Health inspection·December 19, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the discharge needs of each resident are identified and the discharge planning process results in the development of a discharge plan for each resident for 1 (Resident #1) of 4 residents reviewed for discharge planning. The facility failed to develop a discharge plan when Resident #1 was issued a 30-Day Discharge Notice on 11/26/25 due to non-payment. This failure could result in residents experiencing psychosocial harm due to inappropriate discharges and placed residents at risk of being discharged without alternate placement and not having access to available advocacy services, discharge/transfer options, and denying them their rights in the appeal process. Findings included:Record review of Resident #1's admission Record revealed Original admission Date 05/28/25 and re-admission Date 09/10/25. Record review of Resident #1's History & Physical dated 11/17/25 revealed [AGE] year-old female with past medical history of CAD (heart's arteries get clogged with plaque, making them narrow and stiff, so they cannot deliver enough oxygen-rich blood to your heart muscle), DM (a condition where the body has too much sugar in the blood because it does not make enough insulin or cannot use it well), heart failure (the heart muscle becomes weak, stiff, or enlarged, causing blood to back up and fluid to build in the lungs and limbs), COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra mucus, and air flow obstruction), PVD (circulation problem where narrowed or blocked blood vessels outside your heart and brain reduce blood flow to your limbs and organs due to plaque buildup), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), prior CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), CKD 3 (kidneys have moderate damage and are not filtering waste and extra fluid as well as they should) , anoxic encephalopathy (is a severe brain injury from a complete lack of oxygen, causing brain cells to die rapidly), who underwent cardiac arrest. Unable to be extubated (removal of breathing tube from the throat and windpipe after being on a ventilator to help with breathing and remains ventilator dependent), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to bypass a blocked airway, to help with breathing, or remove secretions, providing a direct path for oxygen to the lungs), dysphagia (difficulty swallowing), and peg placement (feeding tube placed directly through the stomach to deliver food, liquids, and medicine). Pt. is bedbound. Stage IV sacral wound, stage IV to left buttocks and right buttocks. Air mattress, change position every two hours, keep area dry with foley (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or for various medical reasons), Provide heel protectors while in bed. Wound care to evaluate and treat. Interface with nutritional/dietary services. Resident does not follow commands, does not blink to threat, no purposeful movements seen. Social Services for Page 1 of 13 676342 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discharge. The resident's family members desire the use of all life-sustaining measures, including, but not limited to cardiopulmonary resuscitation, intubation (a flexible breathing tube placed through the mouth or nose, down into the windpipe to keep the airway open, allowing a machine to help the person breath, deliver oxygen, or remove blockages), use of mechanical ventilation, and use of pressors (are powerful medicines used in emergencies to rapidly raise dangerously low blood pressure by squeezing blood vessels and making the heart beat stronger), We will therefore monitor progress and adjust treatment plan as clinical conditions change. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed reentry date 09/10/25. Section B - B0100. Persistent vegetative state/no discernible consciousness. Section: GG0115 - Functional Limitation in Range of Motion impairment on both sides of upper and lower extremities. Section GG - GG0130. Dependent with toileting hygiene. Indwelling catheter and incontinent of bowel. Active Diagnoses: CAD, heart failure, hypertension, PVD, DM, CVA, COPD, persistent vegetative state (person is awake, eyes opened, sleep-wake cycles, but has lost the ability to think, be aware of themselves or their surroundings, or respond to commands, even though the basic life functions work due to an intact brainstem) , anoxic brain damage (the brain is completely deprived of oxygen, resulting in significant cognitive, physical, and emotional deficits, potentially causing coma or death). Section Q: Family participated in assessment and goal setting. Q0310. Resident's Overall Goal was left blank. Q0400. Discharge Plan. Is active discharge planning already occurring for the resident to return to the community? No. Q0610, Referral. Has a referral been made to the Local Contact Agency? No. Q0620. Reason Referral to Local Contact Agency (LCA) not made code 3 Referral not wanted. Review of Resident #1's admission Agreement dated 05/28/25 revealed family member was designated as resident's responsible party. Authority: Resident authorizes Responsible Party to make: Financial decisions. Admission, care and discharge decisions. Other decisions related to Resident's personal property and well-being. Primary contact for this Resident. Obligations of Resident/Responsible Party. Responsible Party means a person who: has legal