Hayes Residence

Based on observation, interview and record review the facility failed to ensure resident snack refrigerator temperatures were maintained to prevent food and drink items from spoiling and items in the snack refrigerator were labeled and dated. Furthermore, the facility failed to ensure the dishwasher was reaching temperatures required for proper sanitization and expired milk was removed from the main kitchen refrigerator. This had the potential to affect all residents who reside in the facility. Findings include: A facility document titled Nursing Refrigerator Log (bottom fridge) dated 6/2025, directed staff to notify maintenance if the temperature was greater than 41 degrees F. The document indicated temperatures were monitored on the following dates: 6/19/25, for 40 degrees Fahrenheit (F) -6/20/25, no temperature recorded -6/21/25, no temperature recorded -6/22/25, no temperature recorded -6/23/25 50 degrees F. -6/24/25 48 degrees F. A facility document titled Dish machine Temperature Log dated 6/2025, indicated temperatures were monitored twice daily and were within range 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 document review, the facility failed to ensure a comfortable environment, having hot water available for 4 of 4 residents (R36, R34, R31, R15) who were received for concerns with cold showers. Findings include: R36's admission Minimum Data Set (MDS) assessment dated , 4/10/25 indicated cognition moderately impaired and independent for personal hygiene cares including bathing/shower. R36's care plan indicated independent with set up, it was very important showering early in the morning assist as needed. If declines offer at another time and day. R34' s admission MDS assessment dated , 3/26/25 indicated cognitively intact and set up or clean up assistance for personal hygiene cares including bathing/shower. R34's care plan indicated independent with set up assist as needed. If declines shower on assigned date offer another time or day. R31's quarterly MDS assessment dated [DATE] indicated cognitively intact and independent with set up for personal hygiene cares including…

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 call lights were accessible to 1 of 1 resident (R3). Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of paranoid schizophrenia and post traumatic stress disorders (PTSD). It further included R3 had upper extremity impairment on one side, required staff assistance with most activities of daily living (ADL) and mobility, and was frequently incontinent of bladder and occasionally incontinent of bowel. During observation on 6/25/25 at 8:00 a.m., R3 was sitting in his recliner/lift chair in his room. His call light was stuck inside the bottom of his chair and not within reach. During observation and interview on 6/25/25 at 10:13 a.m., nursing assistant (NA)-A entered the room and assisted R3 to reposition in his chair. NA-A verified his call light was stuck in the chair and that it should be within reach. NA-A attempted to remove the call light from being stuck but…

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 document review, the facility failed to provide quality of care for 1 of 1, resident (R34) to ensure bruises were adequately assessed, monitored and documented. Findings include: R34's Minimum Data Set (MDS) dated [DATE], indicated Brief Interview for Mental Status (BIMS) cognition score 13, cognitively intact. R34's Care Area Assessment (CAA) for mood dated 3/26/25, indicated mood severity score 12. Risk for change in mood due to mental illness and needed to adjust to new environment. Staff to observe for change in mood, offer support and reassurance, and update doctor/Psych as needed. Functional abilities: R34 is new admit to [NAME] from home for ongoing support services for mental health and diabetes management. R34 was living in family home with brother until home sold. He was alert and oriented with forgetfulness, mental illness had diagnosis of schizoaffective disorder with baseline delusion about Satan and how he tried to control him. Had challenges of coping with his…

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 document review the facility failed to ensure weekly monitoring and measurement of pressure ulcers were completed for 1 of 1 resident (R3). Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition, delusions, and diagnoses of paranoid schizophrenia and Post Traumatic Stress Disorder (PTSD). It further included upper extremity impairment on one side, required supervision with bed mobility, substantial assistance with toileting hygiene and transfers, was frequently incontinent of bladder and occasionally incontinent of bowel. R3's physician's orders dated 6/17/25, indicated nursing staff to measure wounds on right and left buttocks weekly and document in the nursing progress notes, in the evening every 3 days for wound care. It further included an order dated 1/19/24, which indicated weekly skin checks (to be done on shower day) every night shift, (Friday) for skin monitoring and to document any skin abnormalities in the progress notes.…

