Cycle 1
Health 2025-02-21 · Fire 2025-02-21
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Wolfeboro, NH
Wolfeboro Bay Center
2-star overall rating with 2-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
39 Clipper Drive, Wolfeboro, NH
(603) 569-3950
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
603 Healthcare
Operator or chain grouping
Approved since
1997-02-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 2 overall / 3 health / 2 staffing / 2 quality stars
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
0.73
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
65%
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
8,541
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.55
Baseline 17.67% · Performance 18.40% · Measure score 6.55 · Achievement 6.55 · Improvement 0
Healthcare-associated infections
0.83
Baseline 4.77% · Performance 7.59% · Measure score 0.83 · Achievement 0.83 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0.53
Baseline 3.47 hours · Performance 3.23 hours · Measure score 0.53 · Achievement 0.53 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.19% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 9% · Lower 95% interval 7.35% |
| Discharge to community | 58.34% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 55.56% · Lower 95% interval 49.86% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.62% |
95.27%
2.4 pts better
|
Numerator 41 · Denominator 42 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 42 |
| Discharge self-care score | 24.14% |
53.69%
29.5 pts worse
|
Numerator 7 · Denominator 29 |
| Discharge mobility score | 37.93% |
50.94%
13 pts worse
|
Numerator 11 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 2.44% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 41 · Adjusted rate 2.53% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 5.71% |
8.2%
2.5 pts worse
|
Numerator 4 · Denominator 70 |
| Staff flu vaccination coverage | 53.33% |
42%
11.3 pts better
|
Numerator 40 · Denominator 75 |
| Discharge function score | 44.83% |
56.45%
11.6 pts worse
|
Numerator 13 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 8 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
96.4%
2.7 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
98.0%
1.4 pts worse
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
4.5%
2.8 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.4% · Q3 9.7% · Q4 6.6% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.6% |
9.7%
15.9 pts worse
|
11.4%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 40.7% · Q3 29.0% · Q4 29.3% · 4Q avg 25.6% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.5%
3.1 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 4.3% · Q4 2.2% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.0% |
18.9%
8.9 pts better
|
19.6%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 11.4% · Q3 10.2% · Q4 6.2% · 4Q avg 10.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
18.7%
1.8 pts better
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 21.2% · Q3 13.5% · Q4 16.7% · 4Q avg 16.9% · 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 | 10.5% |
19.2%
8.7 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 18.5% · Q3 7.3% · Q4 3.3% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.6% |
21.9%
7.3 pts better
|
14.9%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 15.4% · Q3 10.4% · Q4 10.4% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.0% |
1.3%
4.7 pts worse
|
1.0%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.8% · Q3 5.1% · Q4 3.6% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.1% |
2.4%
0.7 pts worse
|
1.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 1.9% · Q3 1.6% · Q4 3.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
26.7%
2.1 pts better
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 41.5% · Q3 22.6% · Q4 19.0% · 4Q avg 24.6% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.4%
2.9 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.9% · Q3 1.4% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.0% |
85.6%
6.4 pts better
|
81.7%
10.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 63.6% · Q2 97.4% · Q3 100.0% · Q4 100.0% · 4Q avg 92.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.3% |
14.1%
8.2 pts worse
|
12.0%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 23.7% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
1.7%
2.6 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 4.0% · Q4 6.9% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.5% |
83.0%
6.5 pts better
|
79.7%
9.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
22.1%
3.6 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 28.9% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-19 · Fire 2024-01-19
10 health deficiencies
Top issue: Nursing and Physician Services (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-01-09 · Fire 2023-01-09
15 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-21
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 2025-04-08
D · Potential for more than minimal harm
2025-02-21
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 2025-04-08
D · Potential for more than minimal harm
2025-02-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-08
B · Minimal harm
2024-01-19
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 2024-01-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-01-19
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-19
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 2024-03-07
E · Potential for more than minimal harm
2024-01-19
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 2024-02-29
E · Potential for more than minimal harm
2024-01-19
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 2024-03-04
D · Potential for more than minimal harm
2024-01-19
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 2024-03-04
D · Potential for more than minimal harm
2024-01-19
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-01-19
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-01-19
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-29
B · Minimal harm
2024-01-19
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 2024-02-27
B · Minimal harm
2024-01-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-08
B · Minimal harm
2023-11-01
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-12-13
B · Minimal harm
2023-11-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-13
D · Potential for more than minimal harm
2023-07-18
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 2023-08-28
D · Potential for more than minimal harm
2023-07-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-07-18
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 2023-08-28
E · Potential for more than minimal harm
2023-01-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-09
E · Potential for more than minimal harm
2023-01-09
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-03
E · Potential for more than minimal harm
2023-01-09
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-02-21
D · Potential for more than minimal harm
2023-01-09
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 2023-02-03
D · Potential for more than minimal harm
2023-01-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-02
B · Minimal harm
2023-01-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-03
B · Minimal harm
2023-01-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-02-16
B · Minimal harm
2023-01-09
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-01-11
Penalties and ownership
What sits behind the stars
Ownership
Black Mountain Peak Healthcare, LLC
5% Or Greater Direct Ownership Interest · Organization
603 Healthcare LLC
Operational/Managerial Control · Organization
Aweh, Nelson
Operational/Managerial Control · Individual
Pr Nh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Rausman, Philip
5% Or Greater Indirect Ownership Interest · Individual
Rausman, Robert
5% Or Greater Indirect Ownership Interest · Individual
Rr Nh Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Slattery, Jessica
Operational/Managerial Control · Individual
Stevenson, Sean
5% Or Greater Indirect Ownership Interest · Individual
Stevenson, Sean
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Mountain View Community
Ossipee, NH
2-star overall rating with 2-star inspections with $101,192 in total fines with 3 recent health deficiencies
#2
Belknap County Nursing Home
Laconia, NH
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Golden View Health Care Center
Meredith, NH
5-star overall rating with 4-star inspections with 1 recent health deficiencies
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