Health inspection·November 7, 2024

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. Page 1 of 11 365740 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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. 365740 Page 2 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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. 365740 Page 3 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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 365740 Page 4 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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 365740 Page 5 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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 365740 Page 6 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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. 365740 Page 7 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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. 365740 Page 8 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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 365740 Page 9 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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. 365740 Page 10 of 11 365740 11/07/2024 Majestic Care of Clyde 700 Helen Street Clyde, OH 43410

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 365740 Page 11 of 11