01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-03-05 | 6 | 2026-03-05 | 4 |
| Cycle 2 | 2025-01-16 | 6 | 2025-01-16 | 0 |
| Cycle 3 | 2023-12-14 | 14 | 2023-12-14 | 2 |
CMS CCN 4559602026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Hays Nursing And Rehabilitation Center
1900 Medical Parkway · San Marcos, TX 78666 · Hays County
Certified beds116CMS provider file
Recent citation rows32current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
32 rows in the current release
2 rows carry G–L scope/severity codes; 2 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-05 · HEALTHF0558Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2026-03-282026-03-05 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2026-03-202026-03-05 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-03-222026-03-05 · HEALTHF0810Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Correction field: Deficient, Provider has date of correction · 2026-03-282026-03-05 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-03-282026-03-05 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-03-272026-03-05 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-05-312026-03-05 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2026-04-102026-03-05 · FIREK0355Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2026-03-182026-03-05 · FIREK0372Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-04-032025-01-16 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-01-232025-01-16 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-16 · HEALTHF0679Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2025-01-232025-01-16 · HEALTHF0756Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-01-172025-01-16 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-01-312025-01-16 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-01-172024-07-09 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-07-16 · complaint2024-07-09 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-07-16 · complaint2024-05-02 · HEALTHF0600Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-05-03 · complaint2024-05-02 · HEALTHF0607Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-05-03 · complaint2024-05-02 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-05-03 · complaint2023-12-14 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2024-01-052023-12-14 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2024-01-112023-12-14 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-01-1803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-05-02 | Fine | $8,226 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- GUADALUPE COUNTY HOSPITAL BOARDOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 12/01/2020
- CHUDLEIGH, JAMESIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 02/01/2024
- PHELPS, NELSONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/01/2020
- BURNAM, SOONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2020
- GANN, KODYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/03/2021
- KEETCH, CHADIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2011
- WILLOW SPRINGS CREEK HEALTHCARE, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2020
- CHUDLEIGH, JAMESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2024
- PHELPS, NELSONIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2020
- ENSIGN SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/13/2020
- SAN MARCOS TX PROPCO LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/01/2020
- WILLOW SPRINGS CREEK HEALTHCARE, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 11/25/2025
- CHUDLEIGH, JAMESIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/01/2024
- PHELPS, NELSONIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.27per resident day
RN hours0.46per resident day
Weekend nurse hours2.72per resident day
Staff turnover37.9%CMS reported field
06 / LOCAL RECORDS
Open the San Marcos ledger →