Inspection visit
Inspection
18 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 18 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure
residents had access to their call lights. This affected three residents (#21, #40, and #42) in a facility with a
census of 54.
Residents Affected - Few
Findings include:
1. Review of the electronic medical record for Resident #40 revealed an admission date of 12/27/24 with
diagnoses of chronic obstructive pulmonary disease, type two diabetes mellitus, hypertension,
atherosclerotic heart disease, bipolar disorder, retention of urine, anemia, anxiety, insomnia, and major
depressive disorder.
Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief
Interview for Mental Status (BIMS) score of 14, indicating Resident #17 was cognitively intact. Resident #40
required assistance with her functional abilities and ambulated with a walker.
Observation on 11/04/24 at 8:42 A.M. revealed Resident #40 needed to use the restroom and needed to
use the call light to request assistance from facility staff, but was unable to locate her call light that was
located out of her reach.
Interview on 11/04/24 at 8:42 A.M. with Resident #40 revealed she did not know where her call light was,
and it was frequently out of her reach.
Interview on 11/04/24 at 8:45 A.M. with Administrative Staff #161 verified Resident #40's call light was out
of her reach and Resident #40 was unable to locate it.
2. Review of the electronic medical record for Resident #42 revealed an admission date of 08/03/24 with
diagnoses of sepsis, osteomyelitis, acute kidney failure, chronic obstructive pulmonary disease, type two
diabetes mellitus, osteoarthritis, constipation, depression, anxiety, hyperlipidemia, and hypotension.
Review of the most recent quarterly MDS assessment dated [DATE] revealed a BIMS score of 08,
indicating Resident #42 was moderately cognitively impaired. Resident #42 required partial to moderate
assistance with his functional abilities and utilized a wheelchair.
Observation on 11/04/24 at 8:36 A.M. revealed Resident #42's call light was not able to be located visually.
(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 11
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
11/07/2024
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)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Interview on 11/04/24 at 8:36 A.M. with Resident #42 revealed he was unable to locate his call light in his
room.
Interview on 11/04/24 at 8:40 A.M. with Administrative Staff #161 verified Resident #42 did not know where
his call light was located in his room.
Residents Affected - Few
Further interview on 11/04/24 at 8:40 A.M. with Administrative Staff #161 revealed the call light for Resident
#42 was located out of his reach in his room.
3. Review of the medical record revealed Resident #21 had an admission date of 04/15/20. Diagnoses
included hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, chronic
obstructive pulmonary disease, anxiety disorder, type two diabetes mellitus with diabetic neuropathy,
dementia, and hypertension.
Review of the MDS assessment dated [DATE], revealed the resident had severe cognitive impairment. The
resident had impairment to one side of the body and was dependent for toileting.
Review of the care plan dated 04/19/23 revealed Resident #21 was at risk for falls and had a self-care
performance deficit for activities of daily living (ADL). Interventions included for staff to ensure the call light
was within reach and encourage Resident #21 to use it when assistance was needed.
Observation on 11/05/24 at 7:18 A.M. revealed Resident #21's call light was out of reach positioned
between the bed rail and mattress.
Interview on 11/05/24 at 7:18 A.M., State Tested Nursing Assistant (STNA) #151 and STNA #163 verified
the call light was not in reach.
Review of the undated policy, Answering the Call Light, revealed to ensure when a resident was in bed or
confined to a chair to be sure the call light was within easy reach of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 2 of 11
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
11/07/2024
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)
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
record review, observation, staff interview, and review of facility policy, the facility failed to ensure residents
received adequate hygiene and personal care. This affected one (#43) of six residents reviewed for
Activities of Daily Living (ADLs). The facility census was 54.
Residents Affected - Few
Findings include:
Review of Resident #43's medical record revealed an admission date of 01/19/23. Diagnoses included
vascular dementia, hypertension, and peripheral vascular disease.
Review of Resident #43's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the
resident had severe cognitive impairment and required setup assistance with personal hygiene and oral
care.
