Saint Teresa Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, New Hampshire.
- Location
- 519 Bridge Street, Manchester, New Hampshire 03104
- CMS Provider Number
- 305071
- Inspections on file
- 16
- Latest survey
- March 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Saint Teresa Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
The facility failed to administer medications and treatments as ordered for two residents. A resident did not receive a prescribed lidocaine patch for pain management, despite it being documented as administered. Another resident with a skin tear did not receive proper wound care due to a failure to transcribe the physician's order to the Treatment Administration Record, resulting in the wound not being covered as prescribed.
The facility failed to remove expired medications and properly label multi-dose vials. Observations revealed expired medications on a medication cart and improperly labeled vials in the medication room. Staff confirmed the findings, and a review of policies indicated that outdated medications should be removed immediately.
The facility failed to follow CDC guidance for Transmission Based Precautions (TBP) for five residents with suspected Norovirus. Staff were observed not using proper hand hygiene, PPE was not consistently used, and residents were taken off precautions prematurely. The facility's outbreak line list did not consistently track symptoms, and there was a lack of education provided to staff on proper infection control measures.
The facility failed to implement policies and procedures to ensure staff screening was conducted prior to working. Specifically, an LNA from a staffing agency worked without an employee record or background check, and the facility had used staff from the same agency on multiple dates without background checks.
The facility failed to complete a PASARR screening for a resident admitted with bipolar disease and major depression. Staff confirmed the absence of the required documentation, which is mandated by the facility's policy.
The facility failed to follow physician orders for a resident during a medication pass. Staff L did not administer the prescribed saline nasal spray, and the omission was confirmed upon review of the resident's Medication Administration Record (MAR) and an interview with Staff L.
The facility failed to provide a written notice of transfer/discharge to a resident or their representative and did not send a copy to the LTC Ombudsman. This issue was confirmed through staff interviews and a review of the resident's medical record, which lacked the required documentation.
The facility failed to notify a resident of the bed hold policy before their transfer to the hospital. The omission occurred due to a switch to a new electronic medical system, as confirmed by staff interviews. The facility's policy requires providing bed hold information at admission and before hospital transfers.
The facility failed to ensure accurate MDS documentation for two residents. One resident's MDS incorrectly indicated the use of antianxiety medication instead of antidepressant and anticoagulant medications. Another resident's discharge MDS incorrectly stated that the resident was discharged to a hospital instead of home. These errors were confirmed through interviews and record reviews.
Failure to Administer Medications and Treatments as Ordered
Penalty
Summary
The facility failed to ensure that medications and treatments were administered as ordered for two residents. Resident #197 did not receive a prescribed lidocaine patch for pain management on their right shoulder, despite the medication being documented as administered in the Medication Administration Record (MAR). An interview with the resident and observation by the Unit Manager confirmed the absence of the patch. The physician's order specified the application of the patch to the right knee and shoulder, but this was not adhered to, indicating a discrepancy between the MAR and the actual administration of the medication. Resident #29 had a skin tear on the right forearm that was not properly treated according to the physician's orders. The order required cleansing with normal saline, application of bacitracin, and covering with a dry dressing and kerlix, but these instructions were not transcribed to the Treatment Administration Record (TAR). Observations revealed the wound was not covered as prescribed, and interviews with nursing staff confirmed the lack of documentation and treatment. This oversight in transcribing the order to the TAR resulted in the resident not receiving the necessary wound care.
Expired Medications and Improper Labeling in Medication Storage
Penalty
Summary
The facility failed to ensure that expired medications were removed from stock and that multi-dose vials were labeled with an open expiration date. During an observation of the medication cart, expired medications were found, including a bottle of Carbamine Peroxide ear drops for a resident with a manufacturer's expiration date of February 2025, and a Tiotropium Bromide Monohydrate Capsule inhaler for another resident with a manufacturer's expiration date of September 2024. It was confirmed through interviews with staff that these medications were expired, and the order for the Tiotropium Bromide Monohydrate Capsule had been discontinued in May 2024. Additionally, an observation of the medication room revealed that there were opened multi-dose vials of Tuberculin Purified Protein Derivative (Mantoux) in two refrigerators. One vial had an opened date of January 2025, and another had a manufacturer's expiration date of December 2024. Interviews with staff confirmed these findings, and a review of the manufacturer's instructions indicated that a vial in use for 30 days should be discarded. The facility's policy on medication storage also stated that outdated, contaminated, or discontinued medications should be immediately removed from stock.
