Hays Nursing And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the call light system was accessible to four residents who were dependent on staff for self-care and mobility needs and who had care plans directing that their call lights be kept within reach. Resident #4 had diagnoses including senile degeneration of the brain, severe protein-calorie malnutrition, and anxiety disorder, and her annual MDS reflected a BIMS score of 0 and dependence for self-care and mobility. On 03/03/2026, she was observed lying in bed with her call light on the floor at the foot of the bed. Resident #73 had diagnoses including epilepsy, dementia, and hypertension, and her annual MDS reflected a BIMS score of 0 with dependence for self-care and mobility. On 03/03/2026, she was observed lying in bed with her call light on the floor at the foot of the bed. Resident #83 had diagnoses including hypertensive heart and chronic kidney disease with heart failure and depression, and her annual MDS reflected a BIMS score of 02 with dependence for self-care and mobility. On 03/03/2026, she was observed lying in bed with her call light pinned to the privacy curtain behind her head, and on a later observation it was attached to her bed above her head on the right side. Resident #1 had diagnoses including anoxic brain damage, bipolar disorder, moderate protein calorie malnutrition, generalized anxiety disorder, and dysphagia. Her quarterly MDS reflected a BIMS score of 10, functional limitation in one upper extremity, and dependence on staff for transfers out of bed. During an observation on 03/04/2026, she was sitting in bed with her call button lying above her right shoulder and stated she did not know where it was and could not reach it with either hand. She said it was usually on her chest and she could reach it. Staff entered the room after she called for help, and a CNA clipped the call button to the front of her gown. Interviews with CNAs, an LPN, the DON, and the ADM confirmed that call lights were expected to be placed within reach, that staff were responsible for ensuring this, and that the facility had experienced lapses in doing so.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe, clean, comfortable, and homelike environment for 5 of 11 residents reviewed for environment because the privacy curtains in the rooms of Residents #42, #48, #20, #66, and #8 were dirty. The report states that the curtains had crusty brown stains and, in some rooms, additional permanent staining. These conditions were observed in rooms shared by Residents #42 and #48, next to Resident #20's bed, and next to Resident #66's bed where Resident #8 was also present. Resident #66 was a female with Alzheimer's disease, Resident #42 was a female with depression, Resident #48 was a female with Wernicke's encephalopathy, adjustment disorder with anxiety, need for assistance with personal care, cognitive communication deficit, and anxiety disorder, Resident #8 was a female with lack of coordination, anxiety disorder, insomnia, need for assistance with personal care, mild vascular dementia, and major depressive disorder, and Resident #20 was a male with acquired absence of the right leg below the knee, cerebral infarction, hemiplegia and hemiparesis, and full incontinence of feces. During observation, the privacy curtain between Residents #42 and #48 had a crusty brown stain, and the curtain next to Resident #20's bed had three crusty brown stains. The curtain next to Resident #66's bed had several permanent stains and two crusty brown stains. Resident #20 stated he noticed the stains but did not know what they were and had not reported the curtain as dirty; he also said he had not seen anyone remove and wash the privacy curtain since he had been there and would like it cleaned. Resident #8 stated she had not seen the privacy curtains cleaned and described the condition as disgusting. The housekeeper stated curtains were checked during room cleaning but sometimes were pushed back and the whole curtain could not be seen, and she did not know why the stains were not noticed. The head of housekeeping stated there was no detailed routine washing schedule for privacy curtains and they were washed as needed, while the administrator stated housekeeping and maintenance were responsible for cleaning dirty curtains and that he did not monitor compliance in this area.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents who were unable to perform activities of daily living received necessary grooming and personal hygiene services when four reviewed residents had long, jagged, or dirty fingernails. The deficiency was identified through observation, interview, and record review for Residents #1, #17, #35, and #45, all of whom had care plans indicating dependence or assistance needs for personal hygiene and grooming. The facility’s ADL policy stated residents unable to carry out ADLs would receive necessary services to maintain grooming, personal hygiene, and oral hygiene, and the nail care policy stated the facility promoted cleanliness, safety, and a neat appearance. Resident #1 had diagnoses including diabetes mellitus, anoxic brain damage, bipolar disorder, moderate protein calorie malnutrition, generalized anxiety disorder, and dysphagia. Her MDS reflected moderate cognitive impairment and dependence on staff for personal hygiene. Her care plan directed dependent personal hygiene care, but no nail care attempt was documented during the 30-day lookback period. On observation, she was lying in bed with long, jagged fingernails, and two nails had a red substance underneath. A later