Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Clyde during CMS and state inspections, most recent first.
A cognitively intact resident with psychiatric and respiratory diagnoses was on a speaker-phone call with family in a common area where multiple people could hear the conversation, and the resident stated she could not move to a private location. An unknown staff member then intervened, told the family they would need to come in and speak with the DON if they wished to talk to the resident, and abruptly ended the call. The Administrator and Social Services Designee confirmed that the resident was not offered or provided a private place for the call and that staff terminated the conversation, contrary to the facility’s written policy guaranteeing residents private access to telephone communication.
Surveyors found that the kitchen floor was coated with unidentified brown and white substances and scattered food and non-food debris, which a dietary aide confirmed, in violation of the facility’s Kitchen Sanitation policy requiring clean and contamination-free food preparation areas. In the dry storage room, surveyors also observed multiple large dented canned food items, including pineapple tidbits, collard greens, and baked beans, which were not separated, labeled, or disposed of as required by facility policy for dented cans. All residents were receiving meals prepared in this kitchen.
A resident with severe cognitive impairment, multiple comorbidities, and a confirmed COVID-19 infection was placed on contact and droplet precautions with clear signage requiring hand hygiene, gown, gloves, and face/eye protection for anyone entering the room. An LPN entered the room to obtain vital signs and administer medications wearing only a surgical mask and gloves, without a gown or eye protection, despite the posted instructions. In interview, the LPN acknowledged not using the required PPE and stated she did not believe it was necessary, contrary to the facility’s infection prevention and PPE policies.
The facility failed to provide adequate supervision to prevent sexual contact between two cognitively impaired residents on a secured memory care unit. A female resident with severe dementia, dependent for ambulation and with a history of sexual behaviors and poor impulse control, was in a wheelchair in a common area when a male resident with severe cognitive impairment, independent ambulation, and a similar behavioral history was observed standing over her, holding her shirt open and placing his hand down the front of her shirt. A CNA witnessed and reported the incident and did not believe it was consensual, while the DON and Administrator confirmed the physical contact but characterized it as consensual based on the female resident’s baseline hypersexual behavior and lack of combative response. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the event occurred despite both residents having guardians and known histories of sexual behaviors and poor impulse control.
Three cognitively impaired residents were subjected to repeated sexual abuse by another resident with a history of inappropriate sexual behavior, including exposure and physical contact, as confirmed by staff interviews, medical records, and facility documentation. The incidents involved public masturbation, exposure, and inappropriate touching, with staff and witness statements substantiating the events.
The facility did not ensure timely reporting of multiple abuse allegations involving a resident with moderate cognitive impairment who exposed himself and engaged in inappropriate behavior with other residents. Despite staff observations and documentation, required self-reported incidents were not filed promptly or at all, as confirmed by the DON and in violation of facility policy.
The facility did not thoroughly investigate multiple allegations of abuse involving a resident with cognitive and psychiatric conditions who exposed himself and engaged in inappropriate behavior toward two other residents, both of whom had significant cognitive impairments. Staff confirmed the incidents, but the required investigations were not conducted, and law enforcement was not notified as per facility policy.
A facility failed to maintain a clean and sanitary environment in the west shower room, affecting all residents on the west unit. Observations revealed a hot, humid room with a musty odor and black mold-like spots on the walls and ceiling. The Maintenance Director confirmed the presence of moisture and a lack of an exhaust fan, which may have contributed to the mold, along with a constantly running shower. The facility's policy required maintenance to ensure a sanitary environment, but the Maintenance Director was unaware of the issue due to a lack of staff notification.
The facility failed to report and investigate an abuse allegation involving a resident with cognitive impairment and the misappropriation of Ozempic affecting three residents. The alleged perpetrator was not immediately removed, and the incidents were not reported to the state agency. Investigations were delayed, with missing documentation and untimely assessments, leading to non-compliance with regulatory requirements.
A resident with diabetes was not administered her prescribed Ozempic injections on several occasions, and the physician was not notified of these omissions as required by facility policy. The resident was aware of the missed doses but was not informed of the reasons. The facility's policy mandates timely notification of medication omissions, which was not followed.
A facility failed to report and investigate an abuse allegation involving a resident with cognitive impairment and did not immediately remove the alleged perpetrator. Additionally, the facility did not report or investigate the misappropriation of Ozempic affecting three residents, with missing doses and pens not accounted for. The facility did not adhere to its policy of reporting such incidents to the Department of Health.
A facility failed to provide adequate grooming care for a resident with Parkinson's disease, who was dependent on staff for activities of daily living. Despite the care plan indicating a need for assistance with personal hygiene, observations showed the resident's toenails were excessively long and untrimmed. An LPN confirmed the oversight, and the resident reported that staff had not performed the necessary nail care.
Two residents in an LTC facility experienced medication administration errors. One resident received daily doses of Ozempic instead of weekly due to an incorrect order entry, while another resident missed several weekly doses because the medication was unavailable, and the physician was not consistently notified. Both residents have type two diabetes mellitus, and the facility's policy on medication administration was not followed.
The facility failed to serve food at acceptable temperatures, affecting 20 residents on the 200 hall. Two residents reported meals were sometimes cold, and a test tray confirmed shrimp and french fries were below required temperatures. The Director of Nutritional and Food Services acknowledged the issue, which violated the facility's food production policy.
The facility failed to serve palatable spaghetti, affecting residents who received it with their lunch meal. Observations and interviews revealed that the spaghetti tasted sour and had a gummy texture. The Corporate Dietary Manager confirmed the acidity, and several residents reported the spaghetti as unappetizing and mushy, tasting like it came from a can. The facility's policy requires food to be prepared and served to preserve palatability, monitored through test tray evaluations and resident feedback.
The facility failed to maintain the memory care unit in good condition, affecting several residents. Observations revealed issues such as a spider web in a window, dust buildup on bathroom fans, scrapes on walls, unfinished patches on a bathroom door, and unsanitary bathroom conditions. Additionally, the dining room floors were sticky and not clean. These deficiencies were verified by staff, indicating a failure to adhere to the facility's housekeeping policy.
The facility failed to ensure residents had access to their call lights, affecting three residents. One resident, who was cognitively intact, could not locate her call light, which was out of reach. Another resident, moderately cognitively impaired, also had an out-of-reach call light. A third resident, with severe cognitive impairment, had a call light positioned between the bed rail and mattress, contrary to their care plan and facility policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive adequate oral hygiene care, as evidenced by a white residue buildup on their teeth over consecutive days. Despite the facility's policy requiring assistance with oral care, staff interviews revealed inconsistencies in care delivery, with no documentation of the resident's refusal of care.
The facility failed to provide necessary medications for two residents, leading to deficiencies in pharmaceutical services. A resident with a history of migraines did not receive her PRN Excedrin due to unaccounted tablets, while another resident did not receive her prescribed Risperdal Consta injections. The facility did not adhere to its medication administration policy, resulting in the unavailability of essential medications.
A resident in a LTC facility, who was cognitively intact and required dental extractions before hip surgery, did not receive necessary dental care. Despite the facility's policy to coordinate healthcare appointments, no dentist or oral surgeon was contacted for the resident, even though the facility's dentist visited five times since the resident's admission.
A resident with severe cognitive impairment was found with unexplained bruising on the neck, which the facility failed to report as required by their policy. Initial assessments suggested a pustule, but further evaluations confirmed it was bruising. The facility did not report the incident to the Ohio Department of Health within the mandated timeframe.
A resident with severe cognitive impairment was found with bruising on the neck, but the facility failed to investigate the injury of unknown origin as required by their policy. Staff initially thought the bruise was related to a pustule, but a wound physician later confirmed it was bruising. No self-reported incidents were submitted, indicating non-compliance with the facility's policy.
The facility failed to ensure required RN coverage, affecting all 48 residents. Staff schedules and BIPA documentation showed no RN was present on specific dates, confirmed by the DON, who noted a lack of RN coverage every other weekend.
The facility failed to serve palatable meals, affecting multiple residents. Observations showed that the Mexican corn was tough, and a resident received a chicken breast that was too tough to eat. Other residents reported that meals were often inedible, with some opting for alternative food options. The facility's policy on palatability and nutritive value was not followed.
The facility failed to provide scheduled showers to three residents who were dependent on staff for assistance. One resident, moderately cognitively impaired, received only one shower in thirty days without any documented refusals. Another resident, cognitively intact, also had one shower documented, expressing a desire for more frequent showers. A third resident, fully dependent and rarely understood, had only one documented shower, with staff believing more occurred than recorded. Interviews confirmed the lack of adherence to scheduled showers, contrary to the facility's ADL policy.
The facility failed to provide adequate staffing, affecting residents' personal hygiene needs. A resident with vascular dementia received only one shower in thirty days, while another with cognitive impairment also had insufficient bathing. Interviews revealed staffing shortages, with call-offs and difficulty in finding replacements, leading to delays in care. Staff confirmed that inadequate staffing often resulted in missed showers for residents.
A resident requested a burger instead of the dinner meal, but the facility was out of hamburger meat and offered a peanut butter sandwich instead. The resident, who disliked tacos, chose to skip dinner. Another resident reported similar issues with meal substitutions. The facility's policy required nutritionally comparable menu items to be available, but this was not followed.
Failure to Provide Resident Privacy During Telephone Communication
Penalty
Summary
The facility failed to ensure a resident had privacy during a telephone call with family, as required by resident rights and the facility’s own policy. The resident, admitted in mid-February 2026, had diagnoses including schizophrenia, anxiety, adjustment disorder with mixed anxiety and depression, and emphysema, and was documented as cognitively intact on the admission MDS. An audio recording of a family-initiated call to the facility’s telephone showed that the resident accepted the call and identified herself, along with her son and daughter-in-law. During the call, the resident told her family she was on speaker phone with many people around listening. When her son asked if she could go somewhere private, the resident stated she could not. The audio recording further revealed that an unknown facility employee intervened in the call, told the family that if they wished to speak with the resident they would need to come to the facility and speak with the DON, and then abruptly ended the call. The Administrator confirmed that the recording involved the resident, her family, and an unknown staff member, and verified that privacy was neither offered nor provided and that a staff member abruptly terminated the call. The Social Services Designee reported being contacted by the night shift nurse about the family’s request to speak with the resident and stated she had advised that if the resident wanted to speak with her family, staff could not stop her. She also verified that the resident was not provided a private place for the call and that an unknown staff member abruptly ended the conversation. Review of the facility’s Resident-Patient Rights policy, revised February 2026, showed that residents were to have access to telephone communication with privacy, which was not afforded in this incident.
Unsanitary Kitchen Conditions and Improper Storage of Dented Canned Foods
Penalty
Summary
Surveyors identified a deficiency related to food procurement, storage, preparation, and sanitation practices in the facility kitchen. During an early morning observation, the kitchen floor was found to be coated with unidentified brown and white substances and scattered with miscellaneous unidentified food and non-food debris. A concurrent interview with a dietary aide confirmed the presence of these substances and debris on the kitchen floor. The facility’s own Kitchen Sanitation policy required that good sanitary food handling practices be maintained at all times and that food preparation and serving areas be kept clean, organized, and free of contamination, spills, mold, or buildup. Further observation of the dry storage room revealed multiple dented canned food items, including two large cans of pineapple tidbits with large dents on the sides, one large can of collard greens with a large dent in the top ring, and one large can of baked beans with a large dent in the top ring. The dietary aide confirmed the dents observed on these canned food items. The facility policy specified that dented cans or contaminated food items must be separated, labeled "Dented Cans - Do Not Use," and disposed of accordingly. All residents in the facility, with a census of 64, were identified as receiving meals prepared by this kitchen.
Failure to Use Required PPE for Resident on Contact and Droplet Precautions
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control program and PPE policies for a resident on transmission-based precautions. The resident had multiple medical diagnoses, including cerebral infarction with aphasia and hemiplegia, dysphagia, asthma, heart disease, obesity, bipolar disorder, depression, and the presence of a prosthetic heart valve, and had a BIMS score of 03 indicating severe cognitive impairment. The electronic medical record showed the resident tested positive for SARS CoV-2 (COVID-19) and had a physician order for droplet precautions. Signage posted outside the resident’s room indicated both contact and droplet precautions were in place, requiring hand hygiene before entering and upon exiting, donning gloves and a gown prior to room entry, discarding gloves and gown before exiting, using dedicated or properly disinfected equipment, and ensuring eyes, nose, and mouth were fully covered with appropriate face protection prior to room entry and removed before exiting. Despite these posted requirements and facility policies, an LPN was observed entering the resident’s room to obtain vital signs and administer medications while wearing only a surgical mask and gloves, without a gown or eye protection as required by the contact and droplet precaution signage. During interview, the LPN confirmed she provided care without the appropriate PPE and stated she did not believe PPE was required while providing care to this resident, even though she acknowledged the presence of the contact and droplet precaution signage outside the room. The facility’s written Infection Prevention and Control Program policy required residents with infections or communicable diseases to be placed on transmission-based precautions in accordance with CDC guidelines, and the PPE policy required appropriate use of PPE to prevent transmission of pathogens to residents, visitors, and staff. The observed actions and statements of the LPN demonstrated noncompliance with these established precautions and policies.
