Health inspection·October 3, 2024

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive, accurate, standardized reproducible assessment of the functional capacity was conducted initially and periodically for one (Resident #300) of five residents reviewed for comprehensive assessments. The facility failed to ensure Resident #300's comprehensive admission MDS was conducted within 14 days of admission. The due date was on 10/01/2024 and it was not completed. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. Findings included: Review of Resident #300's face sheet dated 10/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Type 2 Diabetes Mellitus w/o complications, Constipation (unspecified), Hypothyroidism (unspecified), Hypo-osmolality & Hyponatremia, Hypokalemia, Essential (primary) Hypertension, Unspecified Atrial Fibrillation. Review of Resident #300's admission MDS assessment dated [DATE] reflected Resident #300 was assessed to have a BIMS score of 15 indicating cognition was intact. Interview on 10/03/24 at 10:18 AM with the Regional Reimbursement Nurse (RRN), stated that the MDS should have been completed on 10/01/2024 but as of today 10/03/2024 the MDS assessment was not completed. The RRN said the MDS should be completed within 14 days of admissions and (Resident #300's) MDS has not been completed per the 14-day rule. The RRN stated normally they're done the day after ARD but because the facility has not had a MDS coordinator since 09/19/2024 it has not been completed. The RRN stated she is responsible for making sure they were supposed to be completed during the new MDS hiring process. The RRN stated there would not be a consequence to the residents' care if it is not completed in time. Review of undated facility policy titled Policy for Resident Assessments revealed A comprehensive assessment will be completed within 14 days of admission and annually on each resident. The facility will utilize the Resident Assessment Instrument (RAI). Page 1 of 4 676399 676399 10/03/2024 San Saba Nursing & Rehabilitation 2400 West Brown Street San Saba, TX 76877

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 resident's medical records included documentation that indicated the resident, or their responsible party, received education of the benefits, and potential side effects, of the influenza or pneumococcal immunization, receipt of the influenza or pneumococcal immunization, or residents did not receive the influenza or pneumococcal immunization due to medical contraindication, or refusal, for 3 (Resident #300, Resident #29, and Resident #37) of 5 residents reviewed for immunizations. Residents Affected - Some The facility failed to document in Resident #300's, #29's and #37's medical records for having had received education, whether by self or with responsible party, of the benefits, and potential side effects, of the influenza immunization and receipt of the of the pneumococcal immunization or having had not received the pneumococcal immunization due to medical contraindication or refusal. This failure could place residents at risk of contracting a viral illness, influenza and pneumococcal, or being informed of the benefits/risk which could cause respiratory complications and potential adverse health outcomes. Findings include: Resident #300 Review of Resident #300's face sheet dated 10/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Type 2 Diabetes Mellitus w/o complications, Constipation (unspecified), Hypothyroidism (unspecified), Hypo-osmolality & Hyponatremia, Hypokalemia, Essential (primary) Hypertension, Unspecified Atrial Fibrillation. Review of Resident #300's admission MDS assessment dated [DATE] reflected Resident #300 was assessed to have a BIMS score of 15 indicating cognition was intact. Review of Resident #300's comprehensive care plan dated 09/18/2024 reflected no entries regarding immunization status. Review of Resident #300's immunization records in the EMR reflected no pneumococcal vaccine record. Further review of record reflected Resident #300 was offered the influenza and pneumococcal vaccine and declined. The immunization record does not list a date. Resident #29 Review of Resident #29's face sheet dated 10/03/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with an initial admission date of 08/27/20222 with the following diagnoses Unspecified dislocation of left hip (subsequent encounter), Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, Type 2 diabetes mellitus (w/moderate non-proliferative), Diabetic retinopathy w/macular edema, right eye. Review of Resident #29's quarterly MDS assessment dated [DATE] reflected Resident #29 was assessed 676399 Page 2 of 4 676399 10/03/2024 San Saba Nursing & Rehabilitation 2400 West Brown Street San Saba, TX 76877

F 0883 to have a BIMS score of 8 indicating moderate cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Review of Resident #29's comprehensive care plan dated 05/06/2024 reflected no entries regarding immunization status. Residents Affected - Some Review of Resident #29's immunization records in the EMR reflected no pneumococcal vaccine record. Further review of record reflected Resident #29 was offered the influenza and pneumococcal vaccine and declined. The immunization record does not list a date. Review of Resident #37's face sheet dated 10/03/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Malignant neoplasm of unspecified part of unspecified bronchus or lung, secondary malignant and neoplasm or brain, muscle weakness (generalized), constipation (unspecified), depression (unspecified), Gastro-esophageal reflux disease w/o esophagitis, overactive bladder, unspecified protein calorie nutrition, anemia (unspecified), compression of brain, cerebral anemia. Review of Resident #37's admission MDS assessment dated [DATE] reflected Resident #37 was assessed to have a BIMS score of 5 indicating severe cognitive impairment. Review of Resident #37's comprehensive care plan dated 08/20/2024 reflected no entries regarding immunization status. Review of Resident #37's immunization records in the EMR reflected no pneumococcal vaccine record. Further review of record reflected Resident #37 was offered the influenza and pneumococcal vaccine and declined. The immunization record does not list a date. In an interview with the ADON on 10/03/2024 at 10:58 a.m. the ADON stated that Resident #300 refused consents for the pneumococcal vaccine, but resident records reflect she did receive the education. There was not documentation or record showing Resident #300 refusals of the vaccines. Resident #300 refused the influenza vaccine, but the signature page had not been uploaded to the residents' records. The ADON stated Resident #29 record showed a refusal for the pneumococcal vaccines but there was no record documenting the refusal. The ADON stated it was a verbal decline. The ADON stated Resident #37 has a prepared form that will be provided to the resident offering the influenza vaccine. Resident can decline or accept influenza. The ADON stated Resident # 37 gave a verbal refusal for the pneumococcal vaccine and no education was provided to the resident. The ADON stated moving forward she would make sure residents immunization history was recorded for what vaccines were administered and make sure if residents or family's refuse vaccines that education was provided. In an interview with the DON on 10/03/2024 at 12:03 p.m., the DON said, I would expect that they (residents) would be provided informed consent and the discussion be documented and placed in PCC (electronic medical record). Review of the facility's Infection Control Policy dated 03/2024 reflected It is the policy of this company that all residents will be offered the influenza immunization annually October 1 through March 31, unless the immunization is contraindicated, or the resident has already been immunized during this time period. Residents or the resident's representative will have the opportunity to refuse the immunization. The following must occur prior to administering the immunization: Provide a Vaccine 676399 Page 3 of 4 676399 10/03/2024 San Saba Nursing & Rehabilitation 2400 West Brown Street San Saba, TX 76877

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Information Statement (VIS) to the resident and/or resident representative that corresponds to the influenza vaccine being administered to the recipient. The VIS will outline education, benefits and potential risks of the immunization. The facility will maintain documentation of influenza vaccinations or refusals of the influenza immunization in the Point Click Care clinical record and will include: That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindication or refusal. Pneumonia Vaccine: It is the policy of this company that all residents will be offered the pneumonia immunization unless the immunization is contraindicated, or the resident has already been immunized. The following must occur prior to administering the immunization: Provide a Vaccine Information Statement (VIS) to the resident and/or resident representative that corresponds to the pneumonia vaccine being administered to the recipient. The VIS will outline education, benefits, and potential risks of the immunization. The facility will maintain documentation of pneumonia vaccinations or refusals of the pneumonia immunization in the Point Click Care clinical record and will include: That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumonia immunization or did not receive the pneumonia immunization due to medical contraindication or refusal. 676399 Page 4 of 4