Health inspection·May 14, 2024

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review the facility failed to ensure residents/resident representative participated in care planning. This affected two (#26 and #37) of three residents reviewed for care planning process. Findings include: 1. Review of Resident #26's medical records revealed an admission date of 02/02/23. Diagnoses included difficulty walking, amputation and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had impaired cognition and required moderate assistance with toileting, bathing and personal hygiene. Review of a care conference assessment for Resident #26 revealed a care conference was held on 10/12/23. There were no other care conference assessments or any other evidence of care conferences having been completed in the medical record. Review of the care plan dated 03/19/24 revealed Resident #26 required two staff assist with toileting and to encourage the resident to participate as much as able with activities of daily living care. Resident #26 received an anticoagulant and interventions included to monitor for signs of bleeding and lab work. Interview on 05/02/24 at 7:17 A.M. with Resident #26's daughter revealed she had not been invited to any care conferences. Resident #26's daughter was concerned about her mother being on an anticoagulant and having had a bloody emesis. Telephone interview on 05/06/24 at 12:58 P.M. with Social Worker (SW) #268 revealed she no longer worked at the facility as of 04/30/24. SW #268 stated she completed care conferences at least every three months or if a resident had a significant change in condition. SW #268 stated she sent letters to the families one to two weeks prior to the care conferences and if a family did not respond she called to ask if they wanted to participate. SW #268 stated care conferences were documented in the electronic medical records once completed. SW #268 was unable to recall when the last care conference was held for Resident #26 but if a care conference was held there would be documentation in the resident's electronic medical record (PCC). Interview on 05/09/24 at 10:05 A.M. with the Administrator revealed she was not aware of resident/resident representatives having concerns regarding participation in care conferences. Review of Page 1 of 21 366085 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0553 Level of Harm - Minimal harm or potential for actual harm Resident #26's medical records with the Administrator, at time of interview, confirmed there were no documented care conferences after 10/12/23. The Administrator stated a regional social worker was filling in until they were able to fill the vacant social worker position. The Administrator was not able to provide information regarding the procedures for ensuring residents and families participated in the care planning process. Residents Affected - Few 2. Review of Resident #37's medical record revealed an admission date of 11/15/21. Diagnoses included Alzheimer's disease, dementia and altered mental status. Review of MDS assessment dated [DATE] revealed Resident #37 had impaired cognition and required moderate assistance with toileting, bathing and personal hygiene. Review of the progress note dated 02/29/24 authored by Social Worker (SW) #268 revealed a care conference was held, however no family were present. Telephone interview on 05/06/24 at 12:58 P.M. with SW #268 revealed she no longer worked at the facility as of 04/30/24. SW #268 stated she completed care conferences at least every three months or if a resident had a significant change in condition. SW #268 stated she sent letters to the families one to two weeks prior to the care conferences and if a family did not respond she called to ask if they wanted to participate. SW #268 stated care conferences were documented in the electronic medical records once completed. SW #268 could not recall specific information regarding Resident #37's family not attending the 02/29/24 care conference. Telephone interview on 05/07/24 at 10:38 A.M. with Resident #37's daughter revealed a care conference scheduled in February 2024 was canceled and had not been rescheduled. Resident #37's daughter stated the care conference was canceled after she had inquired about placing a camera in Resident #37's room. Interview on 05/09/24 at 10:05 A.M. with the Administrator revealed she did not know why Resident #37's family was not present for the care conference held on 02/29/24. The Administrator stated the social worker suddenly left her employment at the facility. The Administrator was unable to provide information regarding care conferences. This deficiency represents non-compliance investigated under Complaint Number OH00152859 and OH00153683. 