Failure to Protect Cognitively Impaired Resident From Sexual Contact in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision to protect a resident on the secured memory care unit from sexual abuse. A resident with vascular dementia, severe cognitive impairment (BIMS score 0/15), dependence for ambulation, and a history of sexual behaviors and poor impulse control was seated in a wheelchair in the common area of the memory care unit. Another resident with severe cognitive impairment (BIMS score 6/15), independent ambulation, and a similar history of sexual behaviors and poor impulse control was observed standing over her, holding her shirt open with one hand and placing his other hand down the front of her shirt. Both residents had guardians and resided on the secured memory care unit at the time of the incident. The incident was witnessed by a CNA returning to the unit, who immediately reported that the male resident’s hand was inside the female resident’s shirt while both were in the common area. The CNA stated she did not feel the interaction was consensual, although she could not recall whether the female resident displayed her usual combative or rejecting behaviors when she did not want someone in her space. The DON and Administrator confirmed that the male resident’s hand was inside the front of the female resident’s shirt. The DON stated that the interaction was considered consensual based on the female resident’s baseline hypersexual behavior, lack of combative response, and lack of distress or memory of the event shortly afterward. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the facility determined the allegation of sexual abuse to be unsubstantiated and inconclusive, despite both residents having severe cognitive impairment and documented histories of sexual behaviors and poor impulse control.
Failure to Prevent Sexual Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to prevent sexual abuse involving three residents with moderate cognitive impairment and histories of inappropriate or aggressive behaviors. One resident, with diagnoses including schizoaffective disorder and cognitive communication deficit, had a documented history of sexually inappropriate actions such as exposing himself, masturbating in public areas, and entering female residents' rooms. On multiple occasions, this resident was found in another resident's room with his penis exposed, and was observed touching the other resident's breast over her clothing. Staff interviews and witness statements confirmed these incidents, including the resident exposing himself and masturbating in common areas and in front of other residents. Another resident involved had diagnoses of dementia and obsessive-compulsive disorder, and was also moderately cognitively impaired. This resident was found in situations where she was exposed to the inappropriate behaviors of the first resident, including being touched and exposed to indecent acts. The resident did not recall the incident during interview but was identified as a victim in the facility's self-reported incident and staff statements. A third resident, with vascular dementia and major depressive disorder, was also subjected to the first resident's inappropriate sexual behaviors, including exposure and masturbation in their presence. Staff interviews corroborated that the first resident repeatedly exposed himself and engaged in sexual acts in front of other residents. The facility's policy defined such actions as sexual abuse, and the events were substantiated through medical record review, staff and resident interviews, and facility documentation.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported and reported in a timely manner, as required by policy. In one incident, a resident with moderate cognitive impairment and multiple diagnoses, including schizoaffective disorder and major depressive disorder, was found in another resident's room with his penis exposed and was observed touching the other resident's breasts over her clothing. This incident was documented in a nursing progress note, but was not reported as a self-reported incident (SRI) until the following day, after it was discovered during a clinical review meeting. The Director of Nursing confirmed the delay in reporting. In a separate incident, the same resident was observed touching himself in front of another resident, who was rarely understood and had diagnoses including vascular dementia and major depressive disorder. Staff interviews confirmed that the resident had exposed himself to this other resident on more than one occasion. Despite these observations and documentation in the nursing progress notes, there was no SRI filed for these allegations of abuse. The Director of Nursing verified that these incidents were not reported as required by the facility's abuse policy, which mandates immediate reporting to the Administrator and the Department of Health.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated for three residents. In one incident, a resident with moderate cognitive impairment and multiple diagnoses, including schizoaffective disorder and major depressive disorder, was found in another resident's room with his penis exposed and was observed touching the other resident's breasts over her clothing. Both residents involved were moderately cognitively impaired. The incident was documented in the medical record, and staff interviews confirmed the details. However, the police were not notified of the alleged abuse, and there was no evidence that a thorough investigation was conducted as required by facility policy. In a separate incident, the same resident was observed exposing himself and touching his penis in front of another resident who was rarely understood and had vascular dementia and other significant health conditions. Staff interviews confirmed that this behavior had occurred, but the DON verified that an investigation was not conducted for this allegation of abuse. Facility policy requires that an investigation be conducted once the Administrator and Department of Health are notified, but this was not followed in these cases.
