Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hayes Residence during CMS and state inspections, most recent first.
A resident with intact cognition and chronic health conditions requested not to be resuscitated, but conflicting documentation in the EMR and paper chart indicated both CPR and DNR status. The resident's wishes were not promptly communicated to the provider for a verbal order, and staff relied on outdated records, creating a risk that CPR would be performed against the resident's wishes.
The facility did not ensure proper food storage and dish sanitization, as the resident snack refrigerator was repeatedly above safe temperatures and contained unlabeled, open food items, while expired milk was found in the main kitchen. Staff failed to consistently monitor and document refrigerator temperatures or remove unsafe items. Additionally, the high-temperature dishwasher did not reach required sanitization temperatures, and staff did not consistently report or address the issue as required by facility policy.
Several residents were unable to access hot water for showers, with reports of consistently cold water and restricted access to shower rooms and linens. Staff and administration were aware of ongoing boiler issues, and the facility lacked proper documentation and functioning equipment to monitor water temperature. As a result, residents' preferences and care plans for bathing were not met, and facility policy regarding hot water was not followed.
A resident with impaired cognition, upper extremity impairment, and incontinence was observed sitting in a recliner with the call light stuck and out of reach. A nursing assistant confirmed the issue and was unable to immediately resolve it, while both an LPN and the DON stated that call lights should be accessible to all residents for safety. The facility could not provide a call light policy when asked.
A resident with schizoaffective disorder and a history of self-injury developed a bruise under the left eye, which was reported as self-inflicted due to command hallucinations. Although a nursing assistant documented the injury and informed the charge nurse, there was no evidence of a licensed nurse's assessment, measurement, or ongoing monitoring of the bruise as required by facility policy and physician orders.
A resident with cognitive and physical impairments did not receive consistent weekly monitoring and measurement of pressure ulcers as ordered. Medical records showed multiple missed or incomplete wound assessments, and interviews with nursing staff and the DON confirmed that required documentation and skin checks were not consistently performed.
A resident with cognitive impairment and a history of falls experienced multiple unwitnessed falls without a documented root cause analysis or updates to their care plan. Staff failed to identify or implement new interventions, and required risk management forms were not completed or reviewed, despite facility policy mandating reassessment and intervention after each fall.
A resident with moderate cognitive impairment and schizophrenia used a bed rail that was found to be loose and incompatible with the bed frame. Staff confirmed the rail could not be properly secured, and manufacturer compatibility could not be verified due to missing information. The facility's policy required installation per manufacturer guidelines, but this was not followed, resulting in a safety deficiency.
The facility failed to properly label, date, and dispose of food items and maintain clean cooking equipment, potentially affecting all residents consuming food from the kitchen. Observations included uncovered and undated food items, and a KitchenAid mixer with residue, indicating non-compliance with facility policies on food safety and equipment cleaning.
The facility failed to cover linen carts during transport and storage, potentially impacting all 31 residents. Housekeeping staff were unaware of the requirement, and the facility's policy lacked guidance on this matter.
A facility failed to assess and document the need for grab bars for a resident, who was independent in bed mobility and had no documented requirement for such assistance. Despite the facility's policy requiring an assessment and education on risks, no such documentation was found, and staff confirmed the lack of a comprehensive assessment or provider order for the grab bars.
The facility failed to accurately assess and offer pneumococcal vaccinations to two residents according to CDC guidelines. One resident, with alcohol use and nicotine dependence, was not offered the vaccine despite no prior vaccinations. Another resident, with diabetes and lung disease, was not assessed for additional doses of newer vaccines, as required by shared clinical decision-making.
Failure to Accurately Document and Communicate Resident's DNR Wishes
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding resuscitation were accurately and consistently documented across all areas of the medical record. The resident, who had intact cognition and diagnoses including delusional disorders and COPD, expressed a clear desire not to be resuscitated if found without a pulse or respirations. Despite this, the electronic medical record (EMR) and the paper chart contained conflicting information, with some documents indicating a full code (CPR) and others indicating Do Not Resuscitate (DNR). The resident had communicated his wishes to the health unit coordinator (HUC), who completed a new POLST form indicating DNR, but this form was awaiting a physician's signature and had not yet been reflected in the EMR or on the face sheet/banner. Staff interviews revealed inconsistent practices and communication regarding changes in code status. The HUC stated that the process was to update the EMR first and then the paper chart, but the code status would not officially change until the physician signed the POLST. The HUC did not notify nursing staff directly, relying instead on progress notes and the 24-hour report, which nurses were expected to review before each shift. Nursing staff, including LPNs, indicated that in an emergency, they would check the paper chart or the EMR for code status, and would perform CPR if the documentation indicated full code, regardless of any pending changes or verbal requests from the resident. The facility's policy required immediate notification of the physician and documentation of any verbal refusal of CPR, with the resident's wishes to be honored until a written order was obtained. However, in this case, the process was not followed, and the resident's verbal request for DNR was not promptly communicated to the provider for a verbal order, nor was it immediately updated in all relevant records. As a result, there was a significant risk that the resident would have received CPR against his wishes in the event of an emergency, due to the lack of accurate and timely documentation and communication among staff.
