Inspection Reports for St. Teresa Rehabilitation and Nursing Center
NH, 03104
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than New Hampshire average
New Hampshire average: 4.1 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 2
Date: Mar 7, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, skin condition treatment, and medication storage in the nursing facility.
Findings
The facility failed to ensure that medications and treatments were administered as ordered for two residents, including failure to transcribe and carry out physician orders for skin tear treatment and pain management. Additionally, expired medications were found on medication carts and in medication rooms, and multi-dose vials were not properly labeled with open expiration dates.
Deficiencies (2)
Failure to ensure medications and treatments were administered as ordered for Resident #29's skin tear and Resident #197's pain management.
Failure to remove expired medications from stock and label multi-dose vials with open expiration dates in medication carts and medication rooms.
Report Facts
Residents reviewed: 12
Expired medications observed: 2
Dates of medication orders: Mar 4, 2025
Date of survey completion: Mar 7, 2025
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 26, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding staff background checks, resident transfer/discharge notifications, accuracy of resident assessments, PASARR screenings, medication administration, and infection control practices during a norovirus outbreak.
Complaint Details
The complaint investigation focused on multiple issues including staff background checks, resident transfer/discharge notifications, accuracy of resident assessments, PASARR screenings, medication administration, and infection control during a norovirus outbreak. Several residents were found to be affected by these deficiencies.
Findings
The facility failed to implement proper staff background screening, timely resident transfer/discharge notifications, accurate resident assessments and PASARR screenings, adherence to physician medication orders, and infection prevention and control protocols during a norovirus outbreak. Multiple residents were affected by these deficiencies, including failure to follow CDC guidelines for transmission-based precautions.
Deficiencies (7)
Failed to implement policies and procedures to ensure screening of staff was conducted prior to working for 1 of 5 staff reviewed for background checks (Staff H).
Failed to provide the resident or the resident's representative with a written notice of transfer/discharge and failed to send a copy to the LTC Ombudsman for 1 of 2 residents reviewed.
Failed to notify residents of the bed hold policy before transfer for 1 of 1 resident reviewed for hospitalizations.
Failed to ensure that the residents' Minimum Data Set (MDS) accurately reflected the resident's status for 2 of 12 residents reviewed.
Failed to ensure that a Preadmission Screening and Resident Review (PASARR) screening was done for 1 of 2 residents reviewed.
Failed to follow physician orders for 1 of 5 residents reviewed for medication pass (Resident #32).
Failed to provide and implement an infection prevention and control program consistent with CDC guidance for 5 of 9 residents with suspected norovirus.
Report Facts
Staff reviewed for background checks: 5
Residents reviewed for transfer/discharge: 2
Residents reviewed for hospitalizations: 1
Residents reviewed for MDS accuracy: 12
Residents reviewed for PASARR screening: 2
Residents reviewed for medication pass: 5
Residents with suspected norovirus: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nursing Assistant (LNA) | Failed background check screening prior to working |
| Staff D | Regional Clinical Director | Confirmed Staff H worked without background check and confirmed transfer/discharge notification issues |
| Staff I | Director of Nursing | Confirmed background check and transfer/discharge notification issues; sent education email about norovirus outbreak |
| Staff J | Scheduler | Confirmed lack of background checks for agency staff |
| Staff A | Director of Social Services | Confirmed transfer/discharge notification and PASARR screening deficiencies |
| Staff C | Registered Nurse | Confirmed transfer/discharge notification and bed hold policy deficiencies; confirmed MDS inaccuracies |
| Staff F | Director of Clinical Reimbursement | Confirmed MDS inaccuracies |
| Staff G | Infection Prevention | Confirmed norovirus outbreak infection control deficiencies and lack of staff education |
| Staff K | Housekeeper | Failed to wash hands with soap and water as required during norovirus outbreak |
| Staff L | Medication Nursing Assistant | Failed to administer physician ordered saline nasal spray |
| Staff N | Unit Manager | Confirmed early discontinuation of contact precautions for Resident #9 |
| Staff O | Director of Housekeeping | Unable to provide documentation of education to housekeeping staff about norovirus outbreak |
Inspection Report
Routine
Census: 36
Deficiencies: 5
Date: Feb 10, 2023
Visit Reason
Routine inspection conducted to assess compliance with regulatory requirements including notification of significant resident condition changes, infection prevention and control, immunization policies, and call system functionality.
Findings
The facility was found deficient in notifying a resident's Durable Power of Attorney of a significant condition change, following CDC guidelines for PPE and laundry services, administering influenza and COVID-19 vaccinations, and maintaining a functioning call bell system for residents.
Deficiencies (5)
Failed to notify a resident's Durable Power of Attorney of a significant change in condition.
Failed to follow CDC guidelines for PPE, laundry services, and water management to minimize infection risk.
Failed to administer influenza immunization to a resident.
Failed to offer COVID-19 vaccination to a resident and properly document vaccination status.
Failed to ensure the call bell system was functioning properly, resulting in delayed staff response to resident calls.
Report Facts
Residents affected: 1
Residents affected: 36
Residents affected: 1
Residents affected: 1
Pagers observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Confirmed failure to notify DPOA and immunization deficiencies |
| Staff D | Regional Registered Nurse | Observed not wearing required PPE during COVID-19 sample collection |
| Staff E | Administrator | Confirmed laundry room observations and unawareness of call bell system issues |
| Staff G | Maintenance Director | Confirmed lack of water management measures and call bell system maintenance issues |
| Staff F | Regional Nurse Manager | Confirmed COVID-19 vaccination education and offering process |
| Staff I | Licensed Nursing Assistant | Responded to resident call bell during observation |
| Staff M | Registered Nurse | Reported call bell display system issues |
| Staff A | Unit Manager | Reported LNAs do not wear pagers and call bell notification issues |
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