Observation on 11/04/24 at 9:24 A.M. revealed Resident #43's bottom teeth were caked with a white
residue.
Observation on 11/05/24 at 7:26 A.M. revealed Resident #43's teeth were still had a white buildup of
residue.
Interview on 11/05/24 at 7:26 A.M., State Tested Nursing Assistant (STNA) #163 verified the buildup on the
resident's bottom dentures. STNA #163 stated the resident's teeth should get cleaned twice a day. Further
interview with STNA #163 revealed she obtained oral care supplies for the resident.
Interview on 11/06/24 at 7:59 A.M., STNA #176 revealed Resident #43 sometimes would refuse care and
would have to approached again for care later. STNA #176 revealed if the resident refused care multiple
times, then the nurse would be notified. STNA #176 revealed staff cleaned Resident #43's dentures for him.
Review of Resident #43's progress notes revealed no documentation of Resident #43 refusing oral care or
denture care.
Review of policy, Personal Care, revised 01/2021, revealed staff were to assist residents with oral care
including brushing teeth (or cleaning dentures) as needed. Some residents may need their mouth swabbed
with a mouth swab.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 3 of 11
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
11/07/2024
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record revealed Resident #56 had an admission date of 09/30/24. Diagnoses included
Parkinsonism, bipolar disorder, depressive disorder, and type two diabetes mellitus.
Review of the admission MDS assessment dated [DATE] revealed Resident #56 had intact cognition.
Review of discharge medication orders from the resident's previous facility revealed the resident had an
order dated 04/20/24 for Risperdal Consta 37.5 milligrams (mg)/two milliliters (ml) intramuscularly on
Tuesdays every two weeks. The medication was last administered on 09/24/24.
Review of a physician order dated 10/01/24 revealed an order for Risperdal Consta Intramuscular
Suspension Reconstituted Extended Release 37.5 mg, inject two ml intramuscularly in the morning every
14 days for schizoaffective disorder for 14 days. There were no orders to discontinue the medication.
Review of the medication administration record dated 10/01/24 through 11/04/24 revealed the medication
was not administered.
Review of a nurse's electronic medication administration note dated 10/01/24 at 9:34 A.M. revealed the
pharmacy would be contacted for the arrival date of the medication.
Review of an untimed pharmacy invoice dated 10/01/24 revealed the medication was received on 10/01/24.
Review of a physician progress note dated 10/01/24 at 12:34 P.M. revealed a medication reconciliation was
completed including current medication and post discharge medication. The physician noted to continue
home medications. There was no documentation in the medical record the physician was notified the
medication was not administered to the resident.
Interview on 11/04/24 at 8:44 A.M., Resident #56 revealed prior to admission to the facility she had been
taking a shot of Risperdal every two weeks to help even her out. Resident #56 revealed she had not
received the medication since her admission to the facility.
Interview on 11/05/24 at 1:28 P.M., Registered Nurse (RN) #143 revealed on 11/05/24, the physician had
renewed the order for the medication to be given every 14 days for bipolar disorder.
Interview on 11/06/24 at 7:20 A.M., the Director of Nursing (DON) verified the medication was not
administered per physician orders. The DON revealed there was no documentation the physician was
notified the medication was not available. The DON also revealed the physician should have been
contacted for clarification of the stop date on the order as the resident had been on the medication
long-term.
Review of the policy Administration and Documentation of Medications, revised 10/2022, revealed residents
would receive medications as prescribed by the physician.
Based on observation, resident interview, staff interview, review of facility records, and review
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 4 of 11
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
11/07/2024
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
of facility policy, the facility failed to ensure medications were available for administration. This affected
affected two (Residents #22 and #56) of two residents reviewed for availability of medications. The facility
census was 54.
Findings include:
Residents Affected - Few
Review of the facility electronic medical record for Resident #22 revealed an admission date of 11/14/24
with diagnoses of delusional disorders, hypertension, depression, cognitive communication deficit, muscle
weakness, other abnormalities of gait and mobility, paranoid schizophrenia, insomnia, constipation, and
anxiety.
