Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure residents' right to formulate an advance directive for
1 of 26 residents (Resident #23) reviewed for advanced directives, in that:
1. The facility failed to honor Resident #23's, signed [DATE], Out-of-Hospital Do Not Resuscitate
(OOHDNR)
This deficient practice could place residents at-risk for residents' rights not being honored.
The findings were:
1. Record review of Resident #23's face sheet, dated [DATE], revealed an admission date of [DATE] with
diagnoses that included: acute kidney failure (kidneys are unable to filter waste from the blood), anemia
(deficiency of red blood cells), dementia (loss of memory, language, problem-solving and other thinking
abilities that are severe enough to interfere with daily life), major depressive disorder and anxiety disorder.
Further record review revealed resident noted as a Full Code instead of DNR under the Advance Directive
section.
Record review of Resident #23's care plan, revised [DATE], revealed a problem which read, Residents
wishes are to be a DNR Code Status. Date initiated: [DATE], a goal which read, Wishes will be honored
through the review period and reviewed quarterly and prn. Further review read for an intervention honor
resident's wishes; treat with dignity and respect. [initiated: [DATE]].
Record review of Resident #23's admission MDS, dated [DATE], revealed a BIMS score of 3, which
indicated severe cognitive impairment.
Record review of Resident #23's clinical record revealed an OOHDNR correctly signed on [DATE] by all
required parties.
Record review of Resident #23's clinical record revealed a physician order, entered [DATE], which read
CPR/Full Code. Further record review of physicians order did not reveal a DNR order.
During an interview on [DATE] at 2:09 p.m., LVN A pulled Resident #23 EHR and stated she was a full
code. LVN A stated she knows she is a full code because it stated this under the resident's picture. LVN A
continued that if Resident #23 was to code at this moment she would announce code blue and begin CPR.
LVN A also stated that staff announce code blue when they need immediate assistance for a resident.
(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 6
Event ID:
455960
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
455960
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hays Nursing and Rehabilitation Center
1900 Medical Pkwy
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)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview and observation on [DATE] at 2:22 p.m., the SW pulled up Resident #23's EHR and
stated she was a full code. The SW further stated she knows this because was stated under this resident's
picture in her EHR. The SW was asked to further verify that Resident #23 was Full Code and the SW
further looked in the miscellaneous tab for a signed DNR. The SW confirmed there was a correctly signed
DNR for Resident #23 and that the resident's code status was supposed to be a DNR instead of full code.
The SW stated she was the one responsible for making sure the DNR's are signed correctly and then she
would proceed to either the ADON, DON or as a last resort the charge nurse assigned to the resident's
hallway, to have the resident's code status changed in their EHR. The SW also stated she did not have a
process in place that ensured a resident's choice to execute a DNR was fully followed. The SW further
stated the potential harm to this resident was not honoring her wishes to be a DNR.
During an interview and observtion on [DATE] at 2:42 p.m., the ADON pulled up Resident #23's EHR and
stated she was a full code. The ADON stated she knew this resident was a full code because it stated it
under the resident's picture in her EHR. The ADON stated if this resident was to code at this time, staff
would announce code blue and begin CPR. The ADON also stated the SW was responsible for getting a
resident's DNR accurately completed and then the SW would bring it to her, the DON or the charge nurse
on that resident's hallway would change her code status to a DNR. The ADON stated the potential harm
was not honoring the resident's wishes to be a DNR.
During an interview and observation on [DATE] at 2:57 p.m., the DON pulled up Resident #23's EHR and
stated she was aware that the code status was inaccurate, but now says DNR. The DON stated the SW
was responsible for getting a resident's DNR correctly signed. She further stated then she would either go
to the ADON or herself or the charge nurse on the floor to get a resident's code status changed to DNR.
The DON stated the potential harm to this resident was doing CPR when the resident wished to be a DNR.
During an interview on [DATE] at 3:30 p.m., the ADMN stated once a DNR was fully and correctly executed,
then the resident's EHR should reflect this information. The ADMN further stated the potential harm was
going against the resident's wishes, by doing CPR instead of being a DNR. The ADMN further stated this
could cause potential physical harm from performing CPR.