Failure to Maintain Sanitary Environment in Shower Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for residents on the west unit, as observed during a survey. The west shower room was found to be very hot and humid with a musty odor. A black irregular shaped area with moist spots was observed on the wall and ceiling, resembling black dust. This was confirmed by a Certified Nurses Aide (CNA) and the Maintenance Director, who also identified a dinner plate size black stain on the ceiling near the window and along the wall/ceiling area on the north wall of the shower room. The Maintenance Director acknowledged the presence of moisture and the lack of an exhaust fan, which may have contributed to the mold, as well as a constantly running shower due to a faulty shut-off mechanism. The facility's Infection Control information indicated one case of respiratory illness diagnosed as pneumonia during the review period. The facility's policy on maintaining a safe and homelike environment stated that housekeeping and maintenance services should be provided as necessary to ensure a sanitary, orderly, and comfortable environment. However, the Maintenance Director was unaware of the mold issue due to a lack of notification from staff, indicating a breakdown in communication and adherence to the facility's policy. This deficiency was investigated under Complaint Numbers OH00163559 and OH00162562.
Failure to Report and Investigate Abuse and Medication Misappropriation
Penalty
Summary
The facility failed to report and thoroughly investigate an allegation of abuse involving a resident with mild cognitive impairment. The incident occurred when a CNA reported that another CNA physically abused the resident by grabbing and threatening them. Despite the report, the alleged perpetrator was not immediately removed from the unit, and the incident was not reported to the state agency. The resident was not assessed for injuries until two days after the incident, and the investigation was delayed, with interviews and assessments not conducted in a timely manner. Additionally, the facility failed to report and investigate the misappropriation of the medication Ozempic, affecting three residents. The medication was noted as unavailable for several scheduled doses, and missing pens were reported. Despite the missing medications being reported to the DON and Administrator, a thorough investigation was not conducted, and the incident was not reported to the state agency. The facility did not have documentation of staff interviews or statements regarding the missing medications. The facility's policy required immediate reporting of such incidents to the Department of Health and a thorough investigation within five working days. However, these procedures were not followed, leading to a lack of documentation and delayed response to both the abuse allegation and the medication misappropriation. The failure to adhere to these protocols resulted in non-compliance with regulatory requirements.
Failure to Notify Physician of Medication Omissions
Penalty
Summary
The facility failed to notify the physician of medication omissions for a resident, which is a deficiency in their care protocol. Resident #42, who has diagnoses including type two diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, was not administered her prescribed Ozempic injections on multiple occasions. Specifically, the medication was not given on 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25, as per the physician's orders. The facility's electronic medication administration record notes indicated that the Ozempic was unavailable on these dates, yet the physician was not notified of the omissions on 01/10/25, 01/24/25, 02/07/25, and 02/22/25. Interviews conducted during the investigation revealed that the Director of Nursing confirmed the medication was not administered on the specified dates and that the physician was not informed of the omissions. Additionally, Resident #42 was aware that her weekly injections were not administered but was not informed of the reasons for the omissions. The facility's policy on medication administration and change in condition physician notification requires that medications be administered as ordered and that the physician be notified of any omissions within 24 hours, which was not adhered to in this case.
Failure to Report and Investigate Abuse and Medication Misappropriation
Penalty
Summary
The facility failed to report and thoroughly investigate an allegation of abuse involving a resident with mild cognitive impairment. The incident occurred when a CNA reported that another CNA physically abused the resident by grabbing and threatening him. Despite the report, the alleged perpetrator was not immediately removed from the unit, and the incident was not reported to the state agency. The resident was not assessed for injuries until two days after the incident, and there was no documentation of immediate assessment or follow-up actions by the nursing staff. Additionally, the facility failed to report and investigate the misappropriation of the medication Ozempic, affecting three residents. The medication was noted as unavailable for several scheduled doses, and missing pens were reported to the DON and Administrator. However, there was no documentation of a thorough investigation or staff interviews regarding the missing medications. The missing Ozempic pens were not reported to the state agency, and the facility did not provide documentation of reimbursement for the missing medication. The facility's policy required immediate reporting of allegations involving neglect, exploitation, and misappropriation of resident property to the Department of Health. However, the facility did not adhere to this policy, as the incidents were not reported within the required timeframe. The lack of timely reporting and investigation of these incidents represents a significant deficiency in the facility's compliance with regulatory requirements.