Review of Resident #22's most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed
a Brief Interview of Mental Status (BIMS) score of 13, indicating Resident #22 was cognitively intact.
Observation on 11/05/24 at 6:35 A.M. of medication administration for Resident #22 by Licensed Practical
Nurse (LPN) #168 revealed the facility did not have the PRN (as needed) Excedrin that was ordered for
Resident #22. At the time of this discovery, LPN #168 ordered more Excedrin for Resident #22.
Interview on 11/05/24 at 7:55 AM with LPN #168 revealed Resident #22 takes Excedrin routinely as
needed, however it was last documented as administered on 10/31/24.
Concurrent interview on 11/05/24 at 7:55 A.M. with LPN #168 revealed Excedrin was last ordered for
Resident #22 on 10/15/24.
Review on 11/05/24 at 8:10 A.M. of facility medication procurement records revealed the facility received 30
Excedrin for Resident #22 on 10/15/24.
Interview on 11/05/24 at 1:11 P.M. with Resident #22 revealed the facility had not had her Excedrin in
approximately one week. Resident #22 revealed she had spoken to multiple staff members regarding the
facility not having her Excedrin available and requested they obtain this medication for her utilization as this
medication is what helps when she has severe migraine headaches.
Review of facility electronic Medication Administration Records (eMAR) for 10/24 and 11/24 revealed
Resident #22 has received 12 doses of Excedrin since the most recent shipment of this medication was
received on 10/15/24.
Interview on 11/05/24 at 1:26 P.M. with the Assistant Director of Nursing (ADON) verified the facility
received 30 Excedrin for Resident #22 on 10/15/24. The ADON verified Resident #22 had only received 12
doses of Excedrin between the dates of 10/15/24 and 11/05/24 and Resident #22 received no doses of
Excedrin in 11/24.
Further interview on 11/05/24 at 1:26 P.M. with the ADON revealed she was unsure where the 18 missing
Excedrin tables for Resident #22 were located.
Interview on 11/06/24 at 7:24 A.M. with the Director of Nursing (DON) verified Resident #22 had received
12 doses of Excedrin between the dates of 10/15/24 and 11/15/24 and Resident #22 received no doses of
Excedrin in 11/24. The DON revealed she was unsure where the 18 missing Excedrin tablets for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 5 of 11
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
11/07/2024
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)
F 0755
Resident #22 were located.
Level of Harm - Minimal harm
or potential for actual harm
Review of facility policy titled, Administration and Documentation of Medications, revised 10/22, revealed
medications must be ordered in a timely manner. A 3-day supply should always be available within the
facility to allow for unexpected delivery problems.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 6 of 11
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
11/07/2024
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)
F 0791
Provide or obtain dental services for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, resident interview, staff interview, record review, and review of facility policy, the facility failed to
assist residents in obtaining routine and 24-hour emergency dental care. This affected one (Resident #17)
of four residents reviewed for dental care. The facility census was 54.
Residents Affected - Few
Findings include:
Review of the electronic medical record for Resident #17 revealed an admission date of 12/27/24 with
diagnoses of chronic obstructive pulmonary disease, type two diabetes mellitus, mild protein-calorie
malnutrition, hypertension, atherosclerotic heart disease, bipolar disorder, retention of urine, anemia,
anxiety, insomnia, and major depressive disorder.
Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief
Interview for Mental Status (BIMS) score of 14, indicating Resident #17 was cognitively intact.
Review of the care plan for Resident #17 revealed the facility will coordinate arrangements for dental care,
transportation as needed/as ordered.
Interview on 11/04/24 at 10:51 A.M. with Resident #17 revealed he needs to have hip surgery, but cannot
have the surgery until he sees an oral surgeon for dental extractions.