Record review of the facility's policy titled, Advance Directives and Associated Documentation, revised
01/2022, which read It is the policy of this facility that a resident's choice about advance directives will be
recognized and respected. [ .] It is the policy of this facility to implement the resident decisions and
directives that are in compliant with State and/or Federal Law and the policies of this facility. The resident
will not be discriminated against for a decision to implement or not implement Advance Directives.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455960
If continuation sheet
Page 2 of 6
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
455960
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hays Nursing and Rehabilitation Center
1900 Medical Pkwy
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop and implement a comprehensive person-centered
care plan for the resident, consistent with the resident rights, that included measurable objectives and
timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified
in the comprehensive assessment, for 1 (Resident #13) of 24 residents reviewed for comprehensive care
plans, in that:
The facility failed to develop a comprehensive care plan that addressed Resident #13's diagnoses of
Constipation, Insomnia, Diabetes Mellitus, or Hepatitis C.
This deficient practice could place residents at risk for not receiving the appropriate care and services
needed to maintain optimal health.
The findings were:
Record review of Resident #13's face sheet, dated 10/14/2022, revealed the resident was admitted to the
facility on [DATE] with diagnoses including: Atherosclerotic Heart Disease of Native Coronary Artery
Without Angina Pectoris, Major Depressive Disorder, and Essential (Primary) Hypertension.
Record review of Resident #13's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which
indicated intact cognition.
Record review of Resident #13's History and Physical assessment, dated 01/27/2022, revealed the
resident's medical history included diagnoses of Constipation, Insomnia, Diabetes Mellitus, and Hepatitis C.
Record review of Resident #13's comprehensive care plan, revised 09/23/2022, revealed the resident's
diagnoses of Constipation, Insomnia, Diabetes Mellitus, and Hepatitis C were not addressed.
During an interview with the DON on 10/14/2022 at 2:54 p.m., the DON confirmed Resident #13's
comprehensive care plan did not address the resident's diagnoses of Constipation, Insomnia, Diabetes
Mellitus, or Hepatitis C, and reported the failure was an oversight.
Record review of the facility policy, Comprehensive Person-Centered Care Planning, revised January 2022,
revealed, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive
person-centered care plan for each resident that includes measurable objectives and timeframes to meet a
resident's medical, nursing, mental, and psychosocial needs .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455960
If continuation sheet
Page 3 of 6
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
455960
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hays Nursing and Rehabilitation Center
1900 Medical Pkwy
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)
F 0791
Provide or obtain dental services for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to assist the resident in obtaining routine dental
care for 1 of 24 residents (Resident #52) reviewed for dental care in that:
Residents Affected - Few
Resident #52 was not assisted in obtaining routine dental care.
This deficient practice could place residents with dental care at-risk for infections, weight loss, and poor
quality of life.
The findings were:
Record review of Resident #52's face sheet revealed an admission date of 09/05/2018 and readmit date of
12/22/2020 with diagnoses that included: schizoaffective disorder- is a mental health disorder that is
marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood
disorder symptoms, such as depression or mania. Hemiplegia- is a symptom that involves one-sided
paralysis. SENILE DEGENERATION OF BRAIN- is a term used to describe a group of symptoms affecting
memory, thinking, and social abilities severely enough to interfere with daily life.
Record review of Resident #52's care plan, dated 10/14/2022, revealed the care plan did not address the
presence of the resident's broken and missing teeth.
Record review of Resident #52's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which
indicated the patient is cognitively intact.
Observation on 10/14/2022 at 11:27 a.m. revealed Resident #52 had broken teeth on the bottom of their
mouth and missing all upper teeth and molars.
During an interview, Resident #52 stated they wanted to see a dentist, Resident #52 stated the broken and
missing teeth caused no physical pain but stated he felt embarrassed because of them.