Failure to Maintain Safe Food Storage and Dish Sanitization Practices
Penalty
Summary
The facility failed to maintain proper food safety and storage practices, as evidenced by multiple observations and staff interviews. The resident snack refrigerator was repeatedly found to be operating above the required temperature, with recorded readings of 50°F and 48°F on several days, despite the facility's policy requiring temperatures to remain at or below 41°F. The refrigerator contained unlabeled and open food items, including pudding cups, a take-out container, pitchers of juice, and an open gallon of milk, all of which felt warm to the touch. Staff interviews confirmed that items were left open and unlabeled, and that temperature monitoring was inconsistent, with several days missing temperature logs. Nursing and dietary staff were not consistently aware of the temperature issues or the need to remove items or notify maintenance when temperatures were out of range. In the main kitchen, expired milk was found in the refrigerator, with a best-by date that had already passed. The cook acknowledged that expired items should be removed during routine checks but admitted that the expired milk had been missed. This indicates a lapse in the facility's process for monitoring and removing expired food items from storage areas. Additionally, the facility's high-temperature sanitization dishwasher was observed to be functioning improperly, with rinse temperatures consistently below the required 180°F, despite the wash temperature being adequate. Staff were aware of the issue with the temperature gauge but did not consistently report the problem to supervisors or maintenance. The Environmental Service Director and other staff confirmed that the machine had ongoing issues, and that procedures for verifying and documenting corrective actions were not always followed. The facility's policy required staff to notify supervisors and document corrective actions when temperatures were not adequate, but this was not consistently done.
Failure to Provide Hot Water for Resident Showers
Penalty
Summary
The facility failed to provide a comfortable and homelike environment by not ensuring the availability of hot water for resident showers. Multiple residents reported that the water in the showers was consistently cold, with some stating they had to take quick showers or wait extended periods for hot water to become available. Residents also described difficulties accessing shower rooms and linens, with staff either refusing to open shower rooms or requiring residents to seek towels from housekeeping. These issues were observed and corroborated through resident interviews and direct observation. The facility's environmental services director confirmed that the boiler system was old, had ongoing issues, and that the water temperature at the shower fixtures could not be measured due to a broken thermometer. Documentation of boiler temperature checks was not available, and the director was unaware of when a replacement thermometer would be obtained. The boiler system was known to overheat and trip a safety switch, resulting in only cold water being supplied to the showers. Staff and administration were aware of the problem, and maintenance staff had been trained to reset the system, but the issue persisted. Residents' care plans indicated preferences for shower times and the need for assistance, but these preferences were not consistently honored due to the lack of hot water and restricted access to shower facilities. The facility's hot water policy required water temperatures to be maintained within a specific range and for regular temperature logs to be kept, but these procedures were not followed. As a result, residents were unable to receive safe and comfortable bathing experiences as required.
Call Light Inaccessible for Resident with Impaired Mobility and Cognition
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, as required to reasonably accommodate the needs and preferences of each resident. The resident involved had moderately impaired cognition, diagnoses of paranoid schizophrenia and PTSD, upper extremity impairment on one side, required staff assistance with most activities of daily living and mobility, and was frequently incontinent of bladder and occasionally incontinent of bowel. During observation, the resident was found sitting in a recliner/lift chair with the call light stuck inside the bottom of the chair and not within reach. A nursing assistant confirmed the call light was not accessible and was unable to immediately fix the issue, stating it would be addressed later. Both an LPN and the DON confirmed that call lights should be within reach of residents for safety. The facility was unable to provide a policy regarding call lights when requested.