access to the resident's income or resources available to pay for nursing facility care; and has signed an admission agreement or other contract with the facility in which the person agrees to provide payment for the resident's facility care from the resident's income or resources. Financial Agreement: If Resident will not be managing her own financial resources, she may designate a Responsible Party with authority to manage Resident's financial resources and pay for goods and services provided by Health Care Center from Resident's funds. Resident and/or Responsible Party agree to pay for all charges for goods and services provided to Resident pursuant to Health Care Center admission and Financial Agreement, including basic charges and all additional charges for ancillary goods and services requested by Resident and/or Responsible Party. The admission Agreement was signed by responsible party on 05/28/2025. Review of Resident #1's email sent to resident's responsible party on 11/26/25 revealed, Resident #1 would be discharged from the facility on 12/26/25. This discharge is based on your failure, after reasonable and appropriate notice, to pay for provided services and your stay at this facility. The facility staff will work with you to make preparations needed to ensure a safe and orderly transition. An orientation for discharge planning will be held on 12/05/2025. If there is a conflict with this date, we will be happy to reschedule to a mutually agreeable time prior to the date of discharge. Resident #1 will be discharged to the following address: TO BE DETERMINED DURING DISCHARGE PLANNING. You have Fraud and Civil Rights Handbook. Requests must be made within 90 days. A copy of this letter was sent to the local Ombudsman. Review of Resident #1's Care Plan dated 12/15/25 revealed Discharge Care Plan had not been initiated when Discharge Notice was issued on 11/26/25 676342 Page 2 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few due to non-payment of applied income. Review of Report Summary sent to APS on 12/19/25 to report an allegation of exploitation for Resident #1 revealed the resident's daughter was refusing to pay the applied income and using her money for possible financial exploitation. The resident's responsible party is using resident's resources to pay for utilities in the community, home insurance, car payments and loans.Telephone call was placed to resident's responsible party on 12/18/25, no answer. Left message to call the surveyor back. Responsible Party did not return call prior to exit. During an interview on 12/18/25 at 12:28 PM DON reported they have not had a Social Worker since December 11, 2025. He said the Social Worker was responsible for initiating Discharge Plans as soon as possible once they knew that the resident was going to be discharged . He said he and the ADONs were helping with handling Discharge Planning until they hired a social worker. During an interview on 12/18/25 at 3:45 PM Administrator revealed Social Worker S's last day was 11/14/25. She said they had hired new Social Worker T, on 11/24/25 and Social Worker T was terminated on 12/11/25. She said she was in the process of interviewing to hire a new social worker. She said the DON and ADONs were helping with handling Discharge Planning. She said the discharge notice was issued due to non-payment of applied income. She said they were waiting for the 30 days from the date that the discharge notice was issued, to file a complaint with APS for exploitation by resident's responsible party who was not paying the applied income for several months. The Administrator stated they had not started a Discharge Plan when the Discharge Notice was issued to the resident's responsible party on 11/26/25. She said the resident's family had made no attempts to contact the family regarding discharge notice. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. She said, since the responsible party has not made plans for discharge. The resident will have to stay at the facility until the family makes plan for a safe discharge, since the resident is on mechanical ventilation and tracheostomy.During an interview on 12/19/25 at 10:15 AM, RN J MDS Nurse and LVN L MDS Nurse revealed Resident #1 was in a permanent vegetative state, did not respond to verbal and/or painful stimuli, was on mechanical ventilation/tracheostomy, enteral feeding via G-tube, had multiple stage VI pressure ulcers that were present upon admission to the facility and a DTI on left heel. LVN L MDS Nurse said the Social Worker was responsible for initiating the interdisciplinary discharge plan to ensure resident's needs would be met after discharge from the facility. She said the facility had not initiated a Discharge Plan for Resident #1 when the facility had issued the Notice of discharge on [DATE]. During an interview on 12/19/25 at 2:33 PM, Business Office Manager Q revealed Resident #1's family member who was the responsible party had been assigned Representative Payee a few months ago and she was not paying the facility the applied income amount of $2,191.17 a month and currently owed the facility $7257.35. She said the responsible party had only made an $800.00 payment. She said that was why they had issued 30 day Discharge Notice on 11/26/25. She said she had been calling the resident's responsible party, and she did not answer the telephone calls. She said she had emailed the resident's