366085 Page 2 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview and record review the facility failed to ensure resident grievances were addressed regarding call light response times. This had the potential to affect all residents residing in the facility. The facility census was 58. Findings include: Based on observation, interview and record review the facility failed to ensure resident grievances were addressed regarding call light response times. This had the potential to affect all residents residing in the facility. The facility census was 58. Findings include: Review of resident council minutes for February 2024 revealed resident complaints regarding long call light response times and aides at the nurse's station while call lights not being answered. Review of Resident Council Minutes for March 2024 revealed call light response was still too long and aides were still on their phones from time to time. Interview on 05/01/24 at 9:39 A.M. with Resident #39 revealed call light response time was usually 30 to 45 minutes. Resident #39 indicated he had reported this concern to the Administrator and had not received feedback regarding a resolution and call light response continued to be a problem. Observations on 05/01/24 at 1:13 P.M. revealed call lights were on outside of the rooms of Resident #5 and Resident #2. Resident #5's call light was answered at 1:31 P.M. and Resident #2's call light was answered at 1:32 P.M. Interview on 05/06/24 at 10:26 A.M. with Resident #52 revealed call light response time had been over an hour on occasions. Resident #52 indicated this concern was discussed in Resident Council but remained a problem. Interview on 05/06/24 at 3:24 P.M. with State Tested Nurse Aide #215 revealed there had been occasions when a resident required the assistance of two staff members and when that occurred call lights were not answered timely. Interview on 05/07/24 at 12:23 P.M. with the Administrator revealed she kept a concern log and addressed concerns as brought to her attention. Observation on 05/09/24 at 9:48 A.M. revealed call lights on outside of Resident #36, #43, and #46's rooms. Further observation revealed Licensed Practical Nurse (LPN) #208 and LPN #212 were seated at the nurses' station. The call lights for Residents #36 and #46 were answered at 10:02 A.M. This deficiency represents non-compliance investigated under Complaint Number OH00153514. 366085 Page 3 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of a self reported incident, and review of facility policy, the facility failed to ensure verbal abuse did not occur. This affected one (#5) of three residents reviewed for abuse. Facility census was 58. Findings include: Review of Resident #5's medical records revealed an admission date of 04/06/24. Diagnoses included morbid obesity and muscle weakness. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and required moderate assistance with toileting, bathing, personal hygiene and bed mobility. Review of the progress note dated 04/28/24 revealed Resident #5 called Licensed Practical Nurse (LPN) #229 into her room to report an aide calling her an inappropriate name. Resident #5 stated she had used her call light to request ice and when the aide came into her room Resident #5 also asked for a soda. Resident #5 stated the aide rolled her eyes and sighed. Resident #5 stated she was not trying to cause any problems and stated she did not need the soda. Resident #5 stated the aide then slammed down the cup on the bedside table and said, You can have somebody else get your ice you fat (expletive). The aide then left the building. Telephone interview on 05/02/24 at 12:59 P.M. with State Tested Nursing Assistant (STNA) #266 revealed approximately one to two weeks ago she had been frustrated due to the lack of staff. Resident #5 rang her call light and requested a cup of ice and a soda from the vending machine. STNA #266 snapped and told Resident #5 go get it yourself fatty. STNA #266 stated she quit shortly after the incident. Review of the facility investigation related to Self Reported Incident (SRI) #246867 revealed a written statement dated 04/28/24 from Resident #5 indicating Resident #5 had requested ice and a soda from the vending machine. STNA #266 rolled her eyes and said I guess. Resident #5 said to STNA #266, Don't worry about it, I'm not trying to stress anyone out, I'll just take the ice. The statement further indicated STNA #266 slammed the cup of ice down and said you can get someone else to get your (expletive) ice and she turned around and walked away. As STNA #266 was exiting Resident #5's room STNA #266 called Resident #5 a fat (expletive) bitch and slammed the door. Review of written statement authored by LPN #202 revealed she observed STNA #266 say to STNA #222 are you getting a Pepsi for the fatty? Further review of SRI #246867 revealed there was not a statement from STNA #266 and the facility unsubstantiated the allegation. Interview on 05/08/24 at 1:05 P.M. with the Administrator revealed she had not interviewed STNA #266 because in the past STNA #266 had not answered her calls. The Administrator further stated the allegation of verbal abuse was unsubstantiated because LPN #202 had not indicated the comment she heard STNA #266 make to STNA #222 referenced Resident #5. 