During an interview on 10/15/2022 at 2:06 p.m., DON stated she was unaware Resident #52 had broken
and missing teeth.
Observation on 10/16/2022 at 2:25 p.m., during an examination of Resident #52's mouth performed by the
DON, revealed Resident #52 had several broken teeth on the bottom of the mouth and was missing all
upper teeth and back molars.
During an observation and interview with the DON on 10/16/2022 beginning at 2:25 p.m., the DON
confirmed Resident #52 had several broken teeth in the front on top of the mouth and was missing all
bottom teeth and molars. The DON was unaware of any potential physical harm to the resident by not
engaging with dental services however, she stated possible potential emotional distress may occur to a
patient if they continued without dental services.
During an interview with ADON and the Social Worker on 10/16/2022 beginning at 2:30 p.m., ADON and
the SW confirmed Resident #52 had not been seen by a provider of dental services since admission
[DATE] and readmit date of 12/22/2020) and confirmed they were working together to obtain physician
orders and a referral for the resident to receive a dental examination.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455960
If continuation sheet
Page 4 of 6
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
455960
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hays Nursing and Rehabilitation Center
1900 Medical Pkwy
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)
F 0791
Level of Harm - Minimal harm
or potential for actual harm
Record review of facility policy titled Dental Service , dated 1/12018, revealed in order to comply with
facility's obligations as set forth in 42 CFR Section 483.55, the facility will provide or obtain from an outside
resource, routine and emergency dental services for each resident. Assist the residents as necessary or
requested to make an appointment for dental services or arrange transportation to and from dental service
locations.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455960
If continuation sheet
Page 5 of 6
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
455960
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/14/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hays Nursing and Rehabilitation Center
1900 Medical Pkwy
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to maintain medical records on each resident that were
complete, accurately documented, readily accessible, and systematically organized, for 1 (Resident #13) of
24 residents reviewed for medical records, in that:
The facility failed to include Constipation, Insomnia, GERD, Anemia, Diabetes Mellitus, or Hepatitis C in the
list of Resident #13's diagnoses.
This deficient practice could affect residents whose records were maintained by the facility and place them
at risk for errors in care and treatment.
The findings were:
Record review of Resident #13's face sheet, dated 10/14/2022, revealed the resident was admitted to the
facility on [DATE] with diagnoses including: Atherosclerotic Heart Disease of Native Coronary Artery
Without Angina Pectoris, Major Depressive Disorder, and Essential (Primary) Hypertension. Further review
of Resident #13's face sheet revealed it did not include the resident's diagnoses of GERD and
Anemia.
Record review of Resident #13's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which
indicated intact cognition.
Record review of Resident #13's History and Physical assessment, dated 01/27/2022, revealed the
resident's medical history included diagnoses of Constipation, Insomnia, Diabetes Mellitus, and Hepatitis C.
Record review of Resident #13's comprehensive care plan, revised 09/23/2022, revealed the resident had
diagnoses of GERD and anemia which were not included in the resident's list of diagnoses or on the
resident's face sheet.
During an interview with the DON on 10/14/2022 at 2:54 p.m., the DON confirmed Resident #13's care plan
revealed the resident had diagnoses of GERD and anemia which were not included in the resident's list of
diagnoses or on the resident's face sheet, and reported the failure was an oversight. The DON confirmed
that, in the event the resident was sent to the hospital, the face sheet would be sent to inform hospital staff
of the resident's medical conditions and that the resident could be improperly treated if hospital staff were
unaware of all the resident's medical conditions.
During an interview with the Administrator on 10/14/2022 at 3:32 p.m., the Administrator confirmed the
facility did not have a specific policy regarding complete and accurate medical records.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455960
If continuation sheet
Page 6 of 6
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F791 - Dental Services
Provide or obtain dental services for each resident.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the October 14, 2022 survey of HAYS NURSING AND REHABILITATION CENTER?
This was a inspection survey of HAYS NURSING AND REHABILITATION CENTER on October 14, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HAYS NURSING AND REHABILITATION CENTER on October 14, 2022?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.