responsible party the online payment link on 10/01/2025 and she still had not made any payments to the facility. During an interview on 12/19/25 at 2:40 PM the Administrator revealed she did not know if Social Worker T had developed a Discharge Plan for Resident #1 when the facility issued a Notice of discharge on [DATE] to the resident's responsible party. She said the BOM, and the DON had been dealing with the family because they did not have a Social Worker. She said multiple attempts had been made by the BOM to reach the responsible party by telephone and she had not returned any of the calls. She said they had not attempted using any other type of means to contact the responsible party to assist her in developing a Discharge Plan. During an interview on 12/19/25 at 3:54 PM, the Administrator, DON, and Business Manager Q revealed that 676342 Page 3 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a Discharge Plan had not been completed for Resident #1 when they issued a Discharge Notice on 11/26/25 to the Resident's responsible party. The BOM said she had placed several telephone calls and had not been able to contact the resident's responsible party by telephone, and they had not attempted any other means to reach the responsible party to see what type of arrangements they were making to transfer the resident who was on mechanical ventilation/tracheostomy and was in a permanent vegetative state. The BOM said they were planning on calling in a complaint to APS for exploitation but were waiting until the last day of the 30-day discharge notice to file the report.During an interview and record review of Care Plan Conference Notes on 12/19/25 at 4:03 PM, LVN L MDS Nurse revealed Social Worker T had not written Care Plan Conference notes for 12/10/25, because she had quit without notice on 12/11/25. LVN L MDS Nurse said the care plan did not have a Discharge Plan. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. Review of facility's undated policy and procedure on Discharge Planning Process Policy provided by the Administrator on 12/19/25 at 4:41 PM, revealed Nursing Facility must complete discharge planning when you anticipate discharging a resident to a private residence, another Nursing Facility or Skilled Nursing Facility, or another type of residential facility. Discharge Planning includes: Assessing the resident's continuing care needs, including: Consideration of the resident's and family/caregiver's preferences for care; How services will be accessed; and How care should be coordinated among multiple caregivers, as applicable; Include regular re-evaluations of the resident to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed to reflect these changes. Assisting the resident and family/caregivers in locating and coordinating post-discharge services. Refer to Section Q of the RAI manual. 676342 Page 4 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent with bowel and bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #1 and Resident #2) of 4 residents reviewed for incontinence care. - The facility failed to ensure Resident #1's and Resident #2's foley catheter drainage tubes were secured with Catheter Holder prior to turning & repositioning the residents in bed. - The facility failed to ensure CNA B provided perineal care according to facility policy and procedure for Resident #1 when she failed to clean the perineal area from front to back when providing perineal care on 12/18/25. These failures placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Findings included:Resident #1Record review of Resident #1's admission Record revealed Original admission Date 05/28/25 and re-admission Date 09/10/25. Record review of Resident #1's History & Physical dated 11/17/25 revealed [AGE] year-old female with past medical history of CKD 3 (kidneys have moderate damage and are not filtering waste and extra fluid as well as they should) change position every two hours, keep area dry with foley (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or for various medical reasons).Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed reentry date 09/10/25. Section B - B0100. Persistent vegetative state/no discernible consciousness. Section: GG0115 - Functional Limitation in Range of Motion impairment on both sides of upper and lower extremities. Section GG - GG0130. Dependent with toileting hygiene. Indwelling catheter and incontinent of bowel. Review of Resident #1's Care Plan dated 12/15/25 revealed resident was incontinent of bowel. Goal: The resident will not have any complications r/t bowel incontinence. Interventions: Provide perineal care after each incontinent episode. Resident #1 has an ADL Self-Care performance deficit: Toilet use: requires staff x 2 for assistance. The Care plan did not address Resident#1 had a foley catheter. Review of Physician's Order Summary for Resident #1 revealed, Order Date: 10/17/25 Urinary Catheter using 16 FR (the size of the tube)/10 ml bulb to gravity drainage every shift related to neuromuscular dysfunction of bladder (a nerve damage from injury or disease that the signals between your brain and bladder muscles to be interrupted, making it hard to hold or release urine, causing incontinence, sudden urges, or inability to empty fully), Provide catheter care every shift. During an observation and interview on 12/18/25 at 1:07 PM with RN A Treatment Nurse and CNA B, revealed Resident #1 