Hazel I Findlay Country Manor

Based on observation, interview, and record review the facility failed to effectively clean and maintain food service equipment affecting 99 residents. On 09/10/2025 at 08:31 a.m. an initial tour of food services was conducted with Dietary Aide F and then Certified Dietary Manager (CDM) G. The following items were observed:Main Freezer had ice on the floor approximately 1 inch tall and the circumference of a silver dollar. Dietary Aide F explained that it may be coming from the cooler refrigeration fan.Dishwasher was observed to have lime scale on the outside of the machine and floor was visibly soiled around the dishwasher.Hand sink to the right of the entrance was visible soiled and the faucet was covered with lime scale.Hand sink across from the tray line was visible soiled and the faucet was covered with lime scale.The toaster on the tray line had visible breadcrumbs on all sides of the toaster.Soiled sink faucet had visible lime deposit.Oven racks appeared soiled with multiple lays of old burnt color. Those racks were in the oven at this time. Two old racks were observed…

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 implement its own written policies and procedures for Abuse and Neglect for two residents (#6, #15) of 4 residents reviewed. Resident #6 (R6): Per the facility face sheet R6 was admitted to the facility on [DATE]. R6 had stated during the screening process on 9/10/2025 that about two weeks ago she had waited two hours for her call light to be answered. R6 said the RCA (resident certified aid), who she could not recall the name of, entered her room and was disgusted with her, then turned her side to side jerking her side to side; then told her to stop yelling, but she could not because it was hurting her. Review of a SOLUTIONS FORM dated 8/12/25, revealed R6 had reported to her family member that last night she had waited two hours for assistance, and upon receiving that assistance the staff member, who was not identified, .came in and acted disgusted with me, turned me Jerked side to side, and said I am being too loud. Additionally, it was…

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 report an allegation of abuse to the State Agency for two residents (#6,#15) of four residents reviewed for abuse. Findings Included: Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 05/12/2025 with diagnoses that included Huntington’s Disease (inherited condition in which nerve cells in the brain break down over time), dry eye syndrome, bilateral myopia (near sightedness), bilateral astigmatism, dysphagia (difficulty swallowing), gastro-esophageal reflux, depression, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2025, revealed R15 had a Brief Interview for Mental Status (BIMS) of 09 (moderate cognitive impairment) out of 15. During observation and interview on 09/10/2025 at 10:43 a.m. R15 was observed sitting in her electric wheelchair. R15 explained that a staff member was rude to her. R15 could not provide further details nor the name of…

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 investigate allegations of abuse for two residents (#6,#15) out of four residents reviewed for abuse. Findings Included: Resident #15 (R15) Review of the medical record revealed R15 was admitted to the facility 05/12/2025 with diagnoses that included Huntington’s Disease (inherited condition in which nerve cells in the brain break down over time), dry eye syndrome, bilateral myopia (near sightedness), bilateral astigmatism, dysphagia (difficulty swallowing), gastro-esophageal reflux, depression, and insomnia. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/19/2025, revealed R15 had a Brief Interview for Mental Status (BIMS) of 09 (moderate cognitive impairment) out of 15. During observation and interview on 09/10/2025 at 10:43 a.m. R15 was observed sitting in her electric wheelchair. R15 explained that a staff member was rude to her. R15 could not provide further details nor the name of the staff…

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 follow professional practice of medication documentation for one resident (#58) of six residents reviewed during medication administration. Findings Included: Resident #58 (R58)Review of the medical record revealed R58 was admitted to the facility 03/13/2019 with diagnoses that included aortic valve stenosis, muscle weakness, dysphagia (difficulty swallowing), congestive heart disease (CHF), bilateral dry eye syndrome, cerebral infarction (stroke), type 2 diabetes, malignant neoplasm of skin (skin cancer), pain in left shoulder, depression, vascular dementia, gastro-esophageal reflux, right sided hemiparesis (muscle weakness or paralysis), atrial fibrillation, anemia (low red blood cells), fatty liver, obesity, hypertension, mood disorder, spinal stenosis (spinal narrowing), osteoarthritis (flexible tissue between bones wears down), rest less leg syndrome, hyperlipemia (high levels of fat in blood), and fibromyalgia (wide spread body pain and tiredness). During observation of medication administration on…

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 During Interview and record review facility failed to follow provider's orders for one (Resident #5) of 20 sampled causing unjust pain.Findings IncludeResident #5 (R5)Review of the medical record reflected that R5 was admitted to the facility on [DATE] and was re-admitted to the facility on [DATE]. Diagnoses of Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, muscle weakness, lack of coordination and difficulty walking.The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2025 revealed R5 had a Brief Interview of Mental Status (BIMS) of 09 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R5 had impaired mobility of both upper and lower extremities, set up and assist for meals, and dependent on all other care. During an interview on 09/10/2025 at 4:15 PM, R5's family member R stated R5 was taking a medication called Neurontin 100 milligram (mg) capsule for his neuropathy in his legs and feet, and it was…

