St. Teresa Nursing & Rehab Center

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

a Discharge Plan had not been completed for Resident #1 when they issued a Discharge Notice on 11/26/25 to the Resident's responsible party. The BOM said she had placed several telephone calls and had not been able to contact the resident's responsible party by telephone, and they had not attempted any other means to reach the responsible party to see what type of arrangements they were making to transfer

the resident who was on mechanical ventilation/tracheostomy and was in a permanent vegetative state. The BOM said they were planning on calling in a complaint to APS for exploitation but were waiting until the last day of the 30-day discharge notice to file the report.During an interview and record review of Care Plan Conference Notes on 12/19/25 at 4:03 PM, LVN L MDS Nurse revealed Social Worker T had not written Care Plan Conference notes for 12/10/25, because she had quit without notice on 12/11/25. LVN L MDS Nurse said the care plan did not have a Discharge Plan. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. Review of facility's undated policy and procedure on Discharge Planning Process Policy provided by the Administrator on 12/19/25 at 4:41 PM, revealed Nursing Facility must complete discharge planning when you anticipate discharging a resident to a private residence, another Nursing Facility or Skilled Nursing Facility, or another type of residential facility. Discharge Planning includes: Assessing the resident's continuing care needs, including: Consideration of the resident's and family/caregiver's preferences for care; How services will be accessed; and How care should be coordinated among multiple caregivers, as applicable; Include regular re-evaluations of the resident to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed to reflect these changes. Assisting the resident and family/caregivers in locating and coordinating post-discharge services. Refer to Section Q of the RAI manual.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Teresa Nursing & Rehab Center

10350 Montana Avenue El Paso, TX 79925

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

bladder of urine. Procedure documented in part: Gently tug on the catheter to ensure a proper and secure placement in the urinary bladder. Connect the catheter end to closed drainage system. Place the catheter over the leg and position to not put pressure on urethra. The surveyor requested a policy and procedure on catheter care on 12/19/25 at 9:43 AM. The DON did not provide the policy prior to exit. Review of facility's

on Perineal Care effective 05/11/25 provided by DON on 12/19/25 revealed, Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition.

Procedure: Wipe across the pubis area. Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area-CLEAN to DIRTY! Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protects the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened wipes for each stroke. Reposition the resident to their side. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Teresa Nursing & Rehab Center

10350 Montana Avenue El Paso, TX 79925

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0850 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

enteral feeding via G-tube, had multiple stage VI pressure ulcers that were present upon admission to the facility and a DTI on left heel. LVN L MDS Nurse said the Social Worker would initiate interdisciplinary discharge plan to ensure resident's needs would be met after discharge from the facility. She said the facility had not initiated a Discharge Plan for Resident #1 when the facility had issued the Notice of discharge on [DATE REDACTED]. During an interview and record review of Resident #1's Care Plan Conference Notes

on 12/19/25 at 4:03 PM, LVN L MDS Nurse revealed the new Social Worker T had not written Care Plan Conference notes for 12/10/25 in Resident #1's clinical record, because she had quit without notice on 12/11/25. LVN L MDS Nurse said SW T had not initiated a Discharge Plan for Resident #1 when the facility had issued the Discharge Notice on 11/26/25. She said she did not know why the facility had not conducted

the orientation for discharge planning as scheduled for 12/05/25. Review of advertisement dated 12/11/25 provided by the Administrator revealed they were hiring a Social Worker. The state surveyor requested a copy of the Social Worker Job Description on 12/18/25 at 12:45 PM, and it was not provided by the facility Administrator prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Teresa Nursing & Rehab Center

10350 Montana Avenue El Paso, TX 79925

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bowel and bladder. She said that failure to follow EBP placed the staff and residents at risk of cross-contamination and spread of infections. During an interview on 12/19/25 at 9:39 AM, CNA I, in the presence of LVN H Charge Nurse, said EBP was no longer needed for Resident #3 because her catheter had been discontinued. The LVN, said, The catheter was discontinued. However, the resident still needs to be on EBP because she had a G-Tube and pressure ulcer. The CNA, said I was rushing to get residents up for the scheduled Christmas activity this morning and forgot to follow EBP when I entered [Resident #'3] room to assist LVN H turn the resident to the side to check the resident's skin on her buttocks for skin breakdown. During an interview on 12/19/25 at 9:51 AM DON stated the licensed staff and CNAs had been trained on EBP to reduce transmission of multidrug-resistant organisms, and the staff should use a gown and gloves during high contact resident care activities. He said EBP should be followed when changing briefs or assisting with toileting, turning and repositioning or assisting with bed mobility, if the resident has any indwelling medical device such as G-Tube, or has a history of MDROs and pressure ulcers. During an

interview on 12/19/25 at 2:06 PM RN N revealed they had been trained on EBP to reduce transmission of multidrug-resistant organisms, and the staff should use a gown and gloves during high contact resident care activities with residents that had any type of indwelling medical device, wounds, history of multi-drug-resistant organisms. She said she monitored during rounds that the CNAs followed EBP. Review of facility's policy and procedures on Enhanced Barrier Precautions effective 4/1/2024 provided by DON on 12/19/25 revealed, Enhanced Barrier Precaution (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Colonization with a CDC targeted MDRO when Contact Precautions do not otherwise apply. Wounds and/or indwelling catheter devices even if the resident is not known to be infected or colonized with a MDRO.

Indwelling medical device examples include central lines, urinary catheter, feeding tubes, and tracheostomies. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. Donning PPE for Resident on EBP Based on Activity Provided/Assistance While in Resident Room: Administer medications enterally; Perform wound care; changing briefs or assisting with toileting; turn and reposition or assist with bed mobility; dressing a resident; bathing/showering; providing hygiene; changing linen; device care or use-urinary catheter, feeding tube, tracheostomy/ventilator; any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device.

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Facility ID:

If continuation sheet