St. Theresa Care Center

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure a dignified dining experience. This affected three (#60, #4 and #68) of three residents reviewed for dignity during meal service. The facility census was 76.

Inspectors wroteBased on medical record review, review of a facility submitted Self-Reported Incident (SRI), review of staff timecards and schedules, review of a police report, staff interview and policy review, the facility failed to prevent potential abuse following an allegation of staff to resident verbal abuse. This affected one (#30) of three residents reviewed for abuse. The facility census was 76.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure the residents had had access to their personal funds outside of normal business hours and on weekends. This affected one (Resident #9) of one resident reviewed for personal funds.

Inspectors wrote2. Review of the Resident #176's medical record revealed an admission date of 05/21/25. Diagnoses included rheumatoid arthritis, chronic pain syndrome, and fibromyalgia. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #176 had intact cognition. Review of Resident #176's care plan revealed a focus area initiated 05/21/25, indicating the resident was at risk for alteration in their comfort related to generalized pain, discomfort, fibromyalgia, chronic pain, depression, and rheumatoid arthritis. Interventions directed staff to administer analgesia per orders and to anticipate the resident's need for pain relief and to respond immediately to any complaints of pain. Review of the SRI dated 05/27/25 revealed Resident #176's family expressed to hospital staff that a facility staff member was rough and verbally mean to the resident. [...]

Inspectors wroteBased on staff interview, record review, review of Self-Reported Incidents (SRI) and time cards, and facility policy review, the facility failed to immediately protect the resident(s) from the alleged perpetrator(s) when a resident reported an allegation of staff-to-resident physical abuse. This affected one (Resident #176) of five residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer to the appropriate state-designated authority for a level II pre-admission screening and resident review (PASARR) when residents were diagnosed with a new mental illness diagnosis. This affected one (Resident #21) of five residents reviewed for PASARR.

Inspectors wrote2. Review of Resident #21's medical record revealed an admission date of 04/29/24 with a diagnosis of paranoid schizophrenia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe cognitive impairment and had an active diagnosis of schizophrenia. Resident #21's Preadmission Screening and Resident Review Result Notice dated 05/03/24, indicated the resident had no indications of a serious mental illness and/or developmental disability. During an interview on 06/10/25 at 1:31 P.M., Social Services Director (SSD) #105 stated she was responsible for the residents' PASARRs in the facility, but she did not know who was responsible to ensure the accuracy of the PASARR. SSD #105 stated she assumed the PASARR should be accurate when the resident admitted to the facility from a hospital. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the medications were securely stored. This affected one of five medications carts.

Inspectors wrote2. During a concurrent interview and medication administration observation on 06/12/25 at 6:39 A.M., Licensed Practical Nurse (LPN) #10 removed a Prilosec (reduces the amount of acid produced in the stomach) and vitamin B-12 (vitamin) tablet from a bottle, placed them in her bare hand before she placed the tablets in a medication cup, and proceeded to administer the medications to Resident #72. LPN #10 verified she touched the two medications with her bare hands and stated she should never touch the medications with her hands, the medication should be dispensed directly into a medication cup to prevent cross contamination. During an interview on 06/12/25 at 7:03 A.M., the Director of Nursing stated she expected when nurses dispensed medications, they should dispense the medications directly into medication cups without touching the medications. During an interview on 06/13/25 at 11:20 A. [...]

Inspectors wroteBased on record review, observation, staff interview, review of online resources from the Centers for Disease Control (CDC), and policy review, the facility failed to ensure staff utilized proper handwashing technique while completing wound care. This affected one (#15) of the three Residents (#13, #14, and #15) reviewed for wound care. The facility census was 65.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure medical appointments were scheduled timely and transportation was arranged for medical appointments. This affected one (Resident #45) of three residents reviewed for medical appointments. The census was 69.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interview, the facility failed to complete the comprehensive admission Minimum Data Set (MDS) assessment for Resident #12 within 14 days after admission. This affected one (#12) out of five residents reviewed for MDS assessments. The facility census was 66.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive person-centered care plan for Resident #12. This affected one (#12) out of five residents reviewed for care plans. The facility census was 66.

