San Saba Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at San Saba Nursing & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF883Oct 3, 2024

  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. […]

• No harm, potential for more than minimal, patternF641Jun 7, 2022

  45830 Based on interview and record review, the facility failed to ensure resident assessments were accurately completed for four (Residents #1, #2, #3, and #4) of 12 residents reviewed for resident assessments. The MDS Case Manager failed to accurately code Section N (Medications) of the MDS assessment for medications received in a seven-day lookback period for Residents #1, #2, #3, and #4. This failure placed residents at risk of inadequate care due to inaccurate MDS assessments. […]

• No harm, potential for more than minimal, patternF880Feb 2, 2022

  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 2 of 5 staff (LVN A and MA B) reviewed for the following; 1. LVN A failed to don gloves when administering insulin by injection to Resident #1. 2. MA B failed to sanitize a blood pressure monitor between uses on Residents #1 and #2. 3. […]

• No harm, potential for more than minimal, isolatedF636Oct 3, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF684Aug 2, 2023

  Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of 16 residents (Resident #30) reviewed for quality of care. The facility failed to follow a physician order dated 07/11/23 to increase Resident #30's insulin from eight units to ten units. This failure could place residents at risk of uncontrolled blood sugar and kidney injury. Findings included: Review of the undated face sheet for Resident #30 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia, type II diabetes mellitus, and long term (current) use of insulin. […]