Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 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.
Failure to maintain the facility’s Legionella and water management program was identified when records showed no documentation that the hot water tank was flushed annually and no documentation that shower heads were cleaned annually. The IP and Maintenance Director confirmed the missing documentation, and the Maintenance Director stated there was one dead leg at the hot water tank and that the water management plan had been reviewed by facility leadership and department staff.
Failure to Hold Quarterly Care Plan Meeting: A resident’s DPOA reported not being invited to a care plan meeting for several months and expressed concern about the resident’s care. Record review showed the resident’s last care plan meeting was held months earlier, and the RD of Clinical Services confirmed the finding.
Failure to timely report an abuse allegation and an injury of unknown source: A resident who was admitted for skilled nursing after a hip fracture reported waiting over an hour for help when the bed was wet and said an LPN was disrespectful, but the complaint was not immediately reported to the Administrator or DON. In a separate incident, another resident had an unexplained bruise and skin tear to the forearm that was not witnessed and was not reported to the SSA, despite facility policy requiring immediate reporting of such events.
Failure to thoroughly investigate an injury of unknown source for a resident with frequent skin tears. The resident’s DPOA reported concern about repeated unexplained skin tears, and the record showed a bruise with a 3.5 cm skin tear to the forearm with no clear cause or time of occurrence. The nursing note stated staff did not know what caused the injury, and there were no statements or notifications found. The RDCS and Administrator confirmed the event was not thoroughly investigated for a causative factor.
Failure to follow physician orders occurred when an RN administered the wrong dose of trazodone to a resident with insomnia, giving 25 mg instead of the ordered 75 mg. In a separate finding, a resident with CHF had a daily weight order, but weights were missed on multiple days, and the RDCS confirmed the omissions.
Food Service Director Did Not Meet Required Qualifications: The facility failed to ensure the Food Service Director met minimum qualifications. The Administrator stated the facility did not have a full-time dietitian and that the Food Service Director had not completed a course of study in food safety and management. Facility policy required a graduate of a food or nutritional program or equivalent experience, along with ServSafe certification.
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 Maintain Water Management Program and Required Monitoring
Penalty
Summary
The facility failed to update its water management plan as necessary and failed to implement monitoring measures to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. Review of the facility’s Legionella and Water Management Program showed that the Infection Preventionist and Director of Environmental Services were to collaborate with the interdisciplinary team and facility leadership to establish and maintain a facility-specific water management program, and that water management activities were to be documented and reviewed regularly. The plan also included control measures such as assessing and eliminating dead legs in plumbing systems wherever practicable, flushing hot water tank sediment at least annually, and removing and cleaning shower heads, including handheld wands, at least annually. Review of the maintenance logs showed no documentation that the hot water tank had been flushed at least annually and no documentation that shower heads had been cleaned at least annually. During interview, the Maintenance Director stated that the water management plan was reviewed in August 2025 at a safety meeting with facility leadership and department staff, and confirmed that there was one dead leg in the facility at the hot water tank. The Maintenance Director also confirmed there was no documentation that the hot water tank was flushed annually and that the shower heads were not cleaned annually. The Infection Preventionist confirmed these findings during interview.
Failure to Hold Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to facilitate a quarterly care plan meeting for Resident #24, who was included in the final sample of 12 residents reviewed for care planning. During an interview on 4/27/26, the resident’s DPOA stated that he or she had not been invited to a care plan meeting for Resident #24 in the last 6 months or so and expressed concern about not having a meeting because of concerns with the resident’s care. Review of the medical record on 4/28/26 showed that Resident #24’s last care plan meeting was held on 10/27/25. Staff B, the Regional Director of Clinical Services, confirmed these findings during interview on 4/28/26.
