Hayes Residence

In the surveyor’s words

From the most serious findings on record at Hayes Residence, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Jun 26, 2025

  Based on interview and document review, the facility failed to ensure a resident's wishes for resuscitation were accurately documented in all areas of the medical record for 1 of 36 residents (R24) reviewed for advanced directives. This resulted in an IJ for R24 who would have received CPR against his wishes in the absence of a pulse or respirations. The IJ began on [DATE], when the facility failed to accurately document a resident's code status in the EMR. The facility administrator and owner were notified of the IJ on [DATE] at 5:20 p.m. The IJ was removed on [DATE] at 3:44 p.m. but non-compliance remained at the lower scope and severity of a level D, no actual harm with potential for more than minimal harm, that is not immediate jeopardy. […]

• Immediate jeopardy, isolatedF689Jul 3, 2023

  Based on observation, interview, and document review the facility failed to provide 1 of 3 residents (R1) adequate supervision to prevent elopement from the facility who had a history of elopement. This resulted in immediate jeopardy (IJ) when R1 eloped on 6/18/23 and was found an hour and a half later by a concerned citizen and the police returned R1 to the facility. The immediate jeopardy began on 6/18/23, at approximately 12:05 p.m. when R1 eloped from the facility. The immediate jeopardy was identified on 6/29/23, and the assistant administrator was notified on 6/29/23, at 3:45 p.m. The immediate jeopardy was removed on 6/30/23, at 2:50 p.m. […]

• No harm, potential for more than minimal, widespreadF727Sep 10, 2026

  Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled a minimum of eight consecutive hours each day. This had the potential to affect all 36 residents who resided at the facility.Findings include:The Facility's Payroll Based Journal (PBJ) Staffing Data Report dated 9/4/26, submitted for Quarter 3 of 2026 (April 1 to June 30), identified no RN hours for the following dates: 5/10/26, 5/16/26, 5/17/26, 5/24/26, 5/25/26, 5/31/26, and 6/7/26.Staffing schedules, timecard data and/or payroll verification were requested for these dates but not provided.During an interview on 9/10/26 at 12:53 p.m., the administrator stated dates of no RN coverage, the former director of nursing (DON) or herself would come in until an RN was on-site to relieve. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2026

  Based on observation, interview and document review, the facility failed to ensure culinary staff adhered to safe hand hygiene practices while serving resident meals. The facility also failed to ensure a food refrigerator in the medication room was at the proper temperature for food storage. This had the potential to affect all 35 residents receiving meals served from the kitchen.Findings include:Handwashing:During a dining observation on 9/9/26 at 11:44 a.m., culinary aide (CA)-A cleared dirty plates and silverware from a table, rinsed and placed them in dishwasher racks, and returned to serving food to another resident without changing gloves or washing hands.During an interview on 9/9/26 at 11:46 a.m., CA-A confirmed they had not washed their hands or changed gloves before serving… […]

• No harm, potential for more than minimal, widespreadF880Sep 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene practices were followed during blood glucose testing and insulin administration for 4 of 4 residents (R7, R16, R9, and R6), reviewed for medication administration. Findings include:R7's quarterly MDS dated [DATE], indicated R7 was cognitively intact and independent with cares. Diagnoses included congestive heart failure (CHF) and DM-2.R7's order set reviewed on 9/9/26, indicated blood glucose levels were to be assessed four times a day. […]