366085 Page 4 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised 10/27/17 revealed abuse was defined as a willful infliction of mental anguish, that included verbal abuse. The definition of willful indicated the individual must have acted deliberately, not that the individual intended to inflict injury or harm. The policy also indicated Prevention and identification included the deployment of staff on each shift in sufficient numbers to meet the needs of the residents . and The supervision of staff to identify inappropriate behaviors sufficient numbers to meet the needs of the residents . This deficiency represents non-compliance investigated under Complaint Number OH00152859 and OH00153683. 366085 Page 5 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to report an injury of unknown origin to the State Agency as required. This affected one (Resident #37) of three residents reviewed for abuse. Findings include: Review of Resident #37's medical records revealed an admission date of 11/15/21. Diagnoses included Alzheimer's disease, dementia and altered mental status. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #37 had impaired cognition, and required moderate assistance with toileting, bathing and personal hygiene. Review of the care plan dated 05/02/23 revealed Resident #37 was at risk for skin breakdown. Interventions included observing skin for redness and open areas and notify the nurse. Review of the shower sheet dated 04/25/24 revealed bruising to the upper arms. There was no description of the bruising. Telephone interview on 05/07/24 at 10:38 A.M. with Resident #37's daughter revealed she had concerns related to bruising on Resident #37's arms. Resident #37's daughter thought the bruises appeared as though someone had grabbed her by the arms. Resident #37's daughter had not been informed of the bruises and when she observed them on 04/24/24 they appeared to be yellow and healing. Observation on 05/07/24 at 11:23 A.M. of Resident #37 revealed scattered yellow bruises on Resident #37's right upper arm and darker scattered bruises on Resident #37's left upper arm. Resident #37 was not interviewable and was unable to say how the bruises occurred. Observation of Resident #37 on 05/07/24 at 11:26 A.M. with State Tested Nursing Assistant (STNA) #241 confirmed the scattered bruises; however, STNA #241 stated she was unsure how the bruises occurred. Interview on 05/07/24 at 11:34 A.M. with STNA #221 revealed she had observed the bruising on Resident #37's arms approximately two weeks ago and the bruises were dark purple. STNA #221 stated she had reported it to Licensed Practical Nurse (LPN) #229. STNA #221 said she had asked Resident #37 how the bruises occurred and she was unable to state what had happened. Telephone interview on 05/08/24 at 7:39 A.M. with LPN #229 revealed she informed the Administrator of Resident #37's bruises on 05/06/24. LPN #229 stated the Administrator stated she would have the Director of Nursing (DON) look at Resident #37 the following morning. Interview on 05/08/24 at 1:05 P.M. with Administrator revealed she had not been made aware of Resident #37's bruises until 05/06/24 by LPN #229. The Administrator stated she had informed the DON that evening and the DON would observe the bruises the next morning. The Administrator denied she had been informed of Resident #37's bruises prior to 05/06/24. Interview on 05/08/24 at 1:35 P.M. with the DON revealed she had been made aware of the bruises to 366085 Page 6 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #37's arm on the evening of 05/06/24 and stated she had observed Resident #37 on the morning of 05/07/24. The DON stated Resident #37's bruises appeared to be faded yellow and were healing. The DON stated Resident #37 had a fall on 04/24/24 and the bruises were likely from the fall. The DON was shown pictures sent from Resident #37's daughter that were dated 04/24/24 timed 1:20 P.M. which showed faint yellow bruises to the resident's right arm. The DON was made aware the picture was taken several hours prior to Resident #37's fall. The DON confirmed there was no documentation of the bruises prior to 04/24/24 and no documented bruising after 04/24/24 until the shower sheet dated 04/25/24, which did not include any specific description. Follow-up telephone interview on 05/08/24 at 1:55 P.M. with Resident #37's daughter revealed went to the facility on the afternoon of 04/24/24 and had discussed her concerns regarding the bruises on Resident #37's arm with the Administrator. Resident #37's daughter stated she had shown the pictures from 04/24/24 to the Administrator at that time and stated the Administrator told her she would look into the situation. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, revised 10/27/17 revealed identifying events such as suspicious bruising to identify direction of investigation. In the event of suspicions of abuse, reporting to the state agency immediately but no later than two hours after an allegation is made. This deficiency represents non-compliance investigated under Complaint Number OH00152859 and OH00153683. 