Review of a physician progress note dated 08/28/24, Medical Doctor (MD) #197 revealed, we need to work
on getting his teeth removed and then we can fix his hip.
Interview on 11/06/24 at 8:26 A.M. with Social Services Designee (SSD) #121 revealed there have been no
oral surgeons or dentists contacted for this resident.
Concurrent interview on 11/06/24 at 8:26 A.M. with SSD #121 revealed Resident #17 has signed up for
ancillary services, but has not been evaluated by a dentist since his admission on [DATE]. SSD #121 stated
the dentist comes to the facility quarterly and on an as-needed basis.
Review on 11/06/24 at 2:00 P.M. of the facility provided list of dates that the dentist has been at the facility
in the previous one year revealed that since Resident #17's admission on [DATE], the dentist has been at
the facility five times (01/16/24, 04/19/24, 04/26/24, 06/04/24, and 08/23/24).
Review of the facility policy titled, Resident Healthcare Appointments/Ancillary Services, revised 02/22,
revealed upon admission each medical record will be reviewed for indications of need to schedule follow-up
appointments or transportation for scheduled healthcare appointments.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 7 of 11
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
11/07/2024
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)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, resident interview, staff interview, and facility policy, the facility failed to serve
reasonably palatable food. This affected all residents who received spaghetti with the lunch meal. The
facility identified 11 (#3, #10, #14, #17, #22, #29, #30, #31, #41, #46, and #50) residents who did not
receive spaghetti. The facility census was 54.
Residents Affected - Some
Findings include:
Interviews on 11/04/24 between 8:33 A.M. and 3:29 P.M. with Residents #17, #18, #26, #31, #35, #42, #50,
and #55 revealed concerns for food palatability.
Observation on 11/05/24 at 12:03 P.M. revealed the lunch meal test tray included a four ounce spoodle of
spaghetti noodles with marinara sauce. The spaghetti appeared appetizing but tasted sour and was gummy
in texture.
Interview on 11/05/24 with Corporate Dietary Manager #198 verified the spaghetti tasted acidity.
Interview on 11/05/24 from 12:07 P.M. with Resident #1 revealed the spaghetti sauce was not good and
could not eat it.
Interview on 11/05/24 at 12:08 P.M. with Resident #9 revealed the spaghetti was yuck.
Interview on 11/05/24 at 12:11 P.M. with Resident #16 reports the spaghetti was not good and mushy
adding that it tasted like it came from a can.
Interview on 11/05/24 at 12:13 P.M. with Resident #47 revealed the spaghetti did not taste good.
Review of the policy, Palatability and Nutritive Value, dated 06/27/23, revealed food will be prepared, held,
and served in a manner that preserves nutritive value and palatability. Food service staff will monitor
palatability of food at point of service by periodic test tray evaluation and review of resident council
concerns.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 8 of 11
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
11/07/2024
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the medical record, observation, and interviews, the facility failed to ensure the memory care unit
was maintained in good condition. This affected six (#43, #56, #44, #55, #21, #28,) of seven residents
reviewed for environment and had the potential to affect all residents residing in the memory care unit. The
facility census was 54.
Findings include:
1. Review of the medical record for Resident #44 revealed an admission date of 10/11/23. Diagnoses
included dementia, hypertension, and retinal disorder.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had
moderate cognitive impairment.
Observation on 11/04/24 at 8:13 A.M. revealed there was an approximate ten inch wide by five inch tall
spider web in the resident's window between the window and the screen.
Interview on 11/06/24 at 8:54 A.M., the Director of Housekeeping (DOH) #158 verified the spider web in the
window.
2. Review of the medical record for Resident #55 revealed an admission date of 08/28/24. Diagnoses
included dementia, Alzheimer's disease, hypertension, and depressive disorder.
Review of the admission MDS dated [DATE] revealed Resident #55 had severe cognitive impairment.
Observation on 11/04/24 at 8:16 A.M., revealed the resident had a buildup of dust on the bathroom fan.
