Health inspection·January 6, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were complete and accurately documented for 1 of 4 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's inventory record accurately documented items for the resident during her stay at the facility. This failure could place residents at risk of lost, missing or stolen items. Findings include: Record review of Resident #3's face sheet, dated 01/06/24, revealed admission on [DATE], re-admission on [DATE] and most recent re-admission on [DATE] to the facility. Record review of Resident #3's history and physical, dated 04/12/24, revealed an [AGE] year-old female with a diagnosis which included Dementia (neurological conditions that cause a person to lose the ability to think, remember, and reason to the point that it interferes with their daily life). Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 8, which indicated severely impaired cognition. Resident #3 was able to recall or make daily decisions. Record review of Resident #3's Care Plan, reviewed on 08/08/23, revealed impaired cognitive function or impaired thought. Administrator meds as ordered. Record review of Resident #3's Inventory Sheet, dated 02/10/23, revealed clothing/shoes/outer wear/ furniture/other items to be coded as Not Applicable. For jewelry, watches, etc. (used to avoid giving a complete list) was coded for Nothing of Significant Value. Record review of Resident #3's Grievances for 10/21/24 and 12/20/24, revealed no documentation regarding a lost, missing, and or stolen blanket. During an interview on 01/02/24 at 2:19 PM with the DON, he stated he received a grievance from Family Member B which indicated she bought a Christmas blanket to Resident #3. The DON stated the next day Family Member B mentioned the blanket was stolen. The DON stated the blanket appeared to be a little off but looked the same before when it was bought too Resident #3. The DON stated the Administrator replaced the blanket. The DON stated during admission a residents items needed to be (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676342 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676342 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)