Failure to Assess and Monitor Bruising in Resident with Self-Injurious Behavior
Penalty
Summary
The facility failed to provide adequate assessment, monitoring, and documentation of a bruise observed under the left eye of a resident with schizoaffective disorder and a history of self-injurious behavior. The resident, who was cognitively intact and newly admitted for mental health and diabetes management, reported that the bruise was self-inflicted due to command hallucinations. Despite standing orders and care plan interventions requiring regular skin assessments, documentation of abnormal findings, and prompt follow-up for injuries, there was no evidence of a nurse's initial evaluation or ongoing monitoring of the bruise in the medical record. Nursing assistant documentation noted the presence of the bruise and communication to the charge nurse, but there was a lack of subsequent nursing assessment, measurement, or description of the injury in the progress notes or skin and wound documentation. The facility's policy and staff interviews confirmed that the expected process for non-pressure injuries included assessment, implementation of standing orders, provider notification, daily monitoring, and documentation until resolution. Additionally, an incident report and behavioral team notification were required if the injury was behaviorally related or of unknown origin. Despite these protocols, the only documentation related to the bruise was from the nursing assistant, with no follow-up by licensed nursing staff as required. The resident's care plan and physician orders emphasized the need for close monitoring due to his mental health condition and risk for self-harm, yet the facility did not ensure that the bruise was adequately assessed, monitored, or documented according to policy and physician orders.
Failure to Consistently Monitor and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure consistent weekly monitoring and measurement of pressure ulcers for a resident with significant cognitive and physical impairments. The resident had a history of moderately impaired cognition, delusions, paranoid schizophrenia, PTSD, upper extremity impairment, and required substantial assistance with mobility and hygiene. Physician orders and the care plan specified that wounds on the resident's buttocks were to be measured weekly and documented, with additional instructions for regular dressing changes and skin checks. Despite these orders, documentation in the resident's medical record showed multiple instances where wounds were not monitored or measured as required. Specific dates in May and June lacked evidence of wound assessment or measurement, and there were gaps in progress notes regarding the condition of the pressure ulcers. Interviews with nursing staff and the DON confirmed that nurses were responsible for weekly skin checks and documentation, and that these tasks were not consistently performed or recorded. The DON acknowledged that there was no formal wound care program and that documentation was missing for several weeks. The facility's own policy required appropriate staff to provide treatment and services to heal pressure ulcers and prevent further development, but the lack of consistent monitoring and documentation demonstrated a failure to follow these protocols. The deficiency was identified through interviews, document review, and direct observation of the resident's medical record, which showed a pattern of missed or incomplete wound care documentation.
Failure to Conduct Root Cause Analysis and Update Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure a root cause analysis was conducted and appropriate interventions were implemented for a resident with a history of falls. The resident, who had moderately impaired cognition and diagnoses including paranoid schizophrenia, required substantial assistance for toileting and partial assistance for transfers. Despite being identified as high risk for falls due to intermittent confusion, recent falls, and being chair bound, the facility did not document a root cause for the falls or update the care plan with new interventions after two unwitnessed falls. On two separate occasions, the resident was found on the floor in their room, once while reaching for shoes and another time after attempting to use the bathroom. In both instances, documentation failed to indicate whether the resident had appropriate footwear, and the fall assessment forms lacked analysis of contributing factors or evidence that the care plan and treatment sheet were reviewed or revised. Observations showed the resident was assisted by staff with transfers and footwear, but staff interviews revealed a lack of awareness regarding specific fall prevention interventions for the resident. Interviews with nursing staff and the DON confirmed that risk management forms were either not completed or not accessible, and there was no evidence that a root cause analysis or new interventions were determined following the falls. The facility's policy required reassessment and review of the safety plan after any fall, but this process was not followed, resulting in a failure to address the resident's ongoing fall risk.
Failure to Ensure Bed Rail and Bed Frame Compatibility
Penalty
Summary
The facility failed to ensure that a separately purchased bed rail and bed frame were compatible for a resident who was reviewed for bed rail use. The resident, who had moderate cognitive impairment and a diagnosis of schizophrenia, used a grab bar on the bed to assist with independent bed mobility and transfer. During observation, the bed rail was found to be loose, moving back and forth and sliding up and down in its sleeve. The resident confirmed that the rail always moved and demonstrated its instability. Staff interviews revealed that the bed rail could not be tightened further and that the rail was not made for the bed in use. The Environmental Service Director acknowledged that some beds and rails were old, and there was no way to determine compatibility due to missing manufacturer information. The facility's policy required that bed rails be installed per manufacturer guidelines and that compatibility be ensured. However, the staff were unable to provide manufacturer recommendations for the bed rail and bed frame, and the Environmental Service Director admitted to using extra screws in an attempt to secure the rail. The Administrator confirmed that only universal rails were ordered for use with various beds, but acknowledged the loose rail as a safety risk. The facility's failure to ensure compatibility and proper installation of the bed rail and bed frame resulted in a deficiency related to resident safety.
