Nursing homeActive
Hays Nursing and Rehabilitation Center
1900 Medical Parkway, San Marcos, TX 786665123961888116 certified beds · 93 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
7
since 2023
Deficiencies
26
● 0● 24● 2
Penalties · 3 yrs
$8,226
1 fine
Last survey
2026-03-05
Standard
CMS overall
3 / 5
stars as published by CMS
CMS overall 3/5
Health 3
Staffing 3
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2026-03-05 | Standard | 060 | CMS-2567 (Care Compare) | — |
| 2025-01-16 | Standard | 060 | CMS-2567 (Care Compare) | — |
| 2024-07-09 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-05-02 | Complaint | 012 | CMS-2567 (Care Compare) | — |
| 2023-12-14 | Standard | 070 | CMS-2567 (Care Compare) | — |
| 2023-11-20 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-09-23 | Complaint | 010 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-28Record 455960-20260305-F558
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-20Record 455960-20260305-F584
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-22Record 455960-20260305-F677
F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-03-28Record 455960-20260305-F810
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-28Record 455960-20260305-F812
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-03-27Record 455960-20260305-F880
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-23Record 455960-20250116-F550
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-31Record 455960-20250116-F584
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-23Record 455960-20250116-F679
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-17Record 455960-20250116-F756
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-01-31Record 455960-20250116-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-01-17Record 455960-20250116-F812
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 455960-20240709-F656
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-07-16Record 455960-20240709-F880
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-05-03Record 455960-20240502-F600
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity JHarm
Abuse & neglect
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-05-03Record 455960-20240502-F607
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-03Record 455960-20240502-F609
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-05Record 455960-20231214-F584
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-11Record 455960-20231214-F679
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-18Record 455960-20231214-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-12-15Record 455960-20231214-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-18Record 455960-20231214-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-12-21Record 455960-20231214-F692
F908Keep all essential equipment working safely.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-01-19Record 455960-20231214-F908
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-11-27Record 455960-20231120-F677
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-10-12Record 455960-20230923-F761
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2024-05-02 | Civil money penalty | $8,226 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.46
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day3.27
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours2.72
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover38%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover22%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 1.7% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 4.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 5.0% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 1.2% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 15.9% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 4.0% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 20.3% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Guadalupe County Hospital Board Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Chudleigh, James Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Phelps, Nelson Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Willow Springs Creek Healthcare, Inc. Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Burnam, Soon Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Chudleigh, James Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Chudleigh, James Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| Ensign Services Inc Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Gann, Kody Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Keetch, Chad Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Phelps, Nelson Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Phelps, Nelson Individual | MANAGING CONTROL - GOVERNING BODY | NOT APPLICABLE | — | — |
| San Marcos Tx Propco LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Willow Springs Creek Healthcare, Inc. Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Part of a chain
The Ensign Group — 342 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Hays.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Cypress Healthcare and Rehabilitation Center San Marcos | 0.6 mi | 2025-12-06 | 0328 |
| San Marcos Rehabilitation and Healthcare Center San Marcos | 1.9 mi | 2025-12-30 | 0123 |
| Legend Oaks Healthcare and Rehabilitation-Kyle Kyle | 12.0 mi | 2026-05-26 | 0171 |
| Legend Oaks Healthcare And Rehabilitation - New Br New Braunfels | 11.6 mi | 2026-05-20 | 0380 |
| Avir at New Braunfels New Braunfels | 12.4 mi | 2026-05-23 | 1405 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |