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St Theresa Healthcare And Rehabilitation Center

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About St Theresa Healthcare And Rehabilitation Center

General Information

Legal Business NameSt. Theresa Healthcare And Rehabiliation Center, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareAugust 30, 1985 (31 years)
Capacity134
Residents113
Percent Occupied84%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for St Theresa Healthcare And Rehabilitation Center

St Theresa Healthcare And Rehabilitation Center
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of New Mexico Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

November 5, 2015 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionHire sufficient dietary support personnel.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.

November 3, 2015 - 13 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionHeating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FManyPotential for HarmFire Safety InspectionSmoke barrier doors that can resist smoke for at least 20 minutes.

October 1, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$3,900 fine
JFewImmediate JeopardyHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
JFewImmediate JeopardyHealth InspectionProtect each resident from all abuse, physical punishment, and involuntary separation from others.
FManyPotential for HarmHealth InspectionEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility
FManyPotential for HarmHealth InspectionBe licensed under State and local laws.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
ESomePotential for HarmHealth InspectionUse a registered nurse at least 8 hours a day, 7 days a week.
ESomePotential for HarmHealth InspectionProvide housekeeping and maintenance services.
ESomePotential for HarmHealth InspectionEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionProvide activities to meet the interests and needs of each resident.
ESomePotential for HarmHealth InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
ESomePotential for HarmHealth InspectionProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
CManyPotential for Minimal HarmHealth InspectionProvide clean bed and bath linens that are in good condition.
DFewPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmHealth InspectionMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
DFewPotential for HarmHealth InspectionProvide or obtain dental services for each resident.
DFewPotential for HarmHealth InspectionMake sure that a working call system is available in each resident's room or bathroom and bathing area.

September 23, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionProperly protected cooking facilities.
FManyPotential for HarmFire Safety InspectionProper backup exit lighting.
FManyPotential for HarmFire Safety InspectionOther fire safety features required by fire safety codes.
ESomePotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.

May 14, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.

April 5, 2013 - 4 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$2,275 fine

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of St Theresa Healthcare And Rehabilitation Center require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 5min
2hr 20min
ReportedExpected
CNA
40min
40min
ReportedExpected
LPN
20min
1hr 10min
ReportedExpected
RN
3hr 5min
4hr 10min
ReportedExpected
Total Nursing

This facility also provides approximately 35min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

93.6%
91.2%
91.2%
87.8%
Q1 2015Q2 2015Q3 2015NM
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
93.3%
100.0%
78.9%
Q1 2015Q2 2015Q3 2015NM
Assessed and Appropriately Given the Pneumococcal Vaccine
63.3%
67.5%
45.2%
43.9%
Q1 2015Q2 2015Q3 2015NM
Low Risk Residents Who Lose Control of Their Bowel or Bladder
2.7%
3.5%
1.2%
16.3%
Q1 2015Q2 2015Q3 2015NM
Received an Antipsychotic Medication
10.1%
21.3%
20.0%
18.2%
Q1 2015Q2 2015Q3 2015NM
Need for Help with ADLs has Increased
0.0%
1.3%
0.0%
9.8%
Q1 2015Q2 2015Q3 2015NM
Self Report Moderate to Severe Pain
2.6%
4.5%
4.6%
6.8%
Q1 2015Q2 2015Q3 2015NM
Lose Too Much Weight
0.0%
3.3%
1.7%
6.0%
Q1 2015Q2 2015Q3 2015NM
High Risk Residents With Pressure Ulcers
5.3%
2.4%
2.6%
3.0%
Q1 2015Q2 2015Q3 2015NM
Have Depressive Symptoms
0.0%
2.3%
2.3%
4.3%
Q1 2015Q2 2015Q3 2015NM
With a Urinary Tract Infection
1.3%
1.1%
0.0%
3.8%
Q1 2015Q2 2015Q3 2015NM
Experiencing One or More Falls with Major Injury
2.3%
4.1%
7.2%
3.3%
Q1 2015Q2 2015Q3 2015NM
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015NM
Were Physically Restrained

Quality Measures for Short Stay Residents

98.5%
100.0%
99.3%
69.5%
Q1 2015Q2 2015Q3 2015NM
Assessed and Appropriately Given the Pneumococcal Vaccine
95.1%
86.1%
86.1%
68.2%
Q1 2015Q2 2015Q3 2015NM
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
0.6%
4.2%
12.4%
24.2%
Q1 2015Q2 2015Q3 2015NM
Self Report Moderate to Severe Pain
0.8%
0.0%
0.0%
2.3%
Q1 2015Q2 2015Q3 2015NM
Newly Received an Antipsychotic Medication
0.3%
0.6%
0.7%
1.3%
Q1 2015Q2 2015Q3 2015NM
With Pressure Ulcers That Are New or Worsened