Interview on 11/06/24 at 9:04 A.M., the DOH #158 verified the dust build up on the resident's bathroom fan.
3. Review of the medical record for Resident #56 revealed an admission date of 09/30/24. Diagnoses
included Parkinsonism, chronic obstructive pulmonary disease, bipolar disorder, and type two diabetes
mellitus.
Review of the admission MDS assessment dated [DATE] revealed Resident #56 had intact cognition.
Observation on 11/04/24 at 8:34 A.M. revealed there was large scrapes in the wall next to the window.
There was also patched areas on the bathroom door left not sanded or finished.
Interview on 11/04/24 at 8:34 A.M., Resident #56 revealed the scrapes on the wall and patches on the
bathroom door had been there since she moved into the room.
Interview on 11/06/24 at 8:52 A.M., the Director of Maintenance (DOM) #107 and DOH #158 verified the
scraped area on the walls and unfinished patches on the bathroom door. DOM #107 stated he had been
out of paint for a long time. DOM #107 stated he thought paint had been ordered but was not sure
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 9 of 11
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
11/07/2024
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)
F 0921
when it would be received.
Level of Harm - Minimal harm
or potential for actual harm
4. Review of the medical record for Resident #21 revealed an admission date of 04/15/20 and a
readmission date of 11/09/21. Diagnoses included dementia, hemiplegia and hemiparesis following
cerebral infarction, chronic obstructive pulmonary disease, and type two diabetes mellitus.
Residents Affected - Some
Review of the quarterly MDS assessment dated [DATE] revealed Resident #21 had severe cognitive
impairment.
Observation on 11/04/24 at 8:50 A.M. revealed the resident had a build up of dust on his bathroom fan.
Interview on 11/06/24 at 8:56 A.M. with the DOH #158 verified the dust buildup on the bathroom fan.
5. Review of the medical record for Resident #28 revealed an admission date of 01/27/21. Diagnoses
included vascular dementia and type two diabetes mellitus.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had severe cognitive
impairment.
Observation on 11/04/24 at 8:55 A.M. revealed there was a build up of dust on the resident's bathroom fan.
Interview on 11/06/24 at 9:04 A.M., DOH #158 verified the build up of dust on the bathroom fan.
6. Review of the medical record for Resident #43 revealed an admission date of 01/19/23. Diagnoses
included vascular dementia, hypertension, peripheral vascular disease and depressive disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had
severe cognitive impairment. The resident required set-up assistance/clean up assistance for toileting
hygiene.
Observation on 11/04/24 at 8:58 A.M. revealed there was a large puddle of urine on the bathroom floor and
a brown substance smeared on the toilet.
Interview on 11/04/24 at 8:58 A.M. State Tested Nursing Assistant (STNA) #133 verified the puddle of urine
and the brown substance on the toilet lid. STNA #133 revealed the prior shift should have cleaned up the
area.
7. Observation on 11/04/24 at 8:59 A.M. revealed the floors in the dining room in the memory care unit were
sticky and not clean.
Interview on 11/04/24 at 8:59 A.M., Administrative Staff (AS) #161 verified the floors were sticky and not
clean.
Observation on 11/06/24 at 8:59 A.M., revealed the floor in the dining room felt tacky when walked on.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 10 of 11
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
11/07/2024
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Interview on 11/06/24 at 8:59 A.M., DOH #158 verified the floor was tacky. DOH #158 stated some peoples
shoes stick to the floor and some do not.
Review of the policy, Housekeeping, dated 04/2018, revealed resident rooms and common area would be
cleaned and maintained.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365740
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
18 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F791 - Dental Services
Provide or obtain dental services for each resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0361GeneralS&S Fpotential for harm
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0372GeneralS&S Fpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the November 7, 2024 survey of Majestic Care of Clyde?
This was a inspection survey of Majestic Care of Clyde on November 7, 2024. The surveyor cited 18 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Majestic Care of Clyde on November 7, 2024?
Yes, 18 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.