Health inspection·November 20, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some his room, which had a strong foul odor within. Resident #1 presented as clean and groomed, and it was unclear where the odor originated. Resident #1 stated it had been about a week since his last shower. He stated he liked to take showers, but he was not upset he had not gotten one, because the staff were busy doing other things. Review of the undated face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia/hemiparesis (weakness or complete paralysis of one side of the body), dementia, chronic pain, adjustment disorder with depressed mood, conduct disorder, and cognitive communication deficit (trouble communicating due to cognitive impairment). Review of the quarterly MDS assessment for Resident #2 dated 10/26/23 reflected a BIMS score of 12, indicating an intact cognitive response. Review of the section for Functional Abilities and Goals reflected he required supervision and touching assistance with bathing. Review of the care plan for Resident #2 dated 08/10/23 reflected the following: ADL Self Care Performance Deficit r/t hx of CVA with left hemiplegia, impaired cognition-Resident is here for LTC, Peripheral Vertigo 8/10/23 Resident does tasks on own although supervision /touching assist is recommended. Will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score) through the review date. Supervision x 1. There was no care plan item related to refusal of bathing. Review of showers sheets for Resident #2 from 11/03/23 to 11/16/23 reflected he had one shower on 11/09/23, refused a shower on 11/04/23, 11/07/23, 11/11/23, 11/14/23, and all other dates were marked as Not Applicable. Review of shower sheets for Resident #2 from 11/01/23 to 11/16/23 reflected he refused a shower on 11/04/23. There were no other shower sheets for him during that time frame. During observation and interview on 11/16/23 at 10:52 AM, Resident #2 entered the room he shared with Resident #1. His fingernails were long and had a black-brown substance underneath them. He said he really wanted them to cut his fingernails, but they never did. He stated he was not getting his showers and did not know if they were changing his sheets. His bed was unmade, and there was no obvious filth in or on it, but his room had a strong foul odor. He asked if he would start getting his showers after speaking with the surveyor. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia, cognitive communication deficit (trouble communicating due to cognitive impairment), major depressive disorder, and need for assistance with personal care. Review of the quarterly MDS for Resident #3 dated 09/19/23 reflected a BIMS score of 14, indicating an intact cognitive response. Review of the section for Functional Status reflected the activity of bathing itself did not occur during the 7-day lookback period. Review of the care plan for Resident #3 dated 07/05/23 reflected the following: ADL Self Care Performance Deficit r/t Dementia. Will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455960 If continuation sheet Page 2 of 5 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 11/20/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Personal Hygiene through the review date. Requires physical help in part of bathing activity from 1 staff member. There was no care plan item related to refusal of bathing. Review of shower sheets for Resident #3 from 11/03/23 to 11/16/23 reflected all dates were marked as Not Applicable. Residents Affected - Some Review of shower sheets for Resident #3 from 11/01/23 to 11/16/23 reflected he refused a shower on 11/02/23, 11/04/23, and 11/11/23 and had a shower on 11/16/23. There were no other shower sheets for him during that time frame. During observation and an interview on 11/16/23 at 11:42 AM, Resident #3 was ambulating in his wheelchair in the hallway. His fingernails were very long and yellow, but not dirty. He had a slight foul odor about his person. He stated he had showers when he wanted them, but it had been a while since they had cut his fingernails. He stated he did not prefer them long, but he did not mind. During an interview on 11/16/23 at 12:59 PM, CNA B stated Resident #2 had incontinent episodes and was embarrassed so sometimes he did not report them, but he also refused showers. CNA B stated they had trouble on his shower days, because he was often very adamant about his refusals or would say I'll do it later. CNA B stated the last time she had helped him shower was last week, but she did not remember which dates. She stated she cleaned his nails at that time, as well. CNA B stated Resident #3 refused showers, as well, but it was usually CNA C who worked with Resident #3. CNA B stated Resident #1 had his showers scheduled in the afternoon, so she could not speak on what happened with those. CNA B stated the protocol when a resident refused showers was to come back later and try again to offer one, ask another aide to offer the shower, and then let the nurse and the next shift of CNAs know. CNA B stated she let the nurse know by putting the refusals on the shower sheets, but she sometimes said it directly to the nurse. During an interview on 11/16/23 at 01:08 PM, CNA C stated Resident #2 refused showers from time to time, and Resident #3 also refused. CNA C stated when residents refused showers, their next steps depended on why they refused he stated if they did not like the particular CNA trying to give them a shower, another one would try. CNA C stated ultimately it was the residents' right to refuse showers. CNA C