Failure to Follow Norovirus Precautions
Penalty
Summary
The facility failed to follow CDC guidance for Transmission Based Precautions (TBP) for five residents with suspected Norovirus. Staff G, responsible for infection prevention, confirmed that Resident #21 was placed on precautions due to norovirus. However, Staff K, a housekeeper, was observed using alcohol-based hand sanitizer instead of washing hands with soap and water after cleaning Resident #21's room, indicating a lack of proper education on norovirus precautions. Staff K confirmed that they were not educated on the correct hand hygiene protocol until the morning of 3/27/24, several days after the outbreak began. Resident #9 was also not properly managed under TBP. Staff entered Resident #9's room without PPE, and there was no signage indicating the need for precautions. Despite Resident #9 showing symptoms of a gastrointestinal bug, including vomiting and loose stools, the resident was taken off contact precautions prematurely. Staff G and Staff N confirmed that Resident #9 should have remained on precautions during the observed period. Similar issues were observed with Residents #30, #17, and #13. Resident #30 was on TBP for suspected norovirus, but there was a lack of accurate documentation and tracking of symptoms. Resident #17, who continued to have loose stools, was observed walking around the facility and interacting with other residents without proper precautions. Resident #13 was taken off contact precautions before the required 48-hour symptom-free period. The facility's outbreak line list did not consistently track symptoms, and there was a lack of education provided to staff, including housekeeping, on proper infection control measures during the norovirus outbreak.
Failure to Implement Staff Screening Procedures
Penalty
Summary
The facility failed to implement policies and procedures to ensure the screening of staff was conducted prior to working. Specifically, Staff H, a Licensed Nursing Assistant (LNA) from a staffing agency, worked at the facility without an employee record or background check. This was confirmed through observation, interviews, and record reviews. Staff H worked on the [NAME] Unit on 3/26/24 from 7:00 a.m. to 3:00 p.m. without the necessary background check, as confirmed by the Regional Clinical Director and the Director of Nursing. Further review revealed that the facility had used staff from the same agency on multiple dates without having background checks for any of these staff members. The Scheduler confirmed that the facility did not have background checks for staff from the agency that employed Staff H. The facility's policy on Abuse/Staff Treatment of Residents, revised on 3/25/11, mandates procedures for screening potential employees for a history of abuse, neglect, or mistreatment of residents, which was not followed in this case.
Failure to Complete PASARR Screening
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) screening was completed for one of the two residents reviewed for PASARR in a sample of twelve residents. Resident #2, who was admitted in June 2023 with diagnoses of bipolar disease and major depression, did not have a Level I PASARR screening in their medical record. This was confirmed through interviews with the Director of Social Services and Medical Records staff, both of whom could not find the required PASARR documentation. The facility's policy, dated 11/16/17, mandates that all residents be screened for mental disorders or intellectual disabilities prior to admission, but this procedure was not followed for Resident #2.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for one resident, identified as Resident #32, during a medication pass. The physician's order dated 2/26/24 specified that Resident #32 was to receive saline nasal spray, 2 sprays two times a day and as needed. However, on 3/27/24 at 9:03 a.m., Staff L, a Medication Nursing Assistant, was observed administering medications to Resident #32 but did not administer the saline nasal spray as ordered. This was confirmed by Staff L during an interview at 9:47 a.m. on the same day. A review of Resident #32's March Medication Administration Record (MAR) revealed that the saline nasal spray had not been signed off as administered. The facility's policy on Medication Administration, dated January 2021, states that medications should be administered in accordance with written orders of the prescriber. The failure to administer the saline nasal spray as ordered constitutes a deficiency in following physician orders and adhering to the facility's medication administration policy.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge to Resident #14 or the resident's representative when the resident was discharged to the hospital. Additionally, the facility did not send a copy of the written notice to the Long-Term Care (LTC) Ombudsman. This deficiency was confirmed through interviews with the Director of Social Services, a Registered Nurse, and the Regional Clinical Director, who acknowledged that since the facility changed electronic medical records in August 2023, the required notices were not being provided. The incident was identified during a review of Resident #14's medical record, which lacked documentation of the written notice for the discharge on 10/7/23.
