St. Teresa Nursing & Rehab: Catheter Care Failures - TX
That gap matters because catheter care, done wrong, is one of the more direct routes to infection for nursing home residents. A catheter threaded into the bladder and left without proper maintenance or positioning creates a pathway for bacteria. The residents affected here were described in the inspection record as some, not one or two.
The surveyor made the request at 9:43 in the morning. The director of nursing had the rest of the inspection day to locate and hand over a policy governing how staff were supposed to handle urinary catheters for residents in their care. It didn't happen.
What the facility did provide was a perineal care policy, effective May 11, 2025, handed over the same day inspectors asked. That document spelled out, in clinical detail, how staff were supposed to clean residents, wiping from the urethral area toward the rectal area, front to back, one side of the labia majora and then the other, using a clean section of washcloth or pre-moistened wipe for each stroke. For residents with a Foley catheter, the policy called for gently washing the junction where the tubing meets the urethra, moving downward along the catheter about three inches.
The facility's own catheter procedure documentation, what inspectors did manage to review, described the correct steps in general terms: tug gently on the catheter to confirm secure placement in the bladder, connect to a closed drainage system, position the catheter over the leg in a way that avoids putting pressure on the urethra.
Those are the written standards. Whether they were being followed in practice was the question inspectors were there to answer, and the failure to produce a catheter care policy on request left that question without a complete answer.
The inspection was a complaint survey, meaning someone had raised a concern serious enough to send surveyors to the facility. The December 19 visit was the result of that complaint. The deficiency was tagged under F0690, which covers urinary catheters and the care surrounding them, and was cited at a level indicating minimal harm or potential for actual harm to some residents.
Minimal harm is a regulatory classification, not a guarantee that nothing went wrong. It means inspectors did not document evidence of serious injury during this visit. It does not mean the residents with catheters at St. Teresa were not at risk.
Catheter-associated urinary tract infections are among the most common infections acquired in long-term care settings. They are also largely preventable with consistent, properly performed care. The protocol the facility had on paper for perineal care was detailed and medically sound. The problem inspectors flagged was structural: a missing policy for catheter care itself, and a director of nursing who could not locate it under pressure.
St. Teresa Nursing & Rehab Center sits on Montana Avenue in east El Paso, a facility licensed to care for some of the city's most medically dependent residents, many of whom rely on staff for hygiene care they cannot perform themselves. Residents with indwelling catheters have no way to monitor their own catheter placement, drainage, or cleanliness. They depend entirely on the people assigned to care for them, and on the policies those people are supposed to follow.
The director of nursing had until the end of the inspection day. The policy was never provided.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Teresa Nursing & Rehab Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
ST. TERESA NURSING & REHAB CENTER in EL PASO, TX was cited for violations during a health inspection on December 19, 2025.
That gap matters because catheter care, done wrong, is one of the more direct routes to infection for nursing home residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.