Health inspection·October 22, 2024

F 0551 Give the resident's representative the ability to exercise the resident's rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to extend to the resident representative the right to make decisions on behalf of the resident for one (Resident #1) of four residents reviewed for resident representative rights. Residents Affected - Few The facility failed to obtain consent by Resident #1's RP before administering the COVID-19 vaccine. This failure placed residents at risk of denying the resident through the resident representative their wishes and preferences. The findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted the facility on 10/15/21 with diagnoses including unspecified dementia, cognitive communication deficit, anxiety disorder, and major depressive disorder. FM A was listed as her RP. Review of Resident #1's quarterly MDS assessment, dated 09/25/24, reflected a BIMS score of 4, indicating a severe cognitive impairment. Review of Resident #1's quarterly care plan, dated 07/03/24, reflected she had altered cognition with an intervention of assisting with decision making as needed or enlisting family to do so. Review of Resident #1's COVID-19 Vaccine Declination Form, dated 02/14/22, reflected FM A declined the vaccine for Resident #1. Review of Resident #1's COVID-19 Vaccine Consent Form, dated 02/29/24, reflected RN B documented she received verbal consent from Resident #1 for the vaccination. Review of an intake submitted to HHSC, dated 10/03/24, reflected Resident #1 was administered a COVID-19 vaccination without obtaining their RP's consent. During an interview on 10/22/24 at 10:36 AM, RN B stated they had just changed over to a new charting system. She stated in February (2024), in their old charting system, it had Resident #1 listed as her own RP. She stated that was why she felt comfortable administering the COVID vaccine to her when she gave verbal consent. During an interview on 10/22/24 at 10:48 AM, Resident #1 was asked about receiving a COVID-19 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 676226 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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)