Failure to Notify Resident of Bed Hold Policy Before Hospital Transfer
Penalty
Summary
The facility failed to notify residents of the bed hold policy before transfer for one resident reviewed for hospitalization. The medical record of the resident revealed they had been discharged to the hospital, but there was no evidence that the bed hold policy was provided upon transfer. An interview with a Registered Nurse confirmed that the bed hold policy was not provided at the time of transfer due to the facility switching to a new electronic medical system. The Regional Clinical Director confirmed these findings. The facility's policy stated that residents and their representatives should be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the residents' Minimum Data Set (MDS) accurately reflected the residents' status for two residents. For Resident #35, the quarterly MDS indicated that the resident had received an antianxiety medication during the last seven days, which was incorrect. The Medication Administration Record (MAR) showed that the resident was prescribed Citalopram for depression and Eliquis for pulmonary embolism, but no antianxiety medication. Interviews with the Registered Nurse and the Director of Clinical Reimbursement confirmed that the MDS was incorrectly coded and should have included antidepressant and anticoagulant medications instead of antianxiety medication. For Resident #42, the discharge MDS indicated that the resident was discharged to a short-term general hospital, which was incorrect. A progress note and an interview with the Director of Social Services confirmed that the resident was actually discharged to home. The Director of Clinical Reimbursement also confirmed that the MDS was incorrectly coded. These inaccuracies in the MDS assessments reflect a failure to ensure accurate documentation of the residents' statuses.
Latest citations in New Hampshire
Unsanitary conditions were observed in the main kitchen, including debris, wet towels and washcloths on the floor, cloudy liquid under the rinse sink, missing laminate flooring in front of the rinse sink, and buildup of grease and debris under and around the dishwasher, sinks, oven, hood vent, and center island. Bread was stored on shelves with debris underneath, and soda and beer were stored on the floor. The ED confirmed the observations, and the cited FDA Food Code required smooth, easily cleanable, nonabsorbent surfaces.
The facility failed to include personal humidifiers in its Water Management Plan. The Legionella Water Management Program and staff education materials identified humidifiers as a possible source for Legionella exposure, but observations on multiple units found humidifiers in resident rooms and the Water Management Program did not list them or include controls to prevent growth of Legionella and other opportunistic waterborne pathogens. The IP confirmed humidifiers were in use but not included in the plan.
The facility failed to report abuse allegations to the state survey agency. One incident involved two residents with severe cognitive impairment, where an LPN observed one resident exposed while another attempted sexual contact. Another incident involved an LNA witnessing a resident aggressively shake and push another resident’s wheelchair while yelling. Staff confirmed both incidents were not reported to the SSA or law enforcement.
Failure to investigate and report abuse allegations: Staff observed one resident attempting sexual contact with another resident, both with severe cognitive impairment, and another resident aggressively shaking a peer’s wheelchair while yelling. The DON confirmed that neither incident had been investigated, despite staff notification to leadership.
Failure to provide appropriate care to maintain mobility was identified for a resident dependent on an AFO before getting OOB. The resident reported the foot rolled out of the AFO and it caused pain, while the record showed an OT consult order for repair of a broken strap with no evidence the consult was completed or that anyone contacted the AFO provider. The AFO was observed on the bed with the ankle strap missing.
Expired eye drops were found on 2 medication carts, including Timolol for one resident and Latanoprost for another, with staff confirming one should have been discarded. In addition, a medication cart was observed unlocked and unattended, despite facility policy requiring carts to be locked when not in use.
Humidifier equipment was not maintained and cleaned as required for three residents. Staff did not have a reliable tracking system for resident-owned humidifiers, and the DON confirmed the facility was not following manufacturer-specific cleaning instructions. One resident’s humidifier was observed plugged in with an empty tank, another resident did not know how often the unit was cleaned, and staff reported using vinegar for all units instead of the required cleaning methods.
Failure to assess residents for self-administration of medications: two residents had medications left at bedside without the required assessment or provider order. One resident had eye drops on the bedside table and stated he/she self-administered them, while the other had multiple morning meds left at bedside in a medicine cup. Staff confirmed neither resident had documentation authorizing self-administration.
The facility failed to report alleged abuse incidents involving two residents to the SSA within the required timeframe. One resident was documented pushing another resident after grabbing the resident by the chest, and another incident involved physical contact between two residents with one resident sustaining a wrist bruise. The ADON stated these resident-to-resident incidents were not reported to the SSA.
A resident’s fall care plan was not updated after a fall. The fall summary identified a new intervention for staff to offer the resident the choice to keep the curtain open between the sides of the room except during cares, but the care plan was not revised to include it. The UM confirmed the finding, and the facility policy states the IDT fall meeting should develop new fall prevention interventions and update the resident care plan accordingly.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an observation of the main kitchen with the Executive Director, multiple unsanitary conditions were identified, including a white substance buildup on the floor beside the dishwasher, a wet hand towel and a wet washcloth on the floor under the dishwasher, debris under the rinse sink, and a pink container filled with cloudy liquid sitting under the drain beneath the rinse sink. The laminate flooring in front of the rinse sink was missing in an area measuring approximately 4.5 inches by 5 inches, and there was also a large amount of debris under the sanitizing sink, dust between the wall and the left side of the oven, debris under the oven, and a buildup of debris and grease on the hood vent. Additional observations showed debris under the center island where bread was being stored, debris on the shelves under the island, and three cases of soda plus a six pack of beer stored on the floor on the corner shelf. The Executive Director confirmed all of these observations during the interview. Review of the FDA Food Code 2017 cited requirements that nonfood-contact surfaces exposed to splash or food debris be constructed of nonabsorbent materials and that floors, walls, wall coverings, and ceilings be smooth and easily cleanable.
