St. Theresa Care Center

In the surveyor’s words

From the most serious findings on record at St. Theresa Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Apr 9, 2024

  Based on record review, observations, interviews with staff and Environmental Specialist, review of the facilities approved water management plan and timeline and policy review, the facility failed to timely implement their approved water management plan to potentially prevent a Legionella outbreak. This affected one (#84) out of three residents reviewed for Legionella and had the potential to affect all 68 residents residing in the facility. The facility census was 68. Findings include: Review of the medical record for Resident #84 revealed the resident was originally admitted to the facility on [DATE] and was readmitted following a hospital stay on 10/24/23. Resident #84 left the faciity on [DATE], against medical advice. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2024

  Based on observation and staff interview, the facility failed to ensure the dishwasher was properly functioning to ensure the proper sanitation of dishes. This had the potential to affect 65 out of 65 residents who receive their meals from the kitchen, the facility identified one (#62) resident that received no food by mouth/no meals from the kitchen. The facility census was 66. Findings include: Observation of the facility's dishwasher on 01/09/24 at 8:50 A.M. revealed the temperature of the facility's dishwasher was 120 degrees Fahrenheit (F) but the chemicals were zero parts per million (PPM). There was no chemical observed going through the tubing from the chemical tubes to the dishwasher. The dishwasher was not observed to have any leaks. […]

• No harm, potential for more than minimal, widespreadF880Nov 10, 2021

  Based on observation, staff interview, facility policy review and review of online resources from Centers for Medicare and Medicaid Services (CMS), and Centers for Disease Control (CDC) guidelines, the facility failed to ensure staff were screened for COVID-19 to prevent the spread of COVID-19. This had the potential to affect all 73 residents who resided in the facility. Findings included: During entrance to the facility on [DATE] at 7:34 A.M. revealed no staff member present at the main entrance for symptom screening. Observation at same time revealed a screening log on the front counter and a thermometer. During review of the screening log, revealed only four people had screened themselves in on 10/29/21 from midnight through 7:23 A.M. when surveyor arrived. […]

• No harm, potential for more than minimal, patternF804Jan 12, 2026

  Based on observations, resident and staff interviews, review of Resident Council and Food Committee meeting minutes, observation of a meal test tray, and review of facility policy, the facility failed to ensure meals were served at palatable temperatures. This had the potential to affect all residents, except two (#1 and #5) identified by the facility as receiving no food from the kitchen. The facility census was 76.Findings include: Observations on 01/07/26 at 2:47 P.M. of the kitchen revealed the plate warmer equipment was not fully functional. Further observation revealed the hot plate pellet system only had one side of the equipment in service and could hold approximately 30 plates at a time. Interview on 01/07/26 at 2:47 P.M. […]

• No harm, potential for more than minimal, patternF880Jan 9, 2024

  Based on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure appropriate personal protective equipment was used in an isolation room. This affected one (#53) out of three residents reviewed for infection control practices. This had the potential to affect 16 (#42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #54, #55, #56, #57, #58) residents residing on the 3rd floor South Unit floor. The facility census was 66. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnosis of Clostridioides difficile (C-diff), anxiety, depression and dementia. Review of Resident #53 physician orders revealed an order dated 01/09/24 for Isolation: C-Diff. […]