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 the drug regimens for 1 of 5 residents reviewed for antipsychotic drug (#34) use were free of medications used without adequate indications for use, without adequate monitoring, and without a resident-focused, risk-benefit statement completed, resulting in the risk for increased side effects from a potentially unnecessary medication. Findings include:Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R34 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included vascular dementia without behavioral disturbances, psychotic disturbance, mood disturbance, anxiety, urinary tract infection, and depression. The MDS reflected R34 had a BIM (assessment tool) score of 12 which indicated her ability to make daily decisions was moderately impaired. R34 Face Sheet reflected she had an activated Durable Power of Attorney(DPOA) for medical and financial care.Review of R34 Physican…

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 that all medication used in the facility was secured and stored in accordance with professional standards in one of three medication carts. Findings Included: Resident #58 (R58)Review of the medical record revealed R58 was admitted to the facility 03/13/2019 with diagnoses that included aortic valve stenosis, muscle weakness, dysphagia (difficulty swallowing), congestive heart disease (CHF), bilateral dry eye syndrome, cerebral infarction (stroke), type 2 diabetes, malignant neoplasm of skin (skin cancer), pain in left shoulder, depression, vascular dementia, gastro-esophageal reflux, right sided hemiparesis (muscle weakness or paralysis), atrial fibrillation, anemia (low red blood cells), fatty liver, obesity, hypertension, mood disorder, spinal stenosis (spinal narrowing), osteoarthritis (flexible tissue between bones wears down), rest less leg syndrome, hyperlipemia (high levels of fat in blood), and fibromyalgia (wide spread body pain and tiredness). During observation of medication administration…

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 one resident (Resident #6) of five reviewed was free of unnecessary medications. Findings include: Review of the medical record revealed Resident #6 (R6) admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included dementia, anxiety, and major depressive disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/24 revealed R6 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Physician's Note dated 1/29/24 revealed We Discussed this the [sic] Seroquel [antipsychotic medication] is not helping with sleep. Her anxiety is on going especially at HS [bedtime]. We will try to use Hydroxyzine [antihistamine medication] 25 mg [milligrams] at bedtime see if this helps both her sleep and the anxiety. We will adjust dosing if needed. Review of the Physician's Order dated 1/29/24 revealed an order 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 ensure laboratory testing for psychotropic medication monitoring was completed according to Physician's Orders for one (Resident #22) of five reviewed. Findings include: Review of the medical record reflected Resident #22 (R22) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included congestive heart failure, obsessive compulsive disorder and severe vascular dementia with psychotic disturbance. The Significant Change in Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/24/24, reflected R22 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 08/28/24 at 1:19 PM, R22 was observed lying in bed, awake. A Physician's Order, dated 6/30/23, reflected a Hemoglobin A1C (blood test that measures the average amount of sugar in the blood for the past few months) and Lipid Panel (blood test that measures the amount of…

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 accurately document in the medical record for one resident #64 (R64) out of 18 assessed for documentation from a total sample of 18 resulting in incomplete medical records. Findings include: Resident #64 (R64) Medical record revealed Resident #64 (R64) was admitted to the facility on [DATE] initially with diagnoses that included unspecified Dementia, unspecified severity without behavioral disturbance, mood disturbance and anxiety, moderate intellectual disability, unspecified symptoms and signs involving cognitive functions and awareness, major depression disorder, anxiety disorder. According to R64's Minimum Data Set (MDS) dated [DATE], revealed R64 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. MDS section GG0120 Mobility Devices used by R64 was a walker. Independent with transfers and ambulation in her room. R64 needs set up assistant with meals 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.

Based on observation, interview, and record review the facility failed to ensure appropriate treatment and services for contracture management for one resident (#34) of one resident reviewed resulting in the potential for worsening contractures and pain. Findings Included: Resident #34 (R34) Review of the medical record revealed R34 was admitted to the facility 07/07/2016 with diagnoses that included chronic obstructive pulmonary disease (COPD), metabolic encephalopathy (problem in brain caused by chemical imbalance), hypotension, contracture (shortening and hardening of muscle, tendons or other tissue leading to deformity and rigidity of joints), hypokalemia (low potassium), dysphagia (difficulty swallowing)oral pharyngeal phase, obstructive hydrocephalus (build of fluid in the brain cavity), stricture of ureter, osteoarthritis, anemia, hydronephrosis (abnormal enlargement of a kidney), neuralgia (pain along nerve) and neuritis (inflammation of a peripheral nerve), anxiety, obstructive and reflux uropathy (obstruction of urinary tract), peripheral vascular disease (PVD),…

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 1. Label an open eye drop bottle with a resident name and/or open date; and 2. Dispose of an expired insulin pen in 2 of 3 medication carts reviewed for medication labeling and storage, resulting in the potential for decreased medication efficacy and side effects. On [DATE] at 3:11 PM, North Hall Medication Cart was reviewed in the presence of Registered Nurse (RN) C. During the review, an open box of Artificial Tears Lubricant Eye Drops was noted to be labeled with Resident # 61's (R61's) last name with the open eye drop bottle inside the box not noted to be labeled with R61's name. Neither the opened eye drop box, nor the opened eye drop bottle was noted to be labeled with an open date. RN C confirmed absence of an open date on the eye drop box and absence of R61's name and an open date on the eye drop bottle. RN C proceeded to dispose of the opened eye drops and was observed to obtain a new box of Artificial Tears Lubricant Eye Drops…

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.