Water Management Plan Did Not Include Humidifiers
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to identify personal humidifiers in its Water Management Plan. Review of the facility's Legionella Water Management Program showed that the program was intended to identify areas in the water system where Legionella bacteria can grow and spread and specifically listed humidifiers among the water system components that could encourage the growth and spread of Legionella or other waterborne bacteria. Staff education materials also identified humidifiers as a possible pathway for exposure to Legionella bacteria. However, observations on the Granite, Profile, and Maple Units found humidifiers in use in resident rooms, and review of the Water Management Program showed that it did not identify humidifiers in use in the facility or controls to prevent the growth of Legionella and other opportunistic waterborne pathogens. The Infection Preventionist confirmed that humidifiers were in use in the building but were not included in the Water Management Plan.
Failure to Report Abuse Allegations to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the state survey agency for two incidents involving residents with severe cognitive impairment. In one event, a nursing note documented that a LPN entered a resident’s room and observed one resident lying back in a recliner with briefs pulled off and pajama pants pulled above the pelvis while another resident was kneeling in front of the recliner attempting to have sex with the resident. The LPN separated the residents, notified the DON and administrator, and placed the resident on 1:1 safety checks. The record showed both residents had BIMS scores indicating severe cognitive impairment, and staff confirmed the incident was not reported to the State Agency. In another event, a nursing note documented that an LNA witnessed one resident coming out of a room and grabbing the back of another resident’s wheelchair and shaking it aggressively. The LNA later confirmed witnessing the resident shake and push the wheelchair while yelling at the other resident. The administrator confirmed this incident was also not reported to the State Survey Agency or other law enforcement. The facility policy required immediate reporting of abuse allegations to the state licensing/certification agency and other officials according to state law.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that two allegations of abuse were investigated and reported to the State Agency. One incident involved Resident #82 and Resident #11, both of whom had severe cognitive impairment, with BIMS scores of 02 and 00 respectively. A nursing note documented that a LPN entered Resident #82’s room and observed Resident #11 lying back in a recliner with clothing pulled off and Resident #82 kneeling in front of the recliner attempting to have sex with Resident #11. The LPN separated the residents, notified the DON and Administrator, and placed Resident #82 on 1:1 checks, but the DON later confirmed that no investigation was initiated. A second incident involved Resident #29 and Resident #55. A nursing note stated that an LNA witnessed Resident #29 coming out of a peer’s room and grabbing the back of the peer’s wheelchair and shaking it aggressively. The LNA later confirmed that Resident #29 shook and pushed forward Resident #55’s wheelchair while yelling at them. The DON confirmed that this incident had not been investigated.
Failure to Address Broken AFO for Resident With Limited Mobility
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve ROM, limited ROM, and/or mobility was not ensured for a resident with limited mobility. Resident #4’s care plan, initiated on 7/9/25, included an intervention stating the resident was dependent on application of an AFO prior to out of bed to the right lower leg. The medical record showed a physician order dated 3/2/26 for an OT consult to have the resident’s right AFO sent for repair because the strap was broken, but there was no indication that an OT consult had been completed or that anyone had been contacted about the AFO needing repair. During interview, the resident stated they had told their provider that their foot rolls out of the AFO and it causes pain when worn, and that no one had come to see them or talk with them about the AFO since they spoke to their provider a few weeks earlier. Observation of the resident’s room showed the AFO lying on the bed with the ankle strap missing.