Failure to Provide Adequate Grooming Care for a Resident
Penalty
Summary
The facility failed to provide adequate grooming care for a dependent resident, identified as Resident #45, who was under hospice care and had an intact cognitive function. The resident was diagnosed with Parkinson's disease, bipolar disorder, peripheral vascular disease, and chronic obstructive pulmonary disease, and was dependent on staff for activities of daily living. The resident's care plan indicated a need for assistance with personal hygiene, including nail care. However, observations revealed that the resident's toenails were excessively long and in need of trimming, which had not been completed as required on shower days. Interviews with the Licensed Practical Nurse (LPN) confirmed the need for nail trimming and acknowledged that the care should have been provided. The resident also expressed that staff had failed to trim her toenails, and her daughter had to attempt to do so during visits. The facility's policy on activities of daily living stated that necessary services would be provided for grooming, but this was not adhered to in the case of Resident #45. This deficiency was investigated under Complaint Numbers OH00162562.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders, affecting two residents. Resident #64, who has type two diabetes mellitus, hypertension, and hyperlipidemia, was administered Ozempic daily instead of weekly due to an incorrect entry in the electronic record. This error was not identified until several days later, despite the resident receiving multiple doses. The physician was notified, and the order was corrected, but the pharmacy did not question the daily dose, and no side effects were reported by the resident. Resident #42, also diagnosed with type two diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, did not receive her prescribed weekly Ozempic injections on several occasions. The medication was unavailable on these dates, and the physician was not consistently notified of the omissions. The resident was aware of the missed doses but was not informed of the reasons. The facility's policy requires medications to be administered as ordered and timely notification of omissions to the physician, which was not adhered to in these cases.
Facility Fails to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to ensure that residents were served food at an acceptable temperature, affecting 20 residents who received meal trays on the 200 hall. During an interview, two residents reported that meals were sometimes served cold, and they either asked staff to reheat the food or consumed it cold. An observation of the meal tray service revealed that the food cart arrived at the hall, and trays were served promptly. However, a test tray checked for food temperature showed that the shrimp was 100 degrees Fahrenheit and the french fries were 118 degrees Fahrenheit, both below the required serving temperatures. The Director of Nutritional and Food Services confirmed these temperatures and acknowledged they were below the required levels. The facility's policy on food production emphasized preparing food to conserve nutritive value and enhance flavor, which was not adhered to in this instance.
Facility Fails to Serve Palatable Spaghetti
Penalty
Summary
The facility failed to serve reasonably palatable food, specifically affecting residents who received spaghetti with their lunch meal. Observations and interviews conducted on November 4th and 5th, 2024, revealed that several residents expressed concerns about the palatability of the food. During a test tray evaluation, the spaghetti was found to taste sour and had a gummy texture. The Corporate Dietary Manager confirmed the spaghetti tasted acidic. Multiple residents reported that the spaghetti was not good, describing it as mushy and tasting like it came from a can. The facility's policy on Palatability and Nutritive Value, dated June 27, 2023, states that food should be prepared, held, and served in a manner that preserves its nutritive value and palatability, with food service staff monitoring palatability at the point of service through periodic test tray evaluations and resident council reviews.
Environmental Deficiencies in Memory Care Unit
Penalty
Summary
The facility failed to maintain the memory care unit in good condition, affecting six out of seven residents reviewed for environmental concerns. Observations revealed various deficiencies, including a spider web in a resident's window, dust buildup on bathroom fans, large scrapes on walls, unfinished patches on a bathroom door, and unsanitary conditions in a bathroom. These issues were verified by the Director of Housekeeping and the Director of Maintenance, who acknowledged the lack of maintenance and cleaning in these areas. Additionally, the dining room floors in the memory care unit were found to be sticky and not clean, as confirmed by administrative staff. The facility's housekeeping policy, dated April 2018, stated that resident rooms and common areas should be cleaned and maintained, yet these observations indicate a failure to adhere to this policy. The facility census was 54, and the deficiencies had the potential to affect all residents residing in the memory care unit.
Failure to Ensure Resident Access to Call Lights
Penalty
Summary
The facility failed to ensure that residents had access to their call lights, affecting three residents. Resident #40, who was cognitively intact and required assistance with functional abilities, was observed unable to locate her call light, which was out of reach. This was confirmed by both the resident and administrative staff. Similarly, Resident #42, who was moderately cognitively impaired and required partial to moderate assistance, could not locate his call light, which was also out of reach. This was verified by administrative staff. Resident #21, who had severe cognitive impairment and was dependent for toileting, was observed with a call light positioned out of reach between the bed rail and mattress. The care plan for Resident #21 included ensuring the call light was within reach, but this was not adhered to. The facility's policy on answering call lights emphasized the importance of keeping call lights within easy reach, which was not followed in these instances.