Inspectors wroteBased on staff interview, review of the facility policy, and record review, the facility failed to notify residents that the amount of funds in their accounts was 200 dollars less than the social security income resource limit and that the residents may lose eligibility for Medicaid or social security income. This affected three (#17, #19, and #31) of five residents reviewed for personal funds. The facility census was 56.

Inspectors wroteBased on medical record review, review of the facility policy, and staff interview, the facility failed to develop care plans for a resident's cognitive impairment, wandering, and activity needs. This affected two (#43 and #47) residents out of 17 residents reviewed for accuracy of assessments. The facility census was 56.

Inspectors wrote2. Review of Resident #17's medical record revealed Resident #17 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, major depressive disorder, muscle weakness, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact. Resident #17 required supervision from staff with transfers, dressing, eating, toileting, and personal hygiene. Resident #17 was independent with bed mobility. Review of Resident #17's care conferences from 11/15/22 to 05/18/23 revealed Resident #17 had one care conference completed on 01/04/23. Interview with Resident #17 on 05/15/23 at 10:54 A.M. revealed Resident #17 had not been invited to any care conferences and did not have the opportunity to participate in the development of his care plan. [...]

Inspectors wroteBased on record review, observations, staff interviews, and review of tube feed product and preparation guidance, the facility failed to ensure a resident's tube feed formula was properly dated and stored prior to administration. This affected one (#38) of two residents reviewed for tube feeds. The facility census was 56.

Inspectors wroteBased on record review, review of the facility policy, and staff interview, the facility failed to ensure the resident's skin conditions, discharge locations, and feeding tubes were accurately coded on the Minimum Data Set (MDS) assessment. This affected three (#23, #38, and #52) of 17 residents reviewed for accuracy of assessments. The facility census was 56.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to label open medications properly, and remove expired medications from active medication drawers. This affected three medication storage areas observed during the survey and had the potential to affect one (#15) resident on the [NAME] unit, two (#31 and #170) residents on the [NAME] unit who were identified by the facility as a newly admitted and any other resident who could use a stock supply of expired medications. Facility census was 72.

Inspectors wroteBased on record review, resident and staff interview, and review of facility policy, the facility failed to ensure a resident was afforded with dignity when staff failed to provide timely toileting assistance during meal time. This affected one (#26) of 18 residents sampled during the survey. The census was 72.

Inspectors wroteBased on medical record review, review of personal funds documentation, staff interview, and review of facility policy, the facility failed to obtain written authorization to manage resident personal funds. This affected one (#53) of five residents reviewed for personal funds. The census was 72.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide notification of transfer to the Ombudsman. This affected one (#57) of one reviewed for hospitalizations. The facility census was 72.

Inspectors wroteBased on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure accuracy of resident assessments regarding discharge status. This affected one (#72) of two closed records reviewed. The census was 72.

Inspectors wroteBased on observation, record review, and interview the facility failed to complete comprehensive care plans. This affected two (#65, & #120) out of 18 residents reviewed for care plans. Facility census was 72.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to provide activities of daily living (ADL) assistance to dependent residents. This affected one (#69) of three residents reviewed for ADLs. The census was 72.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of facility policy, the facility failed to change a resident's intravenous (IV) dressing as ordered by the attending physician. This affected one (#69) of 18 residents sampled during the survey. The census was 72.

Inspectors wroteBased on medical record review, resident and staff interview, and review of facility policy, the facility failed to adequately treat and manage resident pain. This affected one (#26) of four residents reviewed for pain management. The census was 72.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to ensure resident medication was available for administration. This affected one (#69) of five residents reviewed for medications. The census was 72.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy the facility failed to ensure resident's were free from unnecessary medications when staff failed to monitor pain level for residents receiving opioid pain medications. This affected two (#44 and #26) of six residents reviewed for medications. The census was 72.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to arrange for routine dental services for residents. This affected one (#69) of 18 residents sampled during the survey. The census was 72.

Inspectors wroteBased on medical record review, observations, and resident and staff interview, the facility failed to have all call lights functioning properly. This affected one (#32) out of 18 residents reviewed and observed for the initial pool for functioning of the call light system. Facility census was 72.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to display the state agency survey results, where residents and visitors could visibly access them. This had the potential to affect all 72 residents residing in the facility. Facility censes 72.