Medication carts left unsecured and expired eye drops kept in use
Penalty
Summary
Medications and biologicals were not properly labeled and stored on multiple medication carts. On the Maple Unit short hall cart, a bottle of Timolol Maleate solution for Resident #55 was observed with handwritten opening and expiration dates showing it had been opened on 2/27 and expired on 3/27, while the manufacturer’s instructions provided by the facility stated the unit dose container should be used within one month after the foil package is opened. Staff A, a LMA, confirmed the finding during the observation. On the Meadow Unit long hall cart, a bottle of Latanoprost Solution 0.005% for Resident #23 was observed with handwritten dates showing it had been opened on 2/9/26 and expired on 3/23/26, and Staff B, an RN, confirmed the medication had been administered and should have been discarded. In addition, the Profile Unit medication cart was observed unlocked with no nursing staff present, and Staff D, an RN, confirmed the cart was unattended and unsecured. Facility policy stated medication carts are to be locked when not in use and opened multi-dose vials are to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Humidifiers Not Maintained or Cleaned per Policy and Manufacturer Instructions
Penalty
Summary
The facility failed to maintain safe and clean humidifier equipment for 3 of 3 residents reviewed for environment, identified as residents #41, #63, and #100. The facility’s admission procedures and Resident Information Guide stated that if a humidifier is brought in, nursing staff must be aware of it so it can be placed on the cleaning schedule. However, interview with staff revealed that the Unit Aide Book did not contain information about which residents had humidifiers or any tracking of cleaning dates, and the Director of Nursing confirmed this. The facility’s Humidifier Maintenance policy stated that nursing staff were to unplug the device daily and rinse/refill it with fresh tap water, while housekeeping was to clean humidifiers monthly with a 1:2 acetic acid and water solution. Resident #41 had a Pelonis humidifier plugged into the room, and the resident’s family stated they purchased it and staff were aware of it; later observation showed the humidifier plugged in with an empty water tank. Resident #63 had a Breezome humidifier in the room, and the resident did not know how often it was cleaned. Resident #100 had a Vick’s humidifier in the room, and the manufacturer’s instructions required weekly cleaning with vinegar for scale removal and a bleach solution for disinfecting. Staff stated that all humidifiers were cleaned with vinegar, and the DON confirmed the facility was not following the specific manufacturer instructions for cleaning individual humidifiers.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to determine that self-administration of medications was clinically appropriate for 2 of 3 residents reviewed for choices in a final sample of 35 residents. For one resident, a box of Ketotifen Fumarate Ophthalmic Solution 0.035% eye drops was observed on the bedside table with an open date of 1/26/26. The resident stated that he/she would self-administer the eye drops, and the MDS showed a BIMS score of 15/15, indicating cognitive intactness. However, the medical record contained no documentation of a self-administration assessment or an order allowing the resident to self-administer the eye drops, and staff confirmed that no such assessment or order existed. For another resident, a medicine cup containing multiple pills/capsules was observed on the bedside table while the resident was in bed with eyes closed and no staff present. Staff stated that the morning medications had been left at the bedside, and further stated that the resident did not have a physician's order or assessment to self-administer medication. The MAR showed multiple morning medications left at bedside, including furosemide, levetiracetam, metformin ER, metoprolol tartrate, multivitamin with minerals, omeprazole magnesium, potassium chloride ER, sertraline HCL, Synthroid, and apixaban. The medical record confirmed there was no physician's order or assessment for self-administration.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation, to the State Survey Agency for 2 of 2 residents reviewed for abuse. For Resident #3, nursing progress notes documented that an LNA reported the resident had pushed another resident after grabbing the other resident by the chest while shouting to "get out." The other resident was found on the floor against the wall in a slouched position and was able to get up with assistance from staff. The nursing supervisor was notified, a message was left for the guardian, and 15-minute safety checks were started. Social services notes later referenced the recent resident-to-resident altercation in which one resident pushed another resident who wandered into the room. For Resident #145, nursing progress notes documented a potential altercation between 2 residents after camera footage was reviewed and physical contact was observed between the residents. One resident was observed grabbing at the other resident, and the other resident sustained a bruise to the wrist. The primary nurse was instructed to complete an incident report, and notification was sent to administration. The facility policy titled Abuse And Neglect Policy stated that all allegations of abuse or neglect, including reportable resident-to-resident incidents, would be reported immediately, defined as within 2 hours, yet the Assistant Director of Nursing stated that the resident-to-resident incidents were not reported to the SSA.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise a care plan for one resident reviewed for falls. Resident #178 had a fall on 12/24/25, and the fall summary report identified a new intervention to be added to the resident’s care plan: staff were to offer the resident the choice to keep the curtain open between the sides of the room except during cares per resident choice. However, review of the care plan titled "at risk for falls" showed that this intervention was not added after the fall. During interview on 3/25/26 at 8:30 a.m., Staff O, the Unit Manager, confirmed the findings. The facility policy titled, "Fall/Accident Management Program," revised 12/2024, states that the IDT fall meeting will occur weekly after a fall and include discussion of possible causes of the fall and development of new fall prevention interventions, and that the resident care plan will be updated accordingly.
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