Health inspection·June 26, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, resident interviews, and facility policy, the facility failed to provide showers to residents dependent upon staff for assistance. This affected three ( #33, #58, and #22) of three residents reviewed for activities of daily living. The facility census was 48. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #33 was initially admitted on [DATE] with re-admission on [DATE]. Diagnoses included other secondary parkinsonism, peripheral vascular disease, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, cognitive communication deficit, other idiopathic peripheral autonomic neuropathy. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired and required substantial/maximal assistance with showers/bathing. Review of the most recent care plan revealed Resident #33 requires substantial/max assistance with one staff with showering and to offer a sponge bath when a full bath or shower cannot be tolerated. Review of the shower sheets for the last thirty days revealed on 06/13/24 Resident #33 had a shower. There were no other showers listed. Review of the shower task documentation completed the last thirty days revealed 06/24/24 was the only day Resident #33 had a shower. There was no documentation Resident #33 refused. Interview on 06/26/24 at 11:46 A.M. with Resident #33 initially reported zero recent showers recently. STNA #113 reminded the resident she had a shower a couple of days ago and Resident #33 reported before that she went two weeks without a shower. 2. Review of the medical record review revealed Resident #58 was initially admitted on [DATE] with re-entry on 07/22/23. Diagnoses included pneumonia, chronic obstructive pulmonary disease, systemic lupus, type two diabetes mellitus, rheumatoid arthritis, chronic respiratory failure, Crohn's disease, dorsalgia, hyperlipidemia, peripheral vascular disease, major depressive disorder, and schizoaffective disorder. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Resident #58 required partial/moderate assistance with showering/bathing. Review of the census history revealed Resident #58 was hospitalized from [DATE] to 06/16/24. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 365740 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Clyde 700 Helen Street Clyde, OH 43410 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)