366085 Page 7 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of a self reported incident, and review of the facility abuse policy and procedure, the facility failed to thoroughly investigate an allegation of verbal abuse and an injury of unknown origin. This affected two (#5, #37) of three residents reviewed for abuse. Facility census was 58. Residents Affected - Few Findings include: 1. Review of Resident #5's medical records revealed an admission date of 04/06/24. Diagnoses included morbid obesity and muscle weakness. Review of Resident #5's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had intact cognition and required moderate assistance with toileting, bathing, personal hygiene and bed mobility. Review of the progress note dated 04/28/24 revealed Resident #5 called Licensed Practical Nurse (LPN) #229 into her room to report an aide calling her an inappropriate name. Resident #5 stated she had used her call light to request ice and when the aide came into her room Resident #5 also asked for a soda. Resident #5 stated the aide rolled her eyes and sighed. Resident #5 stated she was not trying to cause any problems and stated she did not need the soda. Resident #5 stated the aide then slammed down the cup on the bedside table and said You can have somebody else get your ice you fat (expletive). The aide then left the building. Telephone interview on 05/02/24 at 12:59 P.M. with State Tested Nursing Assistant (STNA) #266 revealed approximately one to two weeks ago she had been frustrated due to the lack of staff. Resident #5 rang her call light and requested a cup of ice and a soda from the vending machine; STNA #266 stated she snapped and told Resident #5 go get it yourself fatty. STNA #266 stated she quit shortly after the incident. Review of the facility investigation related to Self Reported Incident (SRI) #246867 revealed a written statement dated 04/28/24 from Resident #5 indicating Resident #5 had requested ice and a soda from the vending machine. STNA #266 rolled her eyes and said I guess. Resident #5 said to STNA #266, Don't worry about it, I'm not trying to stress anyone out, I'll just take the ice. The statement further indicated STNA #266 slammed the cup of ice down and said you can get someone else to get your (expletive) ice and she turned around and walked away. As STNA #266 was exiting Resident #5's room STNA #266 called Resident #5 a fat (expletive) bitch and slammed the door. Review of written statement authored by LPN #202 revealed she observed STNA #266 say to STNA #222 are you getting a Pepsi for the fatty? Further review of SRI #246867 revealed there was not a statement from STNA #266 and the facility unsubstantiated the allegation. Interview on 05/08/24 at 1:05 P.M. with the Administrator revealed she had not interviewed STNA #266 because in the past STNA #266 had not answered her calls. The Administrator further stated the allegation of verbal abuse was unsubstantiated because LPN #202 had not indicated the comment she heard STNA #266 make to STNA #222 referenced Resident #5. 366085 Page 8 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property revised 10/27/17 revealed the investigation was to include statements from direct witnesses and review of the employment records of the accused. 2. Review of Resident #37's medical records revealed an admission date of 11/15/21. Diagnoses included Alzheimer's disease, dementia and altered mental status. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #37 had impaired cognition, and required moderate assistance with toileting, bathing and personal hygiene. Review of the care plan dated 05/02/23 revealed Resident #37 was at risk for skin breakdown. Interventions included observing skin for redness and open areas and notify the nurse. Review of the shower sheet dated 04/25/24 revealed bruising to the upper arms. There was no description of the bruising. Telephone interview on 05/07/24 at 10:38 A.M. with Resident #37's daughter revealed she had concerns related to bruising on Resident #37's arms. Resident #37's daughter thought the bruises appeared as though someone had grabbed her by the arms. Resident #37's daughter had not been informed of the bruises and when she observed them on 04/24/24 they appeared to be yellow and healing. Observation on 05/07/24 at 11:23 A.M. of Resident #37 revealed scattered yellow bruises on Resident #37's right upper arm and darker scattered bruises on Resident #37's left upper arm. Resident #37 was not interviewable and was unable to say how the bruises occurred. Observation of Resident #37 on 05/07/24 at 11:26 A.M. with State Tested Nursing Assistant (STNA) #241 confirmed the scattered bruises; however, STNA #241 stated she was unsure how the bruises occurred. Interview on 05/07/24 at 11:34 A.M. with STNA #221 revealed she had observed the bruising on Resident #37's arm approximately two weeks prior and had reported it to Licensed Practical Nurse (LPN) #229. STNA #221 stated Resident #37 was unable to state how the bruises had occurred. Telephone interview on 05/08/24 at 7:39 A.M. with LPN #229 revealed she informed the Administrator of Resident #37's bruises on 05/06/24. LPN #229 stated the Administrator stated she would have the Director of Nursing (DON) look at Resident #37 the following morning. Interview on 05/08/24 at 1:05 P.M. with Administrator revealed she had not been made aware of Resident #37's bruises until 05/06/24 by