observation showed the fingernails were still long and jagged. Resident #35 had dementia with agitation, schizoaffective disorder, major depressive disorder, anxiety disorder, and chronic pain, with severe impairment in daily decision making and dependence on staff for personal hygiene. No nail care attempt was documented in the 30-day lookback period. On observation, she had long and jagged fingernails and stated she wanted them cut, but then spoke about unrelated topics in a confused manner. A later observation showed the fingernails were still long and jagged. Resident #45 had cerebral infarction, hemiplegia and hemiparesis, rheumatoid arthritis, dementia without behavioral disturbance, lack of coordination, cognitive communication deficit, delusional disorder, adjustment disorder, major depressive disorder, generalized anxiety disorder, and need for assistance with personal care. His MDS showed moderate cognitive impairment and partial to moderate assistance with personal hygiene. No nail care attempt was documented in the 30-day lookback period. He was observed with slightly long fingernails that had a brown substance underneath and around the nail beds, and the fingernails remained dirty on a later observation. Resident #17 had cerebral infarction, hemiplegia and hemiparesis, epilepsy, PTSD, and generalized anxiety disorder, with severe impairment in daily decision making and dependence on staff for personal hygiene. No nail care attempt was documented in the 30-day lookback period. She was observed lying in bed with very long and jagged fingernails, and the fingernails remained long and jagged on a later observation. Staff interviews stated nail care was expected to be checked during baths or showers, refusals were to be documented and reported, and residents with diabetes required nurse involvement for nail trimming. Staff also stated they had not been monitoring nail care closely and that refusals had not been documented for some residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards during puree meal preparation in the kitchen. During observation, the kitchen counter was visibly soiled with food particles, liquid spills, and stains, yet CK L began the puree lunch process on that dirty counter without cleaning or sanitizing it. CK L also washed the food processor bowl and blade in the three-compartment sink, dipped them briefly in sanitization water, and then placed the wet blade on the dirty counter before assembling the equipment for puree preparation. During the same meal preparation, CK L was observed washing her hands by dipping them into the dishwashing sink water rather than using the employee hand sink. She later handled food and food-contact items without washing or sanitizing her hands or changing gloves between tasks, including placing a plastic liner inside a puree container with a bare hand, assembling the food processor for another puree, and completing multiple tasks such as putting away food, removing pans from sanitized water, filling a pan with water, turning on the stove, and placing a plastic liner inside a pan without washing hands or changing gloves. CK L also removed one glove and placed her bare hand inside the plastic liner before pouring the beef enchiladas puree. Interviews confirmed that CK L had been trained in puree food preparation, hand hygiene, and sanitizing counters, equipment, and utensils, and she stated she was supposed to wipe down and sanitize kitchen surfaces before and after every task, wash hands at the employee sink, and change gloves when changing tasks. The DM stated kitchen surfaces should be cleaned and sanitized before food preparation and that staff should wash hands with soap and hot water in the employee sink, not the dish wash sinks; she also stated equipment should remain in sanitization water for one minute. The DON and ADM stated the observed actions did not meet their expectations, and the facility records reflected requirements for hand washing, glove use, and cleaning and sanitizing work surfaces, utensils, and equipment after each use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an infection prevention and control program for two residents and for medication storage. During observation of the medication room refrigerator on 03/03/2026, a dark red substance measuring about 40 cm long and 5 cm wide was seen on the bottom of the refrigerator under the crispy drawers. Multiple nurses opened the refrigerator to retrieve medications, and the substance remained unnoticed. The refrigerator was used for medication and biological storage in the medication room. Resident #20 was a [AGE]-year-old male admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, type 2 diabetes mellitus with hyperglycemia, neuromuscular dysfunction of the bladder, and urinary retention. His MDS assessment showed a BIMS score of 13, and his care plan identified an indwelling catheter related to neurogenic bladder. During observation of incontinent care, LPN C and CNA G provided perineal care while standing on both sides of the bed. CNA G wiped the resident’s pubic area and penis, but did not wipe the scrotum area and did not wipe the indwelling catheter from the tip of the penis moving downward away from the body. CNA G then moved the bag with wipes from the middle of the bed to the resident’s feet without removing gloves or performing hand hygiene. LPN C later picked up the bag with wipes from the resident’s feet and placed it inside the resident’s nightstand drawer. Resident #62 was a [AGE]-year-old male admitted and readmitted to the facility with diagnoses including cerebral