Food Safety and Equipment Cleaning Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and disposal of food items, as well as maintaining clean cooking equipment, which could potentially affect all residents consuming food from the kitchen. During an initial tour, several issues were observed: uncovered juices and milks in the refrigerator, undated and discolored lettuce, and a bottle of barbeque sauce with residue on the lid. In the freezers, a package of beef patties and a bag of fish were found undated. Additionally, a KitchenAid mixer was found with yellow particles and a powdery substance on the handle, indicating it had not been cleaned after use. Interviews with staff revealed that the certified dietary manager acknowledged the requirement for foods to be dated and labeled, and stated that she had placed dates on items the morning following the observation. The facility's policies on dating and labeling opened foods and equipment cleaning were not adhered to, as evidenced by the undated food items and unclean equipment. The policies specified that all opened food items should be dated and labeled, and equipment should be cleaned and sanitized after each use, which was not followed in this instance.
Failure to Cover Linen Carts During Transport
Penalty
Summary
The facility failed to ensure that clean linen was transported and stored in a manner that prevents the spread of infection, potentially impacting all 31 residents. On the morning of September 23, a housekeeper transported a cart of linens, including fitted sheets, flat sheets, pillowcases, and fabric incontinent protector/pads, without covering them. The cart was moved through resident areas and stored in the east hallway. Later that day, the same cart, still uncovered, was observed in the west hallway and then moved to the middle hallway near the dining room, where residents were passing by. Interviews with housekeeping staff revealed a lack of awareness regarding the requirement to cover linen carts during transport and storage in resident hallways. Housekeeper A acknowledged the need to cover the cart but noted that the task was taking longer than usual. The infection preventionist confirmed the expectation for linens to be covered to prevent infection. The facility's policy on laundry did not provide guidance on transporting clean linen or the necessity of covering it when stored on resident units.
Failure to Assess and Document Need for Grab Bars
Penalty
Summary
The facility failed to properly assess and document the need for grab bars for a resident, identified as R31, who was observed to have grab bars affixed to their bed. R31 was cognitively intact and had diagnoses of alcohol use and neuropathy, and was independent in bed mobility, as indicated by their admission Minimum Data Set (MDS) and care plan. Despite this, there was no documentation of an assessment or education regarding the risks and benefits of grab bars, nor any attempt to explore alternatives before their installation. During interviews, staff members, including a registered nurse (RN-A) and the Director of Nursing (DON), confirmed the lack of a comprehensive assessment and provider order for the grab bars. The facility's policy required an assessment to determine the need for grab bars, consideration of alternatives, and education of the resident about potential risks, none of which were documented for R31. The oversight was further highlighted by the fact that R31's care plan and provider orders did not indicate a requirement for a grab bar, and the grab bar had been in place since the resident's arrival without proper procedural adherence.
Failure to Accurately Assess and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that two residents were accurately assessed and offered the pneumococcal vaccination according to CDC guidelines. One resident, who was cognitively intact and had diagnoses of alcohol use and nicotine dependence, was not offered the pneumococcal vaccination upon admission, despite having no prior pneumococcal vaccinations recorded. The resident's medical records lacked evidence of assessment or offer of the vaccination prior to the survey entrance. Another resident, with moderate cognitive impairment and diagnoses of diabetes and lung disease, was recorded as up to date for pneumococcal vaccination. However, the resident had not received the newer PCV15, PCV20, or PCV21 vaccines, and shared clinical decision-making was required to determine if an additional dose was necessary. The facility's Infection Preventionist confirmed that the resident had not been accurately assessed for the need for an additional dose, as the MIIC report indicated the vaccinations were complete.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,061 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carondelet Village Care Center | 0.5 mi | ★★★★★ | 6 | 0 |
| Highland Chateau Health And Rehabilitation Center | 1.6 mi | — | 55 | 2 |
| Shirley Chapman Sholom Home East | 1.6 mi | ★★★★★ | 0 | 0 |
| Episcopal Church Home Of Minnesota | 2 mi | ★★★★★ | 17 | 1 |
| The Estates At Lynnhurst Llc | 2.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.