LPN #229. The Administrator stated she had informed the DON that evening and the DON would observe the bruises the next morning. The Administrator denied she had been informed of Resident #37's bruises prior to 05/06/24. Interview on 05/08/24 at 1:35 P.M. with the DON revealed she had been made aware of the bruises to Resident #37's arm on the evening of 05/06/24 and stated she had observed Resident #37 on the morning of 05/07/24. The DON stated Resident #37's bruises appeared to be faded yellow and were healing. The DON stated Resident #37 had a fall on 04/24/24 and the bruises were likely from the fall. The DON was shown pictures sent from Resident #37's daughter that were dated 04/24/24 timed 1:20 P.M. which showed faint yellow bruises to the resident's right arm. The DON was made aware the picture was taken several hours prior to Resident #37's fall. The DON confirmed there was no documentation of the 366085 Page 9 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few bruises prior to 04/24/24 and no documented bruising after 04/24/24 until the shower sheet dated 04/25/24, which did not include any specific description. Follow-up telephone interview on 05/08/24 at 1:55 P.M. with Resident #37's daughter revealed went to the facility on the afternoon of 04/24/24 and had discussed her concerns regarding the bruises on Resident #37's arm with the Administrator. Resident #37's daughter stated she had shown the pictures from 04/24/24 to the Administrator at that time and stated the Administrator told her she would look into the situation. This deficiency represents non-compliance investigated under Complaint Number OH00152859 and OH00153683. 366085 Page 10 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure care plan were implemented as written. This affected two (#29 and #37) of four residents reviewed for skin impairment. The facility census was 58. Findings include: 1. Review of Resident #29's medical records revealed an admission date of 01/12/24. Diagnoses included dementia, altered mental status and difficulty walking. Review of Resident #29's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was rarely understood, was dependent with toileting, bathing and personal hygiene, and incontinent of bowel and bladder. Review of the care plan dated 01/18/24 revealed Resident #29 was at risk for skin breakdown. Interventions included observing skin for redness and open areas and notify the nurse. Telephone interview on 05/08/24 at 10:04 A.M. with Resident #29's daughter revealed she had visited Resident #29 on 05/05/24 and had observed blood on the resident's pillowcase. Resident #29's daughter noted Resident #29 had a bandage to his right hand and asked the nurse what happened and the nurse was unable to state how the injury occurred. Observation on 05/08/24 at 10:35 A.M. of Resident #29 with State Tested Nurse Aide (STNA) #218 and STNA #237 revealed Resident #29 had a soiled bandage to his right hand. STNA #218 and STNA #237 stated they were unaware of what occurred to the resident's hand. Observation on 05/08/24 at 11:51 A.M. of Resident #29 with Licensed Practical Nurse (LPN) #209 confirmed a soiled bandage to Resident #29's right hand. LPN #209 removed the bandage revealing an open area to the inner portion of the thumb. The area was approximately 1 centimeter (cm) in length and 1-2 cm in width and was reddened around the perimeter, with what appeared to be an open blistered area. LPN #209 was unaware of the origin of the injury. Interview on 05/09/24 at 12:34 P.M. with LPN #252 revealed he worked on 05/05/24 and Resident #29's daughter approached him at the end of his shift and had asked him about the bandage to the resident's hand. LPN #252 stated he had not been made aware of any injuries to Resident #29's hand and stated he was unable to locate anything documented in the medical records. LPN #252 stated he had passed the information along to the oncoming night shift nurse. Review of Resident #29's medical records revealed no documented skin impairment on 05/05/24. 2. Review of Resident #37's medical records revealed an admission date of 11/15/21. Diagnoses included Alzheimer's disease, dementia and altered mental status. Review of the MDS assessment dated [DATE] revealed Resident #37 had impaired cognition, and required moderate assistance with toileting, bathing and personal hygiene. Review of the care plan dated 05/02/23 revealed Resident #37 was at risk for skin breakdown. 366085 Page 11 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0656 Interventions included observing skin for redness and open areas and notify the nurse. Level of Harm - Minimal harm or potential for actual harm Review of shower sheet dated 04/21/24 revealed no skin impairment noted. Residents Affected - Few Review of the shower sheet dated 04/25/24 revealed bruising to the upper arms. There was no description of the bruising. Telephone interview on 05/07/24 at 10:38 A.M. with Resident #37's daughter revealed she had concerns related to bruising on Resident #37's arms. Resident #37's daughter thought the bruises appeared as though someone had grabbed her by the arms. Resident #37's