Nursing homes › Texas › Hays Nursing and Rehabilitation Center
1900 Medical Pkwy, San Marcos, TX 78666 · 5123961888 · 116 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 3.27 (Texas median: 3.27). RN hours: 0.46. Weekend total: 2.72. Nursing staff turnover: 38%.
All-time on record: 26 deficiency citations, including 2 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-03-05 | Reasonably accommodate the needs and preferences of each resident. | E | Health | corrected 2026-03-28 |
| 2026-03-05 | 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. | E | Health | corrected 2026-03-20 |
| 2026-03-05 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | Health | corrected 2026-03-22 |
| 2026-03-05 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Health | corrected 2026-03-28 |
| 2026-03-05 | Provide and implement an infection prevention and control program. | E | Health | corrected 2026-03-27 |
| 2026-03-05 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D | Health | corrected 2026-03-28 |
| 2025-01-16 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E | Health | corrected 2025-01-23 |
| 2025-01-16 | Provide activities to meet all resident's needs. | E | Health | corrected 2025-01-23 |
| 2025-01-16 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Health | corrected 2025-01-17 |
| 2025-01-16 | 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. | E | Health | corrected 2025-01-31 |
| 2025-01-16 | 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. | D | Health | corrected 2025-01-31 |
| 2025-01-16 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Health | corrected 2025-01-17 |
| 2024-07-09 | Provide and implement an infection prevention and control program. | E | complaint | corrected 2024-07-16 |
| 2024-07-09 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | complaint | corrected 2024-07-16 |
| 2024-05-02 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | complaint | corrected 2024-05-03 |
| 2024-05-02 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | J | complaint | corrected 2024-05-03 |
| 2024-05-02 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2024-05-03 |
| 2023-12-14 | Keep all essential equipment working safely. | F | Health | corrected 2024-01-19 |
| 2023-12-14 | 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. | E | Health | corrected 2024-01-05 |
| 2023-12-14 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Health | corrected 2023-12-15 |
| 2023-12-14 | Provide activities to meet all resident's needs. | D | Health | corrected 2024-01-11 |
| 2023-12-14 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Health | corrected 2024-01-18 |
| 2023-12-14 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Health | corrected 2024-01-18 |
| 2023-12-14 | Provide enough food/fluids to maintain a resident's health. | D | Health | corrected 2023-12-21 |
| 2023-11-20 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | complaint | corrected 2023-11-27 |
| 2023-09-23 | 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. | D | complaint | corrected 2023-10-12 |
| Date | Type | Amount |
|---|---|---|
| 2024-05-02 | Fine | $8,226 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| GUADALUPE COUNTY HOSPITAL BOARD | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 12/01/2020 |
| CHUDLEIGH, JAMES | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 02/01/2024 |
| PHELPS, NELSON | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 12/01/2020 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 12/01/2020 |
| GANN, KODY | Corporate Officer | Individual | NOT APPLICABLE | since 04/03/2021 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| WILLOW SPRINGS CREEK HEALTHCARE, INC. | Operational/Managerial Control | Organization | NOT APPLICABLE | since 12/01/2020 |
| CHUDLEIGH, JAMES | Operational/Managerial Control | Individual | NOT APPLICABLE | since 02/01/2024 |
| PHELPS, NELSON | Operational/Managerial Control | Individual | NOT APPLICABLE | since 12/01/2020 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 455960. Corrections: data@carerecords.org.