Failure to Timely Report Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident who said a staff member was disrespectful after the resident waited over an hour for help when the bed was wet from a leaking ice pack. Resident #54 was admitted for skilled nursing services after a right hip fracture and was a one-person assist for transfers. The resident stated that after pressing the call bell, the response time was very long and that the staff member who responded made the resident feel bad about needing new sheets and being soaked. The call bell log showed a response time of one hour and nine minutes, and the LPN who spoke with the resident did not notify the Administrator or DON about the resident’s complaint. The facility also failed to report an injury of unknown source involving Resident #24 to the SSA. Resident #24’s DPOA reported concern that the resident frequently gets skin tears and is not aware of how they occurred. A review of the resident’s alteration in skin integrity record documented a bruise with a 3.5 cm skin tear to the left forearm, with scant dry blood and surrounding bruising. The record stated that no staff on duty knew exactly what caused the bruise or when it occurred, and it may have happened during the day shift or earlier on the evening shift. The incident was not witnessed, and no statements or notifications were found. The Administrator, who was also the facility’s abuse coordinator, and the Regional Director of Clinical Services confirmed that the skin integrity incident was not reported to the SSA. The facility policy stated that all allegations, observations, or suspicions of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property must be immediately reported to the Administrator, DON, or supervisor in charge, and that the SSA must also be notified within the required timeframe based on severity.
Failure to Thoroughly Investigate Injury of Unknown Source
Penalty
Summary
The facility failed to thoroughly investigate an alleged injury of unknown source for Resident #24, who had a history of frequent skin tears per the resident’s DPOA. During an interview on 4/27/26, the DPOA stated concern that Resident #24 gets skin tears frequently and was not aware of how they occurred. Observation that evening showed a dressing on the resident’s right leg. Record review later identified an Alteration in Skin Integrity dated 3/29/26 documenting a bruise with a 3.5 cm skin tear to the left forearm, with scant dry blood and surrounding bruising. The nursing note stated that no staff on duty knew exactly what may have caused the bruise or when it may have happened, and it may have occurred during the day shift or earlier on the evening shift. The note also indicated the wound was cleaned, steri-strips were applied, and the area was covered, but there were no statements found and no notifications found. Staff B, the Regional Director of Clinical Services, confirmed the finding was not thoroughly investigated for a causative factor, and Staff A, the Administrator and abuse coordinator, stated the alteration of skin integrity should have been thoroughly investigated for a causative factor. The facility policy required response to allegations or occurrences of abuse, neglect, exploitation, mistreatment, and injuries of unknown source, including a final investigative report with interview results, investigative steps, and final determination.
Failure to Follow Physician Orders for Medication Dose and Daily Weights
Penalty
Summary
Physician’s orders were not followed for Resident #25 during medication administration. The resident had an order for trazodone 50 mg tablets, with instructions to give 1.5 tablets by mouth at bedtime for insomnia, for a total dose of 75 mg. During observation of medication administration, Staff C prepared trazodone for the resident and the medication card and pharmacy label both reflected the ordered dose of 1.5 tablets. However, Staff C administered only a half tablet, equal to 25 mg, instead of the ordered 75 mg dose. Staff C later confirmed that the incorrect dosage had been given. Physician’s orders were also not followed for Resident #6 regarding daily weights ordered under the CHF protocol. Review of the resident’s current physician’s orders showed a daily weight order dated 4/5/26. Review of the resident’s Weights and Vitals Summary showed multiple dates when the weight was not obtained, including 4/8/26, 4/11/26, 4/12/26, 4/13/26, 4/18/26, 4/23/26, and 4/25/26. Staff B, the Regional Director of Clinical Services, confirmed these findings during interview.
Food Service Director Did Not Meet Required Qualifications
Penalty
Summary
The facility failed to ensure the Food Service Director met minimum qualifications for the food and nutrition service. During an interview with the Administrator, it was revealed that the facility did not have a full-time dietitian. The Administrator also stated that the Food Service Director had been employed since 9/16/25 and had not completed a course of study in food safety and management. Review of the facility policy titled, Food Services Director, dated 10/12/21, showed the position required a graduate of a food or nutritional program or equivalent experience, and ServSafe Certification was required.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 387 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Saint Teresa Rehabilitation & Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.