had an EBP sign posted on the wall by the entrance to the resident's room. Upon entering the room, the nurse and CNA washed their hands and put on a gown and gloves. The resident was asleep in bed, lying on her back. Resident's indwelling catheter was draining light yellow urine, and the drainage bag was hanging from the bed frame and was stored in a dignity bag. It was observed that the Catheter Holder was loose and hanging on the catheter tubing. The tube feeding was turned off and the CNA lowered the HOB. When CNA B released the tabs on the side of the disposable brief, it was observed that the wound dressing on the sacral area was intact and had loose fecal matter on the edges of the dressing. It was observed that the brief was saturated with loose brown stool covering the pubis area (the rounded, fatty mound above the genital that gets pubic hair) and buttocks. The RN and CNA placed a disposable pad under the resident. The brief was rolled down towards the rectal area and the CNA started to clean the resident with pre-moistened cleaning wipes from back to front with the cleaning wipes that were full of loose stool. She again cleaned the resident's pubis area using clean wipes and again cleaned the resident from back to front. The RN assisted the CNA to turn the resident to 676342 Page 5 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the left side and continued to clean the buttocks, rectal area and inner thighs with cleaning wipes. The CNA used multiple clean wipes after each stroke to clean the resident, until the resident was clean for the treatment nurse to proceed with wound care. The CNA said, The Catheter Holder comes off when the residents are showered or when cream is applied. I will let the nurse know that the Catheter Holder needs to be replaced.During An interview on 12/18/25 at 1:36 PM CNA B revealed she had been trained in providing Perineal Care to incontinent residents. She said she was trained to wipe the female residents working from front to back, using pre-moistened cleansing wipes to protect the small opening at the tip of the urethra and the vaginal opening from fecal matter to prevent cross contamination and infection; clean the inner thigh with cleaning wipes, and if a resident has a foley catheter to clean the catheter tubing with clean pre-moistened wipes. She said they had been trained to make sure the foley catheter tubing was placed in the Catheter Holder located on the top part of the inner thigh to prevent injury to the urethra when moving the resident in bed. She said they had been trained to immediately report to the nurses when the Catheter Holder fell off, so the nurses can reapply the Catheter Holder as soon as possible to prevent injury to the residents.During an interview on 12/18/25 at 1:45 PM CNA C revealed CNAs had been trained to immediately report to the nurses when the Catheter Holder fell off the inner thigh, so the nurses could reapply the Catheter Holder as soon as possible to prevent injury to the residents. She said they had been trained on perineal care and should wipe a female resident from front to back to prevent cross contamination of the urethra and vaginal area to prevent urinary tract infections. During an interview on 12/18/25 at 1:49 PM LVN Charge Nurse D on the 400 Hall assigned to Resident #1 revealed, she was in a vegetative state, did not respond to verbal or painful stimuli, required total assistance of two persons with Activities of Daily Living, had an indwelling catheter, and was incontinent of bowel. He said CNAs had been trained on how to provide incontinent care and should always clean the female residents from front to back to prevent fecal matter from getting on the urethra and vagina to prevent cross contamination that could result in urinary tract infections. He said that residents that had an indwelling catheter must always have a Catheter Holder on the inner thigh to prevent pulling and putting pressure on their urethra when the residents are turned and repositioned in bed. He said the Catheter Holders frequently fall off and do not stay in place when the residents are showered or when lotion is applied and should be replaced right away to prevent injury to the residents. He said the CNAs had been trained to immediately report to the nurses when the Catheter Holder falls off the inner thigh. He said that failure to place the catheter in the Catheter Holder could result in trauma to the urethra and cause injury and bleeding. During an interview and observation on 12/19/25 at 9:06 AM, CNA R, in the presence of RN G Regional Compliance Nurse, had repositioned Resident #1 on her back at 8:30 AM, after she showered the resident. It was observed that the resident's Catheter Holder had come loose and was hanging from the catheter drainage tube. CNA R said the Catheter Holders come off when the residents are showered or when lotion is applied. She said they had been trained to immediately report to the nurses if the Catheter Holder falls off the resident's inner thigh. She said that failure to keep the catheter tubing in the Catheter Holder, placed the resident at risk of trauma to the urethra when the resident was moved in bed. She said, I will notify the nurse right away. During an interview on 12/19/25 at 9:51 AM DON revealed the CNAs had been trained on perineal care and were trained to clean the female resident from front to back to prevent contamination of