Inadequate Oral Hygiene for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure adequate hygiene and personal care for a resident with severe cognitive impairment, affecting their oral hygiene. The resident, diagnosed with vascular dementia, hypertension, and peripheral vascular disease, required setup assistance for personal hygiene and oral care. Observations on consecutive days revealed a white residue buildup on the resident's bottom teeth, indicating a lack of proper oral care. Interviews with State Tested Nursing Assistants (STNAs) confirmed the presence of the residue and acknowledged that the resident's teeth should be cleaned twice daily. One STNA mentioned that the resident sometimes refused care, necessitating multiple attempts to provide assistance, but there was no documentation of such refusals in the resident's progress notes. The facility's policy required staff to assist residents with oral care, including brushing teeth or cleaning dentures as needed.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure the availability of medications for two residents, leading to deficiencies in pharmaceutical services. For Resident #22, who has a history of delusional disorders, hypertension, and other conditions, the facility did not have the PRN Excedrin available, which was crucial for managing her severe migraine headaches. Despite receiving a shipment of 30 Excedrin tablets on 10/15/24, only 12 doses were administered, and the remaining 18 tablets were unaccounted for. The resident reported the absence of her medication to multiple staff members, but the issue remained unresolved, as confirmed by the Assistant Director of Nursing and the Director of Nursing. Resident #56, with diagnoses including Parkinsonism and bipolar disorder, did not receive her prescribed Risperdal Consta injections since her admission. Although the medication was received on 10/01/24, it was not administered as per the physician's orders. The facility failed to notify the physician about the non-administration of the medication, and there was no clarification sought regarding the continuation of the medication, which the resident had been on long-term. The Director of Nursing confirmed the oversight and the lack of documentation regarding the physician's notification. The facility's policy on the administration and documentation of medications, revised in 10/2022, mandates that medications be ordered timely and that a 3-day supply be maintained to prevent delivery issues. However, the facility did not adhere to this policy, resulting in the unavailability of essential medications for the residents. This deficiency highlights a significant lapse in the facility's medication management and procurement processes.
Failure to Provide Necessary Dental Care
Penalty
Summary
The facility failed to assist residents in obtaining necessary dental care, specifically affecting one resident who required dental extractions before undergoing hip surgery. The resident, who was cognitively intact with a BIMS score of 14, had been admitted with multiple diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, and major depressive disorder. Despite the care plan indicating that the facility would coordinate dental care and transportation, the resident had not been evaluated by a dentist since admission. Interviews and record reviews revealed that no oral surgeons or dentists had been contacted for the resident, even though the facility's dentist had visited five times since the resident's admission. The facility's policy required a review of medical records upon admission to schedule necessary follow-up appointments, but this was not adhered to in the case of the resident, leading to a delay in necessary dental care and subsequent hip surgery.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, which is a violation of their policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. The resident, who was severely cognitively impaired and dependent for all activities of daily living, was found to have bruising on the left side of the neck. Despite the presence of this unexplained injury, the facility did not submit a self-reported incident to the Ohio Department of Health within the required timeframe. The medical record review and staff interviews revealed that the bruising was initially thought to be a pustule that drained white material. However, upon further assessment by a physician and a wound physician, it was determined that there was no open area or pustule present, and the area appeared to be bruising. The facility's policy requires that all incidents of unknown source be reported immediately to the administrator and the Ohio Department of Health, but this protocol was not followed in the case of this resident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, which was identified during a review of medical records, observations, staff interviews, and policy review. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found to have bruising on the left side of the neck. Despite the presence of this injury, no self-reported incidents were submitted by the facility for the injury of unknown origin. The facility's policy requires investigation of all alleged violations, including injuries of unknown source, but this was not adhered to in this case. Interviews with staff, including an LPN and a physician, revealed that the bruising was initially thought to be related to a pustule that had drained white material. However, upon further assessment by a wound physician, it was confirmed that there was no open area or pustule present, and the area appeared to be bruising. The wound physician also noted that bruising would be distinct from an infected area, which would have a red appearance. The failure to investigate the injury as per the facility's policy represents non-compliance, as documented under the complaint number provided.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to ensure the required Registered Nurse (RN) coverage, as mandated by regulations, which had the potential to affect all 48 residents. A review of staff schedules and Benefits Improvement and Protection Act (BIPA) documentation revealed that there was no RN working in the facility on specific dates: 05/05/24, 05/18/24, 05/19/24, and 05/25/24. This was confirmed during an interview with the Director of Nursing (DON) on 06/26/24, who verified the absence of RN coverage on these dates and reported that there is typically no RN coverage every other weekend. This deficiency was investigated under Master Complaint Number OH00154702 and Complaint Number OH00154290.