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 a root cause analysis and ensure interventions were implemented for 1 of 1 residents (R5) reviewed for falls. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderately impaired cognition and diagnoses of paranoid schizophrenia. R5 required substantial assistance for toileting and partial assistance to transfer from bed to chair. R5 was at risk of falls and had 2 or more falls since the prior assessment. R5's fall risk assessment dated [DATE], indicated R5 was at high risk for falls due to intermittent confusion, 1-2 falls in the past 3 months, chair bound and need for assistance with elimination. R5's nursing progress note dated 6/13/25 at 8:15 a.m., indicated R5 was found on the floor at 7:50 a.m., R5 was sitting upright with her back against the bed reaching for their shoes. Apparently, R5 had slid out of bed. No injury was noted. R5 was assisted back to bed. The TMA staff remained with R5…

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 separately purchased bed rails and bed frame were compatible for 1 of 1 resident who was reviewed for bed rail use. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 had moderate cognitive impairment and diagnoses of schizophrenia. R8 had grab bars in place and was independent with sitting to standing and bed mobility. R8's care plan revised 3/17/24, indicated R8 was at risk for falls related to gait instability and used a grab bar on the bed to assist with independent bed mobility and transfer. The manufactures recommendations for R8's bed rails installed at the time of entrance was requested however was not received. An observation on 6/23/25 at 6:40 p.m., R8 was lying in their bed. R8's bed was placed against a wall and had a bed rail placed on the other side. The bed rail mounted in the middle of R8's bed in a sleeve like bar. R8 grabbed the rail to assist themselves up to the edge of the bed. 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 document review the facility failed to ensure food items were properly labeled and dated and disposed of. Furthermore, the facility failed to maintain clean cooking equipment. This had the potential to affect all residents who ate food from the kitchen. Findings include: During the initial tour with cook (C)-A on 9/22/24 at 10:28 a.m., observed the following: Refrigerator: • A tray of juices and milks uncovered in the refrigerator. C-A stated it would be tossed out. • Lettuce that had yellowish brown discoloration and was undated. C-A stated it would be tossed out and verified it was undated. • A 16 ounce bottle of barbeque sauce with barbeque sauce located around the outside of the lid. C-A took it out of the refrigerator and stated it would get wiped down. Freezers: • A package of 10 beef patties in a bag that was twisted shut with no date. C-A stated they were beef patties and verified they were undated. • A blue bag of fish that was undated. Equipment: • A KitchenAid contained yellow particles along the top where the attachments connect and a…

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 document review the facility failed to ensure clean linen was transported and stored in a manner to prevent the spread of infection. This had the potential to impact all 31 residents who reside in the facility. Findings include: An observation on 9/23/24 at 8:25 a.m., housekeeper (HSK)-A had brought up a cart of linens from downstairs. The cart contained fitted sheets, flat sheets, pillowcases, and fabric incontinent protector/pads. The linens were not covered during transport. The cart was transported down past residents and resident rooms and stored on the far end of the east hallway. An observation on 9/23/24 at 12:07 p.m., the same linen cart was now halfway down the west hallway. The cart contained less linens than earlier. The linens remained uncovered. At 12:10 p.m., HSK-B pushed the uncovered linen cart to the middle hallway just outside of the dining room. Residents were coming and going from the dining room for lunch and moving past the uncovered cart. When interviewed on 9/23/24 at 12:12 p.m., HSK-B was not sure if the linen cart…

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 document review, the facility failed to comprehensively assess, discuss risks and benefits, and attempt alternatives prior to installation of grab bars for 1 of 1 residents (R31) who were observed to have grab bars affixed to their bed. Findings include: R31's admission Minimum Data Set (MDS) dated [DATE], indicated R31 was cognitively intact and had diagnoses of alcohol use and neuropathy. R31 was independent with rolling side to side and moving from lying to sitting in bed. R31's physical device review dated 8/29/24, lacked indication R31 was assessed or had been educated on the risks of grab bars or had attempted alternatives prior to installation of grab bars. R31's care plan dated 9/8/24, indicated R31 was independent in bed mobility. R31's care plan lacked indication R31 used a grab bar for assistance. R31's provider and nursing orders lacked indication R31 required a grab bar. An observation on 9/22/24 at 11:05 a.m., R31 was sitting on their bed. R31's bed was placed…