the urethral area that could result in urinary tract infections. He said licensed staff and CNAs had been trained on using Catheter Holders on all residents that had foley catheters to prevent trauma to the urethra and bleeding. He said the Catheter Holder should immediately be replaced by the licensed staff when the 676342 Page 6 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Catheter Holder becomes detached. During an interview on 12/19/25 at 2:06 PM RN N revealed the CNAs had been trained on perineal care and were trained to clean the female resident from front to back to prevent contamination of the urethral area that could result in urinary tract infections. She said CNAs had been trained in using Catheter Holders on all residents that had foley catheters to prevent trauma to the urethra and bleeding. She said the Catheter Holder should immediately be replaced by the licensed staff when the Catheter Holder becomes detached. Resident #2 Record review of Resident #2's admission Record revealed Original admission Date 05/10/25 and re-admission Date 12/11/25. Record review of Resident #2's History & Physical dated 12/15/25 revealed [AGE] year-old male with past medical history of chronic indwelling catheter and history of ESBL in urine (urinary tract infection caused by a bacteria that produce an enzyme resistant to many common antibiotics). Record review of Resident #2's admission MDS assessment dated [DATE] revealed reentry date 11/10/25. No speech. Indwelling catheter. Always incontinent of bowel. Stage 3 pressure ulcer present on admission. Review of Resident #2's Care Plan dated 11/30/25 revealed Resident was incontinent of bowel. Intervention: Provide perineal care after each incontinent episode. Resident has neuromuscular dysfunction of and has an indwelling foley catheter. Interventions: Ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra. Monitor/document pain/discomfort due to catheter. Review of Physician's Order Summary for Resident #2 revealed, Order Date: 10/17/25 Urinary Catheter using 16 FR/5 ml bulb to gravity drainage every shift related to neuromuscular dysfunction of bladder. Provide catheter care every shift. Ensure catheter strap in place and holding, every shift. Change as needed. During an observation and interview on 12/19/25 at 6:54 AM - 7:13 AM, with RN A Treatment Nurse and CNA B, an EBP sign was posted on the wall in the hallway by the entrance to Resident #2's room. Upon entering the room, the Treatment Nurse and CNA washed hands and put on an isolation gown and gloves. Resident #2 was lying in bed awake, turned to his left side, and he was on an air pressure mattress. It was observed that resident had a disposable brief soiled with loose feces, and there was a wound dressing on the sacral area that was intact and was clean. The resident had an indwelling catheter, draining light yellow urine. It was observed that the Catheter Holder was not attached to the skin on the inner thigh and was hanging from the catheter drainage tube. The CNA said the Catheter Holder detached easily when they move the residents in bed, or when they bathe and apply lotion.During an observation and interview on 12/19/25 at 9:14 AM with CNA B, Resident #2 had a bowel movement and she needed to change the brief and needed to get another CNA to help her turn the resident. Upon entering the room, both CNAs washed their hands, put on isolation gowns and gloves. The resident was turned towards the window on his left side, using the bed sheets to move the resident. It was observed that the brief had loose stool, and the resident was cleaned with pre-moistened cleaning wipes. It was observed that the resident's Catheter Holder on the right thigh was not attached to the thigh. CNA B stated she would tell the nurse that the Catheter Strap was detached and needed to be replaced as soon as they finished changing the resident. During an observation and interview on 12/19/25 at 9:19 AM with LVN D Charge Nurse assigned to Resident #2, the resident had been showered that morning and the Catheter Holder had been replaced after the shower. He said the CNAs had been trained to notify the nurse when the Catheter Holder comes off, so a new one can be reapplied, right away to prevent trauma to the urethra by pulling on the catheter and causing bleeding. He said, the CNA had not reported to him that the Catheter Holder had become loose after the resident was placed in bed. He said he would go and re-apply another Catheter Holder. Review of facility's undated Catheter Insertion Policy & Procedure provided by DON on 12/19/25 revealed, Female and male catheterization is the insertion of a catheter into the urinary bladder via the urethra to drain the 676342 Page 7 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bladder of urine. Procedure documented in part: Gently tug on the catheter to ensure a proper and secure placement in the urinary bladder. Connect the catheter end to closed drainage system. Place the catheter over the leg and position to not put pressure on urethra. The surveyor requested a policy and procedure on catheter care on 12/19/25 at 9:43 AM. The DON did not provide the policy prior to exit. Review of facility's on Perineal Care effective 05/11/25 provided by DON on 12/19/25 revealed, Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Procedure: Wipe across the pubis area. Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area-CLEAN to DIRTY! Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protects the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened wipes for each stroke. Reposition the resident to their side. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area. 676342 Page 8 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis. The facility failed to have a full-time social worker since 12/11/25, to address Grievances and complete Discharge Plans. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included:Record review of Resident #1's admission Record revealed Original admission Date 05/28/25 and re-admission Date 09/10/25. Record review of Resident #1's History & Physical dated 11/17/25 revealed [AGE] year-old female with past medical history of CAD (heart's arteries get clogged with plaque, making them narrow and stiff, so they cannot deliver enough oxygen-rich blood to your heart muscle), DM (a condition where the body has too much sugar in the blood because it does not make enough insulin or cannot use it well), heart failure (the heart muscle becomes weak, stiff, or enlarged, causing blood to back up and fluid to build in the lungs and limbs), COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra mucus, and air flow obstruction), PVD (circulation problem where narrowed or blocked blood vessels outside your heart and brain reduce blood flow to your limbs and organs due to plaque buildup), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), prior CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), CKD 3 (kidneys have moderate damage and are not filtering waste and extra fluid as well as they should) , anoxic encephalopathy (is a severe brain injury from a complete lack of oxygen, causing brain cells to die rapidly), who underwent cardiac arrest. Unable to be extubated (removal of breathing tube from the throat and windpipe after being on a ventilator to help with breathing and remains ventilator dependent) and remains ventilator dependent, tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to bypass a blocked airway, to help with breathing, or remove secretions, providing a direct path for oxygen to the lungs), dysphagia (difficulty swallowing), and peg placement (feeding tube placed directly through the stomach to deliver food, liquids, and medicine). Pt. is bedbound. Stage IV sacral wound, stage IV to left buttocks and right buttocks. Air mattress, change position every two hours, keep area dry with foley (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or for various medical reasons), Provide heel protectors while in bed. Wound care to evaluate and treat. Interface with nutritional/dietary services. Resident does not follow commands, does not blink to threat, no purposeful movements seen. Social Services for discharge. The resident's family members desire the use of all life-sustaining measures, including, but not limited to cardiopulmonary resuscitation, intubation (putting a breathing tube through the mouth down into the windpipe to help breath), and use of pressors (powerful drugs used to raise dangerously low blood pressure, to ensure vital organs get enough oxygen and blood flow) we will therefore monitor progress and adjust treatment plan as clinical conditions change. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed reentry date 09/10/25. Section B - B0100. Persistent vegetative state/no discernible consciousness. Section: GG0115 - Functional Limitation in Range of Motion impairment on both sides of upper and lower extremities. Section GG GG0130. Dependent with toileting hygiene. Indwelling catheter and incontinent of bowel. Active Diagnoses: CAD, heart failure, hypertension, PVD, DM, CVA, COPD, persistent vegetative state (person is awake, eyes opened, sleep-wake cycles, but has lost the ability to think, be aware of themselves or their surroundings, or respond to commands, even though the basic life functions Residents Affected - Few 676342 Page 9 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0850 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few work due to an intact brainstem) , anoxic brain damage (the brain is completely deprived of oxygen, resulting in significant cognitive, physical, and emotional deficits, potentially causing coma or death). Section Q: Family participated in assessment and goal setting. Q0310. Resident's Overall Goal was left blank. Q0400. Discharge Plan. Is active discharge planning already occurring for the resident to return to the community? No. Q0610, Referral. Has a referral been made to the Local Contact Agency? No. Q0620. Reason Referral to Local Contact Agency (LCA) not made code 3 Referral not wanted. Review of Resident #1's Care Plan dated 12/15/25 revealed the resident did not have a Discharge Plan. Review of Discharge Notice dated 11/26/25 for Resident #1 revealed, written notification that resident will be discharged from the nursing facility effective thirty-one days from the receipt of this letter. The effective date of discharge is 12/26/2025. This discharge is based on your failure, after reasonable and appropriate notice, to pay for provided services and your stay at this facility. The facility staff will work with you to make preparations needed to ensure a safe and orderly transition. An orientation for discharge planning will be held on 12/05/25. If there is a conflict with this date, we will be happy to reschedule to a mutually time prior to