% |
96.4%
21.2 pts worse
|
93.4%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.0% · Q2 83.3% · Q3 82.6% · Q4 57.7% · 4Q avg 75.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
4.5%
1.4 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.2% · Q3 2.9% · Q4 4.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
9.7%
9.7 pts better
|
11.4%
11.4 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 who lose too much weight | 3.0% |
5.5%
2.5 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 1.8% · Q4 5.3% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
18.9%
3.9 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 17.5% · Q3 16.9% · Q4 13.1% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
18.7%
0.2 pts worse
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 17.0% · Q3 14.3% · Q4 21.7% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.2%
0.1 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.5% |
19.2%
1.3 pts worse
|
16.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 19.9% · Q3 16.4% · Q4 12.9% · 4Q avg 20.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.8% |
21.9%
1.1 pts better
|
14.9%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 19.7% · Q3 20.7% · Q4 23.3% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.3%
0.1 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 3.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.4%
0.9 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 8.5% · Q3 1.5% · Q4 1.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.4% |
26.7%
0.7 pts worse
|
19.8%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 33.3% · Q3 23.4% · Q4 33.2% · 4Q avg 27.4% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
4.4%
3.6 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 9.0% · Q3 10.2% · Q4 7.0% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
85.6%
4.5 pts better
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.2% · Q2 92.7% · Q3 96.1% · Q4 93.8% · 4Q avg 90.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
14.1%
6 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 8.1% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.7%
1.1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
83.0%
16.2 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
22.1%
5 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 25.8% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-08 · Fire 2024-08-08
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-08-02 · Fire 2023-08-02
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-14
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 2025-09-30
D · Potential for more than minimal harm
2025-08-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-30
C · Minimal harm
2025-08-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-30
C · Minimal harm
2025-08-14
K913 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
Corrected 2025-09-30
D · Potential for more than minimal harm
2024-08-08
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-13
D · Potential for more than minimal harm
2023-08-02
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 2023-09-22
C · Minimal harm
2023-08-02
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-09-22
C · Minimal harm
2023-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-22
C · Minimal harm
2023-08-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-22
C · Minimal harm
2023-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-14
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 2025-08-28
D · Potential for more than minimal harm
2025-08-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-08-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-14
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 2025-09-09
D · Potential for more than minimal harm
2025-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-14
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 2025-09-30
B · Minimal harm
2025-08-14
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-09-30
E · Potential for more than minimal harm
2024-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-08
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 2024-09-11
B · Minimal harm
2024-08-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-10
B · Minimal harm
2024-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-12
B · Minimal harm
2024-08-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-08-12
E · Potential for more than minimal harm
2023-08-02
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 2023-08-23
E · Potential for more than minimal harm
2023-08-02
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 2023-09-01
Penalties and ownership
What sits behind the stars
Ownership
Covenant Health
Operational/Managerial Control · Organization
Milliard, Raymond
Corporate Director · Individual
Milliard, Raymond
Contracted Managing Employee · Individual
Murray-Potrin, Kathy
Corporate Director · Individual
Murray-Potrin, Kathy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Warde Health Center
Windham, NH
5-star overall rating with 5-star inspections
#2
Cedar View Rehabilitation And Healthcare Center
Methuen, MA
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#3
Nevins Nursing & Rehabilitation Center
Methuen, MA
1-star overall rating with 2-star inspections with $17,966 in total fines with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Jump out