Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
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 Staff confirmed the findings, and a review of policies indicated that outdated medications should be removed immediately.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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Residence | 0.4 mi | — | 10 | 0 |
| Hanover Hill Health Care Center | 0.5 mi | — | 2 | 0 |
| Mount Carmel Rehabilitation And Nursing Center | 0.8 mi | — | 0 | 0 |
| Maple Leaf Health Care Center | 0.9 mi | — | 2 | 0 |
| Villa Crest Nursing And Retirement Center | 1.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.