Health 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. Page 1 of 4 365740 365740 10/02/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 10/01/24 at 4:00 P.M., with Wound Physician #501 stated no knowledge of Resident #22. Wound Physician #501 verified bruising would be distinct and an boil or ingrown hair would have an infected red appearance. Observation on 10/01/24 at 4:42 P.M., with Wound Physician #501 assessing Resident #22's neck verified there was no open area or pustule present. Wound Physician #501 stated the area appears to be bruising. Review of policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, stated an injury of unknown source is when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extend of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incident of injuries over time. All incidents of unknown source must be reportedly immediately to the Administrator/designee and will be reported to the Ohio Department of Health immediately, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency represents non-compliance investigated under Complaint Number OH00157863. 365740 Page 2 of 4 365740 10/02/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

F 0610 Respond appropriately to all alleged violations. 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, observations, staff interview, and policy review, the facility failed to investigate an injury of unknown origin. This affected one (#22) of three residents reviewed for injury of unknown origin. The facility census was 57. Residents Affected - Few 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. Interview on 10/01/24 at 4:00 P.M., with Wound Physician #501 stated no knowledge of Resident #22. Wound Physician #501 verified bruising would be distinct and an boil or ingrown hair would have an infected red appearance. Observation on 10/01/24 at 4:42 P.M., with Wound Physician #501 assessing Resident #22's neck verified there was no open area or pustule present. Wound Physician #501 stated the area appears to be bruising. Review of policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2022, stated an injury of unknown source is when the source of the injury 365740 Page 3 of 4 365740 10/02/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extend of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incident of injuries over time. It is the facility's policy to investigate all alleged violations of Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, Exploitation and Mistreatment, including Injuries of Unknown Source, in accordance with this policy. This deficiency represents non-compliance investigated under Complaint Number OH00157863. 365740 Page 4 of 4