Health inspection·November 6, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to ensure Resident #59 was treated with respect and dignity. This affected one resident (#59) of nine sampled residents. The facility census was 118. Findings include: Review of the medical record for Resident #59 revealed an initial admission date of 10/28/22 with the diagnoses including but not limited to early onset Alzheimer's disease, chronic obstructive pulmonary disease, severe dementia with mood disturbance, psychotic disorder with delusions, major depressive disorder, hypertension, hyperlipidemia, osteoarthritis, mood disorder, sleep disorders, atrial fibrillation, anxiety disorder, insomnia, wandering in diseases, hypothyroidism, constipation, sleep apnea and drug induced secondary Parkinsonism. Review of the plan of care dated 10/28/22 revealed the resident needed assistance with activities of daily living due to impaired mobility, weakness, debility, secondary Parkinsonism, dementia, osteoarthritis, anxiety, depression and psychotic mood disorder. Interventions included resident required staff assistance with dressing. Review of the resident's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. Review of the resident's monthly physician orders for November 2024 identified orders dated 10/28/22 for non-skid footwear. On 11/04/24 at 10:48 A.M., observation of Resident #59 revealed he was wandering behind the memory care unit nurse's station with one yellow non-skid sock on the right foot and a white low cut sock on the left foot. Licensed Practical Nurse (LPN) #235 was notified the resident's socks were not matching and of the same type. LPN #235 took Resident #59 to his room to change his socks. On 11/04/24 at 10:50 A.M., observation of Resident #59 revealed the resident had a yellow non-skid sock on his right foot and a navy blue non-skid sock on his left foot. LPN #235 verified the resident was not being treated in a dignified manner by having mismatched non-skid socks on. Review of the facility policy titled, Dignity, dated 01/02/24 revealed it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances each (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 6 Event ID: 366201 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 366201 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Whitehall 4805 Langley Avenue Whitehall, OH 43213 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)