Health inspection·June 7, 2022

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #2's care plan last revised on 5/25/2022 reflected she was on pain medication therapy related to chronic pain syndrome, arthritis, kyphosis (hunchback), and intervertebral disc disorder with myelopathy lumbar region (nervous system disorder of the spine). Resident #2's intervention for pain reflected she was to be administered medication as ordered. A record review of Resident #2's physician orders reflected an active order dated 9/07/2021 for Norco tablet (opioid medication) 5-325 mg to be given by mouth two times a day for pain. A record review of Resident #2's MAR dated April 2022 reflected she received Norco tablet 5-325 mg twice a day from 4/07/2022-4/13/2022. A record review of Section N (Medications) of Resident #2's MDS assessment dated [DATE] reflected she received opioid medication zero days during the seven-day lookback period from 4/07/2022-4/13/2022 . A review of Section C (Cognitive Patterns) of Resident #2's MDS assessment dated [DATE] did not reflect a BIMS score. A record review of Resident #3's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes, major depressive disorder (depression), chronic obstructive pulmonary disease (inflammatory lung disease), malnutrition, cirrhosis of liver (liver disease), chronic kidney disease, hyperlipidemia (high cholesterol), gastroesophageal reflux disease (acid reflux), osteoporosis (weak bones), and chronic pain syndrome. A record review of Resident #3's care plan last revised on 2/09/2022 reflected she had a potential for uncontrolled pain. Resident #2's intervention for pain reflected she was to be administered medications as per orders. A record review of Resident #3's physician orders reflected an active order dated 3/08/2022 for Acetaminophen-Codeine (opioid medication) tablet 300-30 mg to be given by mouth once a day for pain. A record review of Resident #3's MAR dated April 2022 reflected she received Acetaminophen-Codeine tablet 300-30 mg once a day from 4/10/2022-4/16/2022. A record review of Section N (Medications) of Resident #3's MDS assessment dated [DATE] reflected she received opioid medication zero days during the seven-day lookback period from 4/10/2022-4/16/2022 . A review of Section C (Cognitive Patterns) of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 12. A record review of Resident #4's face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnoses of heart disease, chronic obstructive pulmonary disease (inflammatory lung disease), type 2 diabetes, dysphagia (difficulty swallowing), chronic kidney disease, major depressive disorder (depression), hypertension (high blood pressure), dilated cardiomyopathy (enlarged and weakened heart), malnutrition, hypothyroidism (underactive thyroid), hyperlipidemia (high cholesterol), urticaria (skin rash) and pruritus (skin irritation). A record review of Resident #4's care plan last revised on 5/20/2022 reflected she had potential/actual impairment to skin integrity related to allergies and fragile skin. Resident #4's intervention for skin impairment reflected she was to avoid scratching. A record review of Resident #4's physician orders reflected an active order dated 7/14/2021 for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676399 If continuation sheet Page 2 of 4 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 676399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Saba Nursing & Rehabilitation 2400 West Brown Street San Saba, TX 76877 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)

F 0641 Level of Harm - Minimal harm or potential for actual harm Hydroxyzine HCl (antianxiety medication) tablet 25 mg to be given by mouth every four hours as needed for itching. A record review of Resident #4's MAR dated March 2022 reflected she received Hydroxyzine HCl tablet 25 mg on 3/27/2022. Residents Affected - Some A record review of Section N (Medications) of Resident #4's MDS assessment dated [DATE] reflected she received antianxiety medication zero days during the seven-day lookback period from 3/24/2022-3/30/2022 . A review of Section C (Cognitive Patterns) of Resident #4's MDS assessment dated [DATE] reflected a BIMS score of 8. During an interview on 6/07/2022 at 11:56 a.m., the MDS Case Manager stated she was responsible for completing the residents' MDS assessments. When asked what the process for completing assessments was, the MDS Case Manager stated she would go through the MAR, see which medications the resident had taken in the last seven days, and input that information in their MDS assessment. The MDS Case Manager stated the lookback period for completing MDS assessments was seven days. When asked what kind of medications she looked for in the MAR, the MDS Case Manager stated antianxiety and opioid medications. The MDS Case Manager stated the MDS Regional Coordinator monitored this process and ensured compliance. The MDS Case Manager stated the MDS Regional Coordinator would come in and check all the MDS Case Manager's MDS assessments. During an interview on 6/07/2022 at 1:20 p.m., the MDS Case Manager stated opioid medications should be coded in the MDS if the resident had taken that medication in the seven-day lookback period. The MDS Case Manager stated the MDS Regional Coordinator would come into the facility about once a month to oversee the process of completing MDS assessments-any issues in MDS assessments would be identified and corrected by the MDS Regional Coordinator. The MDS Case Manager stated when MDS assessments were completed, the DON would sign off on them. The MDS Case Manager stated she followed the RAI Manual for coding medications in MDS assessments . During an interview on 6/07/2022 at 1:45 p.m., the DON stated opioid medications should be documented in MDS assessments. The DON stated that MDS were used for financial reimbursement and if they were not accurately completed, it could affect reimbursement. The DON stated she signed off on all MDS assessments when they were complete. During an interview on 6/07/2022 at 1:58 p.m., the MDS Regional Coordinator stated he was required to visit the facility once a quarter and stated he was last in the facility on 5/03/2022. The MDS Regional Coordinator stated he would go through MDS assessments completed by the MDS Case Manager. The MDS Regional Coordinator stated opioid medications should be marked appropriately but they were not a reimbursable item. During an interview on 6/07/2022 at 2:00 p.m., the Administrator stated the facility did not have a specific policy regarding MDS assessments, but that the facility followed the RAI Manual . During an interview on 6/07/2022 at 2:04 p.m., the MDS Case Manager stated she was not sure whether Hydroxyzine was considered an antianxiety medication. A record review of CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019 reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676399 If continuation sheet Page 3 of 4 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 676399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Saba Nursing & Rehabilitation 2400 West Brown Street San Saba, TX 76877 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)

F 0641 Steps for Assessment: Level of Harm - Minimal harm or potential for actual harm Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Residents Affected - Some Coding Instructions: N0410A-H: Code medications according to the pharmacological classification, not how they are being used. N0410B, Antianxiety: Record the number of days an anxiolytic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). N0410H, Opioid: Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Coding Tips and Special Populations: Code medications in Item N0410 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. Code a medication even if it was given only once during the look-back period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676399 If continuation sheet Page 4 of 4