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 document review the facility failed to ensure 2 of 5 residents (R31, R1) were accurately assessed and offered the pneumococcal vaccination according to the Centers of Disease Control (CDC). Findings include: R31's admission Minimum Data Set (MDS) dated [DATE], indicated R31 was [AGE] years old, was cognitively intact and had diagnoses of alcohol use and nicotine dependence. Furthermore R31's MDS indicated R31 was not offered the pneumococcal vaccination. R31's Minnesota Information Connection (MIIC) printed 9/24/24, indicated R31 had no prior pneumococcal vaccinations. The CDC identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, directed residents 19-[AGE] years of age who had no history of previous vaccination and a risk factor of smoking to give one dose of pneumococcal 15-valent Conjugate Vaccine (PCV15), pneumococcal 20-valent Conjugate Vaccine (PCV20), or pneumococcal 21-valent Conjugate Vaccine (PCV21). R31's paper and electronic medical record lacked…

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 document review, the facility failed to ensure proper infection control practices were maintained during medication administration and laundry services. This had the potential to affect all 31 residents residing in the facility. Findings include: Hand Hygiene During medication administration observation on 8/28/23 at 1:34 p.m., trained medication aide (TMA)-A prepared medications for resident (R)26. TMA-A crushed a pill and stirred it into a cup of applesauce and poured a cup of water. TMA-A took the two cups and entered R26's room. R26 was standing by his bed holding on to his walker with his soiled pants and soiled brief around his ankles. TMA-A placed the two cups on the TV stand and donned gloves. TMA-A gathered a new brief and clean pants and helped R26 don the new items. TMA-A picked up the soiled brief and placed in the trash and grabbed the soiled pants and placed in the laundry. TMA-A removed gloves, picked up the two cups and proceeded to spoon the applesauce into R26's mouth and handed him the water cup for consumption. Hand hygiene…

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 document review, the facility failed to ensure physician orders for orthostatic blood pressures (BPs) (BPs-measured while sitting and standing to detect a significant drop upon standing which may cause dizziness or light-headedness and may contribute to falls) were transcribed into the electronic medical record (EMR) and carried out for 6 of 7 sampled residents (R7, R13, R14, R26, R29, R30) receiving antipsychotic medications. Findings include: R7 R7's annual MDS dated [DATE], indicated R7 was cognitively intact, independent with ambulation, did not exhibit rejection of care, and received antipsychotic medications. R7's diagnoses included schizoaffective disorder (mental illness affecting thought, mood, and behavior), and anxiety. R7's care plan, revised 8/29/22, indicated R7 would remain free from psychotropic drug related complications including hypotension (low BP). R7's physician order sheet signed as reviewed by registered nurse (RN)-A on 8/1/23, indicated BLOOD PRESSURE…

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 R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact and had delusions. R2 required extensive assistance with bed mobility and toileting, limited assistance with transfers, supervision when walking in corridor, and was independent when walking in room. Diagnoses included diabetes mellitus and schizophrenia. R2's care plan dated 8/7/23, indicated R2 had potential for skin breakdown related to daily bladder and occasional bowel incontinence and refused repositioning. Staff were directed to monitor skin weekly to ensure intact, provide good peri cares with each incontinent episode and apply protective barrier cream for skin protection. R2's physician orders dated 8/8/18, directed staff to apply Bacitracin ointment 500 unit/gm applied topically as needed for skin tears and/or abrasions. R2's order dated 1/21/20, directed staff to toilet R2 every two to three hours every day and evening shift. An order dated 9/16/20, directed staff to place small cushion/pillow under one buttock…

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.