infarction, hemiplegia, hemiparesis, acute and chronic respiratory failure with hypoxia, heart failure, and essential hypertension. His quarterly MDS assessment showed a BIMS score of 09, indicating moderate cognitive impairment, and his care plan identified him as at risk for infection. During observation of medication administration, MA F did not perform hand hygiene before entering the resident’s room to administer medications and did not perform hand hygiene after administering medications. She left the room, logged back onto the facility laptop, and began charting without performing hand hygiene. Interviews with LPN C, CNA G, MA F, ADON A, the DON, and the ADM/DON confirmed staff training on infection control and hand hygiene expectations, and the facility’s policies stated that medication storage areas are to be kept clean and that hands are to be washed or sanitized during medication administration and perineal care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide special eating equipment and utensils for a resident who had an order for a two-handled drinking cup with meals. The resident had anoxic brain damage, schizophreniform disorder, bipolar disorder, moderate protein calorie malnutrition, generalized anxiety disorder, dysphagia, and a BIMS score of 10 indicating moderate cognitive impairment. Her care plan and dietitian note both documented the need for adaptive dining equipment, including a scoop dish and a two-handled cup, with meals. During observation, the resident was found in bed with her lunch tray and a disposable foam cup that she punctured with her thumbnail, causing water to spill onto her blanket and tray. She stated she was thirsty and did not know where her call button was. Her call button was not positioned where she could reach it, and she could not reach it with either hand because of range-of-motion limitations. Staff entered the room, and an LPN later returned with a foam cup of water and held the straw to the resident’s mouth so she could drink. The LPN stated the resident was supposed to have a sippy cup, but the kitchen often did not send it. Interviews with CNA staff and nursing staff reflected that the two-handled cup was sometimes on the tray and sometimes missing, and staff reported that the kitchen frequently lost the cups. One LPN stated the resident nearly always had to use her light and ask for help with the foam cup. The dietary manager stated the resident should have received the adaptive equipment every day and that if the cup was not available, someone should have gone to the store to get it right away. The DON and ADON stated dietary was responsible for providing the cup, while nursing staff were also expected to notice when it was missing and report it. A facility policy for specialized, adaptive dietary equipment was requested but not provided.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, resulting in several instances of cross-contamination among residents. Resident #1, who has severe cognitive impairment and is incontinent, was observed sleeping in the bed of Resident #2 on multiple occasions. Despite staff awareness of this behavior, the linens were not consistently changed after Resident #1 used them, potentially exposing Resident #2 to bodily fluids and food particles. Staff interviews revealed a lack of consistent intervention and monitoring of Resident #1's behavior, which was not adequately addressed in her care plan. Additionally, Resident #1 was observed eating from Resident #3's meal tray, and Resident #3 subsequently consumed the remaining food, leading to potential cross-contamination. Staff failed to prevent this interaction, and the contaminated food was not replaced. This incident highlights a lapse in supervision and infection control practices during meal times, particularly in the secure unit where residents with severe cognitive impairments are housed. Furthermore, a shared baby doll used by multiple residents, including Resident #4 and Resident #5, was not sanitized between uses. The doll, which was in close contact with residents' faces and hands, was not cleaned before being given to another resident, increasing the risk of infection transmission. Staff acknowledged the need for more dolls and the requirement to sanitize shared items but had not implemented these measures. The Director of Nursing, responsible for infection control, admitted to not providing specific training on these issues, indicating a gap in the facility's infection prevention education.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which is a requirement under S483.10(c)(2) and S483.10(c)(3). The care plan did not address the resident's behavior of sleeping in other residents' beds, despite this behavior being observed and documented multiple times by staff. The resident, a female with severe cognitive impairment and several diagnoses including vascular dementia and major depressive disorder, was noted to have this behavior in nursing progress notes and during observations by surveyors. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's behavior. The Assistant Business Office Manager (ABOM) believed the behavior was care planned, while the Director of Nursing (DON) acknowledged having seen the behavior but was unaware of its frequency. The DON also indicated that the issue had not been discussed in meetings or identified as a concern, leading to uncertainty about responsibility for addressing the behavior. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan within seven days of completing the Minimum Data Set (MDS), but this was not adhered to in this case.

Penalty

Inspection fine: $8,226

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents in the Memory Care Unit (MCU) from engaging in sexual activities when neither had the capacity to consent. Resident #1, an elderly female with diagnoses including unspecified dementia, cognitive communication deficit, Alzheimer's disease, and hallucinations, was found performing oral sex on Resident #2. Resident #2, an elderly male with diagnoses including cerebral infarction, vascular dementia, and other cognitive impairments, was also involved in the incident. Both residents were documented as having significant cognitive impairments, with Resident #1 unable to complete a cognitive interview and Resident #2 having a moderate cognitive impairment. The incident was reported by a CNA who found the residents in bed together. Both residents were upset when interrupted, and staff initially believed the interaction was consensual. However, interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the incident was not reported to the Health and Human Services Commission (HHSC) because they believed it was consensual. Family members and a Power of Attorney (PPA) expressed concerns, stating that neither resident had the capacity to consent and that the incident was upsetting and potentially traumatic. The facility's policy on abuse and neglect clearly states that each resident has the right to be free from abuse, including non-consensual sexual contact. Despite this, the facility failed to assess the residents' capacity to consent properly and did not report the incident as required. The Immediate Jeopardy (IJ) was identified, and the facility was notified, but the failure to protect the residents from abuse placed them at significant risk.

Removal Plan

• The Medical Director was notified of the Immediate Jeopardy.
• Resident #1 was assessed by ADON with no adverse effects. Resident #2 was discharged from facility. All Full-time, Part-time, PRN and agency staff will be in-serviced prior to working the floor on how to handle residents engaging in a sexual encounters. In-service includes separating residents and informing ED or DON/ADON immediately and IDT meeting will be scheduled. New staff will also be in-serviced during the orientation process prior to resident interactions. All staff currently working the floor have already been in-serviced by RN interim DON.
• Staff will separate residents wanting to engage in sexual encounter until the IDT process is completed and staff have been informed of IDT decision by ED or DON and plan of care is updated. These individuals will be identified based on staff interviews and observations.
• Facility process for residents to have sexual encounter is for staff to inform ED or DON of residents' desire based on interviews or observed behaviors. It will then be brought to the IDT (to include, but not limited to MD, ED, DON, ADON, SW) for them to make a determination of consent and need for further interventions and care plan updates, which will be done as soon as possible but up to three days. Staff made aware on case by case basis based on IDT determination. Facility will determine if needs or choices are changed as identified during quarterly care plan reviews. Staff will be made aware based on care plan. If staff encounter a situation involving residents, they will separate the residents and inform the ED or DON/ADON.
• Train the trainer in-service was given by the Clinical Resource RN and was completed with interim DON and Executive Director related to resident's capacity to consent and the IDT process to determine consensual relationships of residents.
• Summary of IJ and corrective action to be reviewed by QAPI Committee weekly or until substantial compliance established and continue monthly to ensure ongoing compliance.

Penalty

Inspection fine: $8,226

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for two residents in the Memory Care Unit (MCU). The deficiency involved the facility's failure to protect two residents from engaging in sexual activities when neither had the capacity to consent. This incident was not reported to the appropriate state or federal agencies as required by the facility's policy and applicable regulations. The Director of Nursing (DON) and Administrator (ADM) reviewed video footage and interviews and concluded that the interaction was consensual, despite the residents' cognitive impairments and inability to consent. This decision was made without proper assessment of the residents' capacity to consent to sexual activities, leading to a failure in protecting the residents from potential abuse and neglect. Resident #1, an elderly female with diagnoses including unspecified dementia, cognitive communication deficit, Alzheimer's disease, and hallucinations, was found performing oral sex on Resident #2, an elderly male with diagnoses including cerebral infarction, vascular dementia, and memory deficit. Both residents resided in the MCU and had documented cognitive impairments. The incident was reported by a Certified Nursing Assistant (CNA) who found the residents in bed together. The residents were upset when interrupted, and the staff initially believed the interaction was consensual. However, the residents' Power of Attorney (PPA) later stated that neither resident had the ability to consent, highlighting the potential for emotional trauma and the need for proper assessment of consent capacity. The facility's policy on Freedom from Abuse, Neglect, and Exploitation clearly states that each resident has the right to be free from abuse, including non-consensual sexual contact. The policy also mandates reporting allegations of abuse to the appropriate state or federal agencies within specified timeframes. The facility's failure to report the incident and properly assess the residents' capacity to consent resulted in an Immediate Jeopardy (IJ) situation, which was later removed after corrective actions were implemented. However, the facility remained at a level of actual no harm at a scope of isolated that is not immediate jeopardy, indicating the need for further evaluation of the effectiveness of the corrective systems.

Removal Plan

• The Medical Director was notified of the Immediate Jeopardy.
• Resident #1 was assessed by ADON with no adverse effects. Resident #2 was discharged from facility. All Full-time, Part-time, PRN and agency staff will be in-serviced prior to working the floor on Abuse and Neglect policy. New staff will also be in-serviced during orientation process prior to resident interactions. All Staff currently working the floor have already been in-serviced by RN interim DON.
• Facility process for residents to have sexual encounter is for staff to inform ED or DON of residents' desire based on interviews or observed behaviors. It will then be brought to the IDT (to include, but not limited to MD, ED, DON, ADON, SW) for them to make a determination of consent and need for further interventions and care plan updates, which will be done as soon as possible but up to three days. Staff made aware as needed on a case by case basis based on IDT determination. Facility will determine if needs or choices are changed as identified during quarterly care plan reviews. Staff will be made aware based on care plan. If staff encounter a situation involving residents, they will separate the residents and inform the ED or DON/ADON immediately and IDT meeting will be scheduled.
• Train the trainer in-service was given by the Clinical Resource RN and was completed with interim DON and Executive Director related to resident's capacity to consent and the IDT process to determine consensual relationships of residents.
• Summary of IJ and corrective action to be reviewed by QAPI Committee weekly or until substantial compliance established and continue monthly to ensure ongoing compliance.

Penalty

Inspection fine: $8,226

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an incident involving two residents who were not cognitively able to give consent and were found engaging in sexual activities. Resident #1, an elderly female with diagnoses including unspecified dementia and Alzheimer's disease, and Resident #2, an elderly male with diagnoses including vascular dementia and memory deficits following a stroke, were discovered by a CNA in bed together performing oral sex. Both residents were upset when interrupted, and the incident was documented by an LVN. Despite the facility's policy requiring the reporting of such incidents, the Director of Nursing (DON) and the Administrator (ADM) decided not to report the incident to the State Agency, believing it was consensual and caused no harm. The facility's policy on abuse, neglect, and exploitation mandates that all allegations of abuse or neglect be reported to the appropriate state or federal agencies within 24 hours. However, the DON and ADM reviewed video footage and interviews and concluded that the incident was consensual, despite the residents' cognitive impairments. This decision was contrary to the facility's policy and state regulations, which define non-consensual sexual contact as abuse and require timely reporting of such incidents. The failure to report this incident could place residents at risk of not having required incidents reported as mandated.