Cycle 1
Health 2025-03-07 · Fire 2025-03-07
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Manchester, NH
Saint Teresa Rehabilitation & Nursing Center
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
519 Bridge Street, Manchester, NH
(603) 668-2373
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Catholic Charities New Hampshire
Operator or chain grouping
Approved since
1996-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 4 health / 4 staffing / 3 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
0.68
Registered nurse staffing · state 0.74 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.76 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.39 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 3.88 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.49 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 3.44 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.52
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,793
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.29% · Performance 22.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.89% · Performance 9.91% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.03
Baseline 52.27% · Performance 43.14% · Measure score 5.03 · Achievement 5.03 · Improvement 2.83
Adjusted total nurse staffing
3.99
Baseline 4.49 hours · Performance 4.21 hours · Measure score 3.99 · Achievement 3.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 4.76% · Lower 95% interval 6.27% |
| Discharge to community | 46.98% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 42.11% · Lower 95% interval 36.82% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95% |
95.27%
0.3 pts worse
|
Numerator 38 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 74.19% |
53.69%
20.5 pts better
|
Numerator 23 · Denominator 31 |
| Discharge mobility score | 48.39% |
50.94%
2.5 pts worse
|
Numerator 15 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 2.83% |
| Healthcare-associated infections requiring hospitalization | 9.91% |
7.12%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 19.05% · Lower 95% interval 6.17% |
| Staff COVID-19 vaccination coverage | 13.41% |
8.2%
5.2 pts better
|
Numerator 11 · Denominator 82 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 58.06% |
56.45%
1.6 pts better
|
Numerator 18 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 36% |
25.2%
10.8 pts better
|
Numerator 9 · Denominator 25 |
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 | 1.4 |
1.9
0.5 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
96.4%
2.9 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
4.5%
1.2 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 2.5% · Q4 5.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
9.7%
9 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
5.5%
2 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 21.2% · Q3 0.0% · Q4 0.0% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
18.9%
8.3 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 8.6% · Q3 13.9% · Q4 13.5% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.9% |
18.7%
17.8 pts better
|
16.7%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · 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 | 25.2% |
19.2%
6 pts worse
|
16.3%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 25.8% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.4% |
21.9%
4.5 pts worse
|
14.9%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 34.3% · Q3 27.8% · Q4 16.7% · 4Q avg 26.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.3%
1.8 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 4.0% · Q4 4.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
2.4%
1.6 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.3% · Q3 2.5% · Q4 5.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.0% |
26.7%
12.3 pts worse
|
19.8%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.4% · Q2 45.1% · Q3 31.3% · Q4 39.6% · 4Q avg 39.0% |
| 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 3.5% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
85.6%
8.2 pts better
|
81.7%
12.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.7% · Q2 97.4% · Q3 97.4% · Q4 85.2% · 4Q avg 93.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
14.1%
1.6 pts better
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 11.1% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.7%
0.5 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
83.0%
11.6 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
22.1%
8.2 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 11.1% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-02-10 · Fire 2023-02-10
5 health deficiencies
Top issue: Infection Control (3 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-21
E · Potential for more than minimal harm
2025-03-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-21
D · Potential for more than minimal harm
2025-03-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-21
F · Potential for more than minimal harm
2024-03-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-03-28
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-03-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-08
E · Potential for more than minimal harm
2024-03-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-08
C · Minimal harm
2024-03-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-08
C · Minimal harm
2024-03-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-08
E · Potential for more than minimal harm
2023-02-10
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-31
C · Minimal harm
2023-02-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-31
C · Minimal harm
2023-02-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-03-31
C · Minimal harm
2023-02-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-03-31
C · Minimal harm
2023-02-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-15
D · Potential for more than minimal harm
2025-03-07
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 2025-04-15
E · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-03-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-03-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-03-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-20
B · Minimal harm
2024-03-28
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 2024-04-10
B · Minimal harm
2024-03-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-04-10
B · Minimal harm
2024-03-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-11
F · Potential for more than minimal harm
2023-02-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-02-10
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-10
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-10
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-03-20
Penalties and ownership
What sits behind the stars
Ownership
Nh Catholic Charities Inc
5% Or Greater Direct Ownership Interest · Organization
Barrett, Kevin
Corporate Director · Individual
Bernard, Alain
W-2 Managing Employee · Individual
Blonski, Thomas
Corporate Officer · Individual
Blonski, Thomas
W-2 Managing Employee · Individual
Coughlin, Jamie
Corporate Director · Individual
Gilbert, Michael
Corporate Director · Individual
Gossett, Robert
Corporate Director · Individual
Grip, Brian
Corporate Director · Individual
Hildenbrand, David
Corporate Officer · Individual
Hilton, Richard
Corporate Director · Individual
Jalbert, Jason
Corporate Director · Individual
Legere, Tina
Corporate Director · Individual
Libasci, Peter
Corporate Director · Individual
Mirable, Catherine
Corporate Director · Individual
Mullikin, Anu
Corporate Director · Individual
Nh Catholic Charities Inc
Operational/Managerial Control · Organization
Ouellette, Russ
Corporate Director · Individual
Patenaude, John
Corporate Director · Individual
Powers, Edward
Corporate Director · Individual
Raczka, Joseph
Corporate Director · Individual
Richardson, Sarah
W-2 Managing Employee · Individual
Rogers, Luanne
W-2 Managing Employee · Individual
Ryan, Maria
Corporate Director · Individual
Shuster, Patricia
Corporate Director · Individual
Steinmetz, Thomas
Corporate Director · Individual
Zirkle, Karen
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
St Joseph Residence
Manchester, NH
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Hanover Hill Health Care Center
Manchester, NH
1-star overall rating with 1-star inspections with $8,512 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Mount Carmel Rehabilitation And Nursing Center
Manchester, NH
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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