Hazel I Findlay Country Manor

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteDuring 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #6) of five reviewed was free of unnecessary medications.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]