Hayes Convalescent Hospital

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary storage of foods brought to residents by family when the foods are stored in a communal refrigerator, comingled with staff lunch bags, not labeled, and not placed in a re-sealable container with tightly fitting lids. This failure had the potential to cause food borne illness when stored food are served to residents. FINDINGS: During concurrent observation and interview on 12/10/24 at 12:13 p.m., in the breakroom with DS (Dietary Supervisor), the refrigerator that family members store food brought from outside the facility and also used for staff to store their food was observed to have plastic grocery bags containing food items, brown paper bag with food items inside, unlabeled opened milk carton of Kerns Milk and [NAME] Drink, unlabeled opened liquid coffee creamer, 1 apple, one small individual container of pudding, one small individual container of jello, a plastic container of food item unlabeled. The label outside refrigerator did not specify or designate space/storage for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy regarding restraints for two of 12 sample residents (Resident 8 and 18). For Resident 18 the facility failed to assess her restraint on a regular basis for restraint reduction and/or elimination. For Resident 8 the facility failed to obtain consent from the responsible party and a Physician order. Failure to follow their restraint policy did not ensure Resident 8 and 18 were free from restraints. Findings: Review of Resident 18's MDS (Minimum Data Set, a standardized resident assessment tool) dated 9/14/24 indicated: 1. She was severely impaired in her cognition. 2. She had no impairment in range of motion for her upper and lower extremities. 3. She used a walker as a mobility device. 4. she required set up for meals and was dependent on staff for all other ADLs (activity of daily living). 5. She exhibited behaviors not directed towards other (screaming, disruptive sounds, hitting or scratching self, etc.). Observation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy regarding care planning restraints for two of 12 sample residents (Resident 8 and 18). The facility failed to address these issues in Resident 18's care plan: 1. assess her restraint on a regular basis for restraint reduction and/or elimination. 2. Formulate interventions for restraint reduction and/or elimination. For Resident 8 the facility failed to formulate a restraint care plan for her side rails. Failure to follow facility policy regarding care planning restraints did not ensure Resident 8 and 18 were free from restraints. Findings: Review of Resident 18's MDS dated [DATE] indicated: 1. She was severely impaired in her cognition. 2. She had no impairment in range of motion for her upper and lower extremities. 3. She used a walker as a mobility device. 4. she required set up for meals and was dependent on staff for all other ADLs 5. She exhibited behaviors not directed towards other (screaming, disruptive sounds,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that Resident 18 (R18) had a signed informed consent form before receiving an antipsychotic medication, Citalopram. This failure has the potential to harm the resident while taking the medication without knowing the harm or side effects associated with this type of medication. Findings: The clinical record of Resident 18 was reviewed. The Minimum Data Set (MDS, an assessment tool) dated 09/03/2023 indicated, R18 was admitted to the facility on [DATE] with diagnoses including: Hypertension (High blood pressure), Gastroesophageal Reflux Disease (GERD, acid reflux), Viral Hepatitis, (infection that causes liver inflammation and damage), Thyroid disorder (a disease in the thyroid gland), Arthritis (a condition that affects bone joints), Alzheimer's Disease (brain disorder affecting a person's ability to function), Asthma, Cataracts, Diverticulosis (condition in which small bulging pouches develop in the digestive tract). Resident 18 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that a current copy of a resident's advance directive was in the resident's medical record for Resident 10 (R10). This failure could result in the Resident or her representative's inability to make decisions regarding her health care and related treatment choices. Findings: The clinical record of R10 was reviewed. The Minimum Data Set (MDS, an assessment tool) dated 08/03/2023, indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including Hypertension (High blood pressure), Diabetes Mellitus (High blood Sugar), Hyperlipidemia (High Cholesterol), Depression (a mood disorder), Osteoarthritis (disease that affects joints). R10's Brief Interview for Mental Status (BIMS) score was 04 (severely impaired). During observation on 10/09/23 at 8:45 AM, R10 looked clean, in good spirit, communicated and her environment looked clean and homelike. During a concurrent interview R10 