stated when they refused, he told the nurse verbally or turned in the shower sheets. CNA C stated nail care was not done on a schedule but was done when it was needed or requested. CNA C stated he cleaned the nails but did not clip nails of residents with diabetes. During an interview on 11/16/23 at 01:30 PM, LVN A stated if residents refused showers, the aides told her, and they tried to ask again a little later. LVN A stated she had noticed the odor in the room for Resident #1 and 2 was very strong. She stated the main problem was Resident #2 had a bowel movement, he would not let the staff help him but wanted to clean up after himself. LVN A stated it was rare that he allowed them to help him, and he often refused showers. LVN A stated Resident #2 was able to toilet and change independently, and he did not enjoy having his independence taken away. LVN A stated the dark substance under Resident #2's nails would be feces from trying to clean himself. LVN B stated management was aware of the issue, and they had planned to engage psych services to see if there was something about his refusals related to his mental health. LVN A stated she monitored that nail care was getting done by checking on her residents. She stated if nails were really dirty and long, she would put them on the list for podiatry. LVN A stated only the podiatrists should have cut toenails for residents with diabetes. LVN A stated the aides should have cut nails for any resident that did not have diabetes. LVN A stated Resident #3 would complain if he wanted something like his nails cut, so she had not noticed he had long nails. She stated she thought she had cut (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455960 If continuation sheet Page 3 of 5 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 11/20/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #3's nails once or twice but was not sure when. LVN A stated she was not aware of any refusals of showers or nail care from Resident #1. During an interview on 11/16/23 at 02:21 PM, the ADON stated they liked the charge nurses to monitor that nail care and showers were being done and did not monitor directly. She stated if a resident did not want to shower, their policy was to find out if there was a legitimate reason. The ADON stated she had not been in the room for Residents #1 and 2 and did not know it had a foul odor. She stated they knew Resident #2 had some behaviors when they admitted him. The ADON stated when residents were consistently refusing showers, the charge nurses brought the issue to the IDT. She stated the IDT had discussed Resident #2 and his refusal to shower or allow staff to help him clean up. She stated he was very strong willed and had finally agreed to psych services and a mood stabilizer. She stated they were trying to improve his mood to get him to participate in healthier behaviors. She stated she did not know a lot about Residents #1 and 3 refusing showers or what was being done about that. She stated potential negative impacts of missing showers and nail care were skin breakdown and infection. During an interview on 11/20/23 at 4:43 PM, the ADM stated he monitored for ADL care by talking about it in different meetings such as daily morning meeting and weekly skilled meetings. He stated he knew there was something where if a resident was diabetic, a CNA could not cut their toenails. The ADM stated they had not thought about nail care. He stated he has once or twice had a concern about a resident's nails that were long and gross and looked like a piece of macaroni or pasta. He stated he was aware that some residents were refusing showers routinely. He stated they did talk about those people and how part of the problem with them was they smelled bad. He stated he was not aware of Resident #1 being a problem, but the ADM had quite a bit of interaction with Residents #1, 2, and 3 for different reasons. The ADM stated, as far as he knew, the IDT had not talked about strategies to get to the bottom of the refusals. The ADM stated he understood that the efforts to provide showers to Residents #1, 2, and 3 and get around their refusals had not been exhausted. He stated it was not good for Resident #2 do have feces under his fingernails. He stated there was always potential for a negative outcome, but the feces thing under the fingernails was really gross. He stated with the amount of bacteria that could be on Resident #2's hands, and then Resident #2 was probably interacting with other residents and staff; it was an infection control problem. The ADM stated one of the reasons showers were so important was they could not do proper skin checks without them. The ADM stated they might miss a fungus or something. Review of in-services from 8/16/23 to 11/16/23 revealed there were no in-services about nail care or shower refusals. Review of undated facility policy titled ADL Care reflected the following: It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. PROCEDURES: 1. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain: - Good nutrition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455960 If continuation sheet Page 4 of 5 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 11/20/2023 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 0677 - Grooming Level of Harm - Minimal harm or potential for actual harm - Personal hygiene - Oral hygiene. Residents Affected - Some Review of undated facility policy titled Bath, Showers reflected the following: It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455960 If continuation sheet Page 5 of 5