St. Teresa Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at St. Teresa Nursing & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 16, 2025

  Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse was provided for 2 (Resident #1 and Resident #2) of 8 residents reviewed for abuse, in that: The facility failed to protect Resident #1 from abuse on 3/20/25 when Resident #1 hit Resident #2 on the face. As a result, there was bruising immediately starting to form on Resident #1's right side of face close to the right [NAME], bruising notes to right hand on knuckles, and bruise noted to right shin. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/20/2025 and ended on 03/25/2025. […]

• Actual harm, isolatedF689Apr 25, 2024

  Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #10) of 10 residents reviewed for assistance with ADL's. CNA G failed to ask for assistance on 3/7/24 when providing perineal care to Resident #10, who required 2-person assistance, that resulted in fall with injury. This failure resulted in actual harm to Resident #10 on 03/07/24. It was determined to be past non-compliance due to the facility having implemented action that corrected it before the investigation began. […]

• Actual harm, isolatedF689Jun 9, 2023

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 6 (Resident #2, Resident #5 and Resident #6) residents reviewed for Hoyer lift transfer. The facility failed to ensure Resident #2 had a safe Hoyer lift transfer which resulted in nose bone fracture. The facility failed to ensure Hoyer lift brakes were in place when transferring Resident's #5 and #6. These failures could place residents at risk of injuries due to not placing breaks in Hoyer lift as suggested from manufacturer. Findings included: Resident #2 Record review of Resident #2's face sheet dated 6/9/23 revealed a [AGE] year-old male admitted on [DATE]. […]

• Actual harm, isolatedF689Oct 10, 2022

  Based on interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent an accident for 1 of 5 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure SNA B and SNA C used the shower gurney which required lock pins to secure and hold side rails to the gurney. This resulted in Resident #1 falling from the shower gurney and sustaining a non-displace nasal fracture. This failure resulted in actual harm to Resident #1 on 9/29/2022. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. […]

• Actual harm, isolatedF689Dec 17, 2021

  Based on observations, interviews and record review the facility failed to ensure the resident environment remains free of accident hazards and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for bed mobility and incontinent care in that: CNA's provided bed mobility and incontinent care without following Resident's #1 care plan resulting in fracture to the left femur (leg). This failure placed residents at risk for accident/hazard which could cause injuries. […]