Cycle 1
Health 2025-12-11 · Fire 2025-12-11
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Unity, NH
Sullivan County Health Care
1-star overall rating with 2-star inspections with $16,153 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5 Nursing Home Drive, Unity, NH
(603) 542-9511
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
156
Certified beds
Average residents
125
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-09-15
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
13%
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
1,928
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0076
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
2.37
Baseline 38.02% · Performance 53.99% · Measure score 2.37 · Achievement 2.37 · Improvement 0
Adjusted total nurse staffing
8.22
Baseline 4.55 hours · Performance 5.42 hours · Measure score 8.22 · Achievement 8.22 · Improvement 6.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 8.33% · Lower 95% interval 6.49% |
| Discharge to community | 45.74% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 38.24% · Lower 95% interval 31.81% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 28.95% |
95.27%
66.3 pts worse
|
Numerator 11 · Denominator 38 |
| Falls with major injury | 7.89% |
0.77%
7.1 pts worse
|
Numerator 3 · Denominator 38 |
| Discharge self-care score | 34.48% |
53.69%
19.2 pts worse
|
Numerator 10 · Denominator 29 |
| Discharge mobility score | 37.93% |
50.94%
13 pts worse
|
Numerator 11 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 2.63% |
2.29%
0.3 pts worse
|
Numerator 1 · Denominator 38 · Adjusted rate 2.31% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 11.06% |
8.2%
2.9 pts better
|
Numerator 23 · Denominator 208 |
| Staff flu vaccination coverage | 51.94% |
42%
9.9 pts better
|
Numerator 107 · Denominator 206 |
| Discharge function score | 34.48% |
56.45%
22 pts worse
|
Numerator 10 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
96.4%
5.1 pts worse
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 94.2% · Q3 91.5% · Q4 86.7% · 4Q avg 91.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
98.0%
6.6 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| 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 4.8% · Q2 3.3% · Q3 6.0% · Q4 3.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
9.7%
8.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 1.1% · Q4 1.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.5%
1.5 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.2% · Q3 2.7% · Q4 2.6% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
18.9%
4.3 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 15.3% · Q3 19.3% · Q4 14.5% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.8% |
18.7%
5.1 pts worse
|
16.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 22.6% · Q3 26.9% · Q4 22.6% · 4Q avg 23.8% · 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 20.2% · Q2 20.6% · Q3 15.9% · Q4 20.1% · 4Q avg 19.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.5% |
21.9%
10.6 pts worse
|
14.9%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.2% · Q2 32.7% · Q3 34.9% · Q4 36.7% · 4Q avg 32.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.9% |
1.3%
3.6 pts worse
|
1.0%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.0% · Q3 3.6% · Q4 3.4% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.4%
0.5 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 1.7% · Q4 2.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
26.7%
4.6 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 27.5% · Q3 23.4% · Q4 36.3% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.4%
0.4 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.5% · Q3 4.5% · Q4 3.4% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.7% |
85.6%
46.9 pts worse
|
81.7%
43 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.6% · Q2 40.0% · Q3 27.3% · Q4 26.7% · 4Q avg 38.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
14.1%
10.9 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 25.0% · Expected 11.2% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.0% |
83.0%
55 pts worse
|
79.7%
51.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 28.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
22.1%
1.3 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 21.4% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-16 · Fire 2024-10-16
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-10-19 · Fire 2023-10-19
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
C · Minimal harm
2025-12-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-12-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-09
J · Immediate jeopardy
2025-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-04
D · Potential for more than minimal harm
2024-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-25
B · Minimal harm
2024-10-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-01-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-04
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 2024-01-31
E · Potential for more than minimal harm
2023-10-19
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-10-19
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 2023-11-03
D · Potential for more than minimal harm
2023-10-19
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 2023-11-03
Penalties and ownership
What sits behind the stars
$16,153
2025-06-06
Fine
Fine · fine $16,153
Fine
$0
2023-10-19
Payment Denial
Payment Denial · denial start 2024-01-19 · 35 days
35 day denial
Ownership
Lagos, Matthew
Corporate Director · Individual
Lagos, Matthew
W-2 Managing Employee · Individual
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