Inspection·October 2, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, and policy review, the facility failed to report an injury of unknown origin. This affected one (#22) of three residents reviewed for injury of unknown origin. The facility census was 57. Findings include: Review of Resident #22's medical record revealed an admission date of 08/01/22. Diagnoses included Parkinson's disease, neurocognitive disorder with lewy bodies, vascular dementia, and major depressive disorder. Review of the Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident was severely cognitively impaired and dependent for all activities of daily living. Review of the skin check assessment, dated 09/29/24, revealed Resident #22 had bruising on the left side of the neck. Review of the physician note, dated 09/30/24, revealed staff noticed a bruise on the left side of his neck and thought was a pustule that drained white material in the center of it. Review of the facility self-reported incidents, dated 09/28/24 through 10/01/24, revealed no self reported incidents were submitted for injury of unknown origin for Resident #22. Observation on 10/01/24 at 11:20 A.M., of Resident #22 revealed a purple bruise like area to the left side of the neck. The purple area looked like a [NAME] Mouse head with the center of the bruise larger than a fifty cent coin and with two area above approximately the size of a nickel. The center had no bruising. Resident #22 was unable to provide information regarding the skin condition. Interview on 10/01/24 at approximately 11:30 A.M., with Licensed Practical Nurse (LPN) #300 revealed she had assessed the bruised area on 09/30/24 and reported there was a pustule in the center and another nurse had reported to her it drained white pus. LPN #300 verified the interdisciplinary team met and determined the bruising was from the pustule. Interview on 10/01/24 at 12:11 P.M., with Physician #500 stated he had assessed Resident #22 on 09/30/24 and staff had reported white pus had drained from the area on the neck. Physician #500 stated he did not see an open area, only bruising and does not know what could have caused the bruising. (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 4 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 10/02/2024 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)