the date of discharge. During an interview on 12/18/25 at 12:28 PM DON reported they have not had a Social Worker since December 11, 2025. He said the Social Worker was responsible for addressing Grievances and initiating Discharge Plans as soon as possible once they knew that the resident was going to be discharged . He said he and the ADONs were helping with handling Grievances and Discharge Planning until they hired a social worker. During an interview on 12/18/25 at 3:45 PM Administrator revealed Social Worker S's last day was 11/14/25. She said they had hired new Social Worker T, on 11/24/25 and Social Worker T was terminated on 12/11/25. She said she was in the process of interviewing to hire a new social worker. She said she was a social worker and she and the DON and ADONs were helping with handling Grievances and Discharge Planning. She said Grievances were discussed in the daily morning meeting, and staff had been trained to immediately write concerns/grievances on the Grievance Forms to assign to the appropriate Department Head. She said she was responsible for checking that Grievances were resolved and the Social Worker was responsible for notifying the families of the Grievance resolutions. She said she was not aware that Resident #1's family had voiced concerns on Tuesday 12/16/25 until today 12/18/25 when the DON informed her that he had not completed the Grievance Form on 12/16/25 according to facility policy. However, he had immediately addressed the family's concerns and requested a Neurologist consultation, MRI (a magnetic test that uses magnets and radio waves to make detailed pictures of the body organs, muscles, soft tissues, and structures) and a different mattress. She said they had issued a Discharge Notice on 11/26/25 to resident's responsible party and had sent an email to the local ombudsman. She said the discharge notice was issued to Resident #1 due to non-payment of applied income. She said they were waiting for the 30 days from the date that the discharge notice was issued, to file a complaint with APS for exploitation by resident's responsible party who had not paid the applied income to the facility for several months. The Administrator stated they had not started a Discharge Plan when the Discharge Notice was issued to the resident's responsible party on 11/26/25. She said the resident's family had made no attempts to contact the facility regarding discharge notice. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. She said so the family has not made plans for discharge. She said, So the resident will stay at the facility until the family makes plan for a safe discharge, since the resident is on mechanical ventilation and tracheostomy. During an interview on 12/19/25 at 10:15 AM, RN J MDS Nurse and LVN L MDS Nurse revealed Resident #1 was in a permanent vegetative state, did not respond to verbal and/or painful stimuli, was on mechanical ventilation/tracheostomy, 676342 Page 10 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0850 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few enteral feeding via G-tube, had multiple stage VI pressure ulcers that were present upon admission to the facility and a DTI on left heel. LVN L MDS Nurse said the Social Worker would initiate interdisciplinary discharge plan to ensure resident's needs would be met after discharge from the facility. She said the facility had not initiated a Discharge Plan for Resident #1 when the facility had issued the Notice of discharge on [DATE]. During an interview and record review of Resident #1's Care Plan Conference Notes on 12/19/25 at 4:03 PM, LVN L MDS Nurse revealed the new Social Worker T had not written Care Plan Conference notes for 12/10/25 in Resident #1's clinical record, because she had quit without notice on 12/11/25. LVN L MDS Nurse said SW T had not initiated a Discharge Plan for Resident #1 when the facility had issued the Discharge Notice on 11/26/25. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. Review of advertisement dated 12/11/25 provided by the Administrator revealed they were hiring a Social Worker. The state surveyor requested a copy of the Social Worker Job Description on 12/18/25 at 12:45 PM, and it was not provided by the facility Administrator prior to exit. 676342 Page 11 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #3) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions during high contact resident care activities for Resident #3 who had a wound and indwelling medical device. This failure could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organisms (MDROs). The findings included:Record review of Resident #3's admission Record revealed Original admission Date 07/22/21 and re-admission Date 04/12/25. Record review of Resident #3's History & Physical dated 04/14/25 revealed [AGE] year-old female with past medical history of frequent UTIs (a common bacterial infection in any part of the urinary system). Assessment: Indwelling foley catheter (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or for various medical reasons), Peg tube (feeding tube placed directly through the stomach to deliver food, liquids, and medicine). Record review of Resident #3's Quarterly MDS dated [DATE] revealed, BIMS Score of 2 (severe cognitive impairment), dependent (resident does none of the effort to complete the activity) with toileting hygiene, shower, and personal hygiene. Dependent with turning & repositioning in bed and transfers to shower, indwelling catheter, incontinent of bowel, Feeding Tube (G-Tube). Record review of Resident #3's Care Plan dated 09/19/25 revealed, Resident was incontinent of bowel. Provide incontinent care PRN. Resident has an indwelling catheter. Ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling. Resident has a feeding tube. Clean insertion site daily as ordered. Monitor for sign and symptoms of infection or breakdown. The Care Plan did not document Resident #3 was on EBP. Record review of Resident #3's Physician Order Summary dated 12/19/25 revealed, Enteral Feed Order via G-tube three times a day. Cleanse stage 2 pressure ulcer to LLE with wound cleanser, pat dry, and apply skin prep, cover with dry dressing Tuesday, Thursday, Saturday and PRN. Resident is on Hospice. The physician's order did not document Resident #3 was on EBP. During an interview on 12/18/25 at 1:45 PM CNA C revealed they had been trained on EBP and are supposed to use a gown and gloves when providing direct care to those residents that have pressure ulcers, catheters, feeding tubes, to prevent cross contamination of uniforms and spread of infections.During an interview on 12/18/25 at 1:49 PM LVN Charge Nurse D on the 400 Hall revealed the staff had been trained on EBP, signs are posted in the hall by the entrance to the resident rooms, and PPE as kept by the door as you entered the room. The staff should use a gown, gloves, and goggles as needed when direct care was provided to the residents to prevent cross contamination of their uniforms and prevent the spread of infections. During an observation on 12/19/25 at 9:30 AM with LVN H and CNA I, there was an EBP sign posted on the wall in the hallway by the entrance to Resident #3's room. The Nurse and CNA entered the room, did not wash their hands and did not put on a gown or gloves before having direct contact with the resident. The resident was turned to the left side using the sheet, CNA untied the tags on the side of the brief. It was observed that the resident was clean and dry. There was no redness noted on the buttocks or sacral area. The nurse and the CNA washed their hands and left the room. During an interview on 12/19/25 at 9:33 AM LVN H revealed they had been trained on EBP and she got nervous and forgot to wash her hands when they entered the room and forgot to follow EBP and did not put on an isolation gown and gloves prior to having direct contact with the resident. She said the resident had a G-tube, pressure ulcer on one of the heels, and was incontinent of Residents Affected - Few 676342 Page 12 of 13 676342 12/19/2025 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bowel and bladder. She said that failure to follow EBP placed the staff and residents at risk of cross-contamination and spread of infections. During an interview on 12/19/25 at 9:39 AM, CNA I, in the presence of LVN H Charge Nurse, said EBP was no longer needed for Resident #3 because her catheter had been discontinued. The LVN, said, The catheter was discontinued. However, the resident still needs to be on EBP because she had a G-Tube and pressure ulcer. The CNA, said I was rushing to get residents up for the scheduled Christmas activity this morning and forgot to follow EBP when I entered [Resident #'3] room to assist LVN H turn the resident to the side to check the resident's skin on her buttocks for skin breakdown. During an interview on 12/19/25 at 9:51 AM DON stated the licensed staff and CNAs had been trained on EBP to reduce transmission of multidrug-resistant organisms, and the staff should use a gown and gloves during high contact resident care activities. He said EBP should be followed when changing briefs or assisting with toileting, turning and repositioning or assisting with bed mobility, if the resident has any indwelling medical device such as G-Tube, or has a history of MDROs and pressure ulcers. During an interview on 12/19/25 at 2:06 PM RN N revealed they had been trained on EBP to reduce transmission of multidrug-resistant organisms, and the staff should use a gown and gloves during high contact resident care activities with residents that had any type of indwelling medical device, wounds, history of multi-drug-resistant organisms. She said she monitored during rounds that the CNAs followed EBP. Review of facility's policy and procedures on Enhanced Barrier Precautions effective 4/1/2024 provided by DON on 12/19/25 revealed, Enhanced Barrier Precaution (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Colonization with a CDC targeted MDRO when Contact Precautions do not otherwise apply. Wounds and/or indwelling catheter devices even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical device examples include central lines, urinary catheter, feeding tubes, and tracheostomies. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. Donning PPE for Resident on EBP Based on Activity Provided/Assistance While in Resident Room: Administer medications enterally; Perform wound care; changing briefs or assisting with toileting; turn and reposition or assist with bed mobility; dressing a resident; bathing/showering; providing hygiene; changing linen; device care or use-urinary catheter, feeding tube, tracheostomy/ventilator; any other high-contact activity that includes close bodily contact or coming into contact with the indwelling medical device. 676342 Page 13 of 13