St. Teresa Nursing & Rehab Center
ST. TERESA NURSING & REHAB CENTER in EL PASO, TX — inspection on December 19, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Teresa Nursing & Rehab Center
10350 Montana Avenue El Paso, TX 79925
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Teresa Nursing & Rehab Center
10350 Montana Avenue El Paso, TX 79925
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/19/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St.
Teresa Nursing & Rehab Center
10350 Montana Avenue El Paso, TX 79925
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: