St Therese of Woodbury LLC

In the surveyor’s words

From the most serious findings on record at St Therese of Woodbury LLC, in the surveyor’s own words.

• Actual harm, isolatedF689May 29, 2026

  Based on observation, interview, and document review, the facility failed to ensure safe use of a wheelchair without foot pedals and added cushions was assessed for 1 of 2 residents (R28) reviewed for falls. This resulted in actual harm when R28 fell from the wheelchair during transport, sustained a right leg fracture and required hospitalization. The facility had implemented actions to prevent recurrence prior to survey on 5/26/26, therefore the citation was issued at past noncompliance. Furthermore, the facility failed to provide supervision with meals for 1 of 1 resident (R61) reviewed for nutrition. […]

• Actual harm, isolatedF686Sep 17, 2024

  Based on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in actual harm for 2 of 3 residents when (R1) admitted with a stage 1 pressure ulcer that developed into an unstageable pressure ulcer and R2 admitted with a stage 2 pressure ulcer that developed into an unstageable pressure ulcer resulting in ongoing pain. Findings include: Definitions of pressure ulcers: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2025

  Based on observation, interview and record review the facility failed to ensure facial hair was covered when plating food for delivery and failed to ensure dishwasher temperatures were maintained at required temperatures needed for proper sanitization. Furthermore, the facility failed to ensure refrigerated items were removed after expiration from 1 of 2 unit kitchens reviewed. This had the potential to impact all residents who reside in the facility. Findings include: Facial hair An observation on 3/19/25 at 11:45 a.m., cook-A and cook-B were observed in the main kitchen plating food onto plates for delivery. Cook-A and cook-B both had facial hair and with no beard covers. […]

• No harm, potential for more than minimal, patternF919May 29, 2026

  Based on observation, interview, and document review, the facility failed to ensure that a resident's call light was accessible and within reach while the resident was in the shower for 1 of 1 resident (R47) reviewed for call light accessibility. This failure had the potential to impact all residents who use the shower. Findings include:R47's quarterly Minimum Data Set (MDS), dated [DATE], identified that R47 was cognitively intact and had diagnoses of hemiplegia and hemiparesis (severe or complete paralysis of one side of the body) following a cerebral infarction (stroke) affecting the left non-dominant side, heart failure, abnormalities of gait and mobility, and muscle weakness. […]

• No harm, potential for more than minimal, patternF880May 23, 2024

  Based on observation, interview and record review the facility failed to ensure 1 of 1 residents (R360) colonized with a multidrug resistant organism (MRDO) was placed on enhanced barrier precautions (EBP). This had the potential to impact all residents who reside in the facility. Furthermore, the facility failed to ensure proper hand hygiene and glove use was utilized for 1 of 1 residents (R360) observed during personal cares. Findings include: R360's face sheet printed 5/22/24, indicated R360 was recently admitted and had a diagnosis of a traumatic subdural hematoma (head bleed). R360's care plan dated 5/15/24, indicated R360 required assist of one for toileting and had occasional incontinence. […]