Failure to Serve Palatable Meals
Penalty
Summary
The facility failed to serve palatable meals to its residents, affecting 33 individuals who received the dinner vegetable and one resident who received the chicken breast. The dinner menu included two beef tacos in a soft shell, cilantro lime rice, Mexican corn, and a seedless watermelon wedge. Observations revealed that the Mexican corn was not cooked well and felt tough while chewing. This was confirmed by the Corporate Dietary Manager, who acknowledged that the corn did not meet palatability standards. Additionally, a resident expressed dissatisfaction with a tough chicken breast that was served, which was so difficult to eat that she resorted to eating chocolate instead. The Dietary Manager verified that the chicken breast was indeed very tough. Other residents also reported that the meals were not edible, with one resident frequently opting for a peanut butter and jelly sandwich instead. Another resident mentioned that the vegetables and pasta were often over or undercooked, and yet another resident expressed their dissatisfaction with the food by making a gagging motion. The facility's policy on palatability and nutritive value, reviewed in June 2023, states that food should be prepared, held, and served in a manner that preserves nutritive value and palatability, which was not adhered to in this instance.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide adequate showering assistance to three residents who were dependent on staff for their activities of daily living. Resident #33, who was moderately cognitively impaired and required substantial assistance, only received one documented shower in the last thirty days, despite no records of refusal. Similarly, Resident #58, who was cognitively intact and required moderate assistance, only had one shower documented in the same period, with the resident expressing a desire for more frequent showers and noting staff's lack of time as a barrier. Resident #22, who was rarely understood and fully dependent on staff for bathing, also had only one documented shower, with staff believing more showers occurred than were recorded. Interviews with the residents and staff, including a Corporate Registered Nurse and the Director of Nursing, confirmed the lack of adherence to scheduled showers. The facility's policy on Activities of Daily Living, revised in January 2022, mandates that resident bathing and other ADLs be incorporated into daily activities as much as possible. This deficiency was investigated under Complaint Number OH00154290, highlighting a significant lapse in the facility's compliance with its own policies and the needs of its residents.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, affecting three residents who were reviewed for staffing and activities of daily living. Resident #22, who has multiple diagnoses including vascular dementia and major depressive disorder, was found to have only received one shower in the last thirty days, with no documentation of refusal. Similarly, Resident #33, who requires substantial assistance due to cognitive impairment, also received only one shower in the same period, despite the care plan indicating the need for more frequent bathing. Resident #58, who is cognitively intact and prefers showers on the night shift, was also found to have not received adequate showers, with only one documented shower in the last thirty days. Interviews with residents and staff revealed a consistent theme of inadequate staffing, with reports of call-offs and difficulty in finding replacements. Residents expressed concerns about the lack of showers and the overworked staff, while staff members, including STNAs, LPNs, and RNs, confirmed that staffing shortages often led to delays in resident care, including bathing. The facility's staffing schedules for June 2023 showed frequent call-offs without replacements, contributing to the deficiency in meeting residents' needs for personal hygiene.
Failure to Provide Meal Substitutions
Penalty
Summary
The facility failed to provide meal substitutions that accommodated resident preferences, affecting one resident who was reviewed for preferences. During an observation, a State tested Nursing Assistant (STNA) called the kitchen on behalf of a resident who requested a burger instead of the dinner meal. The kitchen staff informed the STNA that there were no burgers available and offered a peanut butter sandwich as an alternative. The resident, who did not like tacos, expressed dissatisfaction with the peanut butter sandwich option and chose to skip dinner, leaving the meal tray untouched. Further interviews revealed that meal substitutions were not consistently available, as another resident also reported similar issues. The facility's Always Available Menu listed several substitutions, including a cheeseburger on a bun, deli sandwich, roasted chicken breast, side salad, chef salad, peanut butter and jelly sandwich, and grilled cheese sandwich. However, the facility was out of hamburger meat, and no hamburgers were made, as confirmed by the Dietary Manager. The facility's policy stated that nutritionally comparable menu items should be available to accommodate resident food preferences, but this was not adhered to in this instance.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 187 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clyde
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows At Bellevue | 4.6 mi | ★★★★★ | 0 | 0 |
| Spring Creek Nursing And Rehabilitation Center Llc | 5 mi | ★★★★★ | 10 | 0 |
| Countryside Manor Nursing And Rehabilitation Llc | 7.4 mi | ★★★★★ | 14 | 1 |
| Valley View Health Campus | 7.8 mi | ★★★★★ | 3 | 0 |
| Bellevue Care Center | 8.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.