communicated a little bit but stated to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide adequate supervision as per physician's orders for one of seven sampled residents (Resident 22) when staff removed the tabletop tray from Resident 22's Geri chair (recliner chair with tray top). This failure resulted in Resident 22 falling to the floor from her Geri chair on 6/30/23. Findings: Review of Resident 22's clinical records indicated Resident 22 was admitted on [DATE] with diagnoses including vascular dementia with behavioral disturbance (loss of brain function with changes in behavior), delusional disorders (having beliefs not based on reality) and hypertensive heart disease with heart failure (heart muscle not pumping effectively). During observation on 10/9/23 at 9:05 AM, Resident 22 was observed sitting in a Geri chair, calling out for help. During an interview with the Director of Nursing (DON) on 10/10/23 at 1:42 PM, the DON confirmed the fall happened on 6/30/23 at 11:00 PM during night shift. The DON reported the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to act upon the Pharmacist Consultant's (PC) recommendations: A) to change the timing of administration of Omeprazole (a medication that decreases the amount of acid produced by the stomach) to be given before all other medications and before food, for one of seven sampled residents (Resident 22). B) when there was no monitoring of target behavior for the use of Mirtazapine (an antidepressant) for one of 12 sampled Residents (Resident 21). These failures placed Resident 22 at risk for harm due to possible decreased therapeutic effects of Omeprazole and the potential of inadequate monitoring for effectiveness and potential side effects of Mirtazapine for Resident 21. Findings: A. Review of Resident 22's clinical records indicated Resident 22 was admitted on [DATE] with diagnoses including vascular dementia with behavioral disturbance (loss of brain function with changes in behavior), delusional disorders (having beliefs not based in reality) and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 12 sampled residents' (Resident 9) drug regimen was free from unnecessary drugs when Resident 9 was not monitored for signs and symptoms of bleeding/bruising and thromboembolism (a circulating blood clot that gets stuck and causes an obstruction) for the use of Clopidogrel (a medication used to prevent blood clot). This failure placed Resident 9 at risk for experiencing unidentified side effects of the medication. Findings: Review of Resident 9's admission Record indicated he was admitted on [DATE] with diagnoses including peripheral vascular disease (a disorder that causes the blood vessels outside of the heart and brain to narrow, spasm, or block blood circulation), thrombocytopenia [low blood platelet (a blood component that controls bleeding) count], and spontaneous ecchymoses (discoloration of the skin due to the rupture of the blood vessels below the surface of the skin). During a review of Resident 9's clinical records with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (5%) when two medication errors occurred out of 32 opportunities, resulting in an error rate of 6.25%: 1. Resident 12 was ordered Aspirin EC (enteric coated - a special coating that prevents release and absorption of the medication contents until they reach the intestine) 81 mg (milligrams, a unit of measure) but was given chewable Aspirin 81 mg. 2. Resident 12 was administered two different eye drops with one minute interval. This resulted in medications not given according to the prescriber's order and had the potential for Resident 12 to not receive the full therapeutic effect of the medications. Findings: 1. During medication administration observation on 10/11/23 at 8:21 AM, Licensed Vocational Nurse (LVN) 2 administered crushed chewable Aspirin 81 mg tablet mixed in applesauce to Resident 12. During a concurrent interview and review on 10/11/23 at 10:01 AM with LVN 2, Resident 12's physician's order (PO) and Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection control and prevention program when Certified Nursing Assistant (CNA) 1 did not wear appropriate personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while inside the room of one of one sampled resident (Resident 80) who was on isolation for COVID-19 infection (a highly contagious viral infection). This failure had the potential for spread of COVID-19 infection among residents, staff, and visitors. Findings: Review of Resident 80 's admission Record, indicated she was admitted on [DATE]. Review of the facility document, titled COVID-19 Outbreak Surveillance (9/29/2023), indicated Resident 80 tested positive for COVID-19 on 9/29/23. During an observation on 10/9/23 at 8:55 AM, Resident 80's room door had a signage indicating gloves, gown, eye protection, and N-95 respirator (a protective device designed to achieve a very close facial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.