0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Windham, NH
5-star overall rating with 5-star inspections
21 Searles Road, Windham, NH
(603) 890-1290
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
32
Certified beds
Average residents
31
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Catholic Charities New Hampshire
Operator or chain grouping
Approved since
1993-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.51
Registered nurse staffing
LPN hours / resident day
1.28
Licensed practical nurse staffing
Aide hours / resident day
2.41
Nurse aide staffing
Weekend hours
3.78
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
1.9
1.7 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.4%
3.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
98.0%
5.1 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
4.5%
0.9 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.5%
1.5 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
18.9%
9.9 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
18.7%
12.6 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.6% |
19.2%
3.6 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.0% |
21.9%
0.1 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
2.4%
3.2 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.9% |
26.7%
8.2 pts worse
|
19.8%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.4%
1.8 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
85.6%
12.5 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.0% |
14.1%
5.9 pts worse
|
12.0%
8 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.3% |
83.0%
6.3 pts better
|
79.7%
9.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
22.1%
0.2 pts worse
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
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 2024-05-21
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-22
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-03-14
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
Salem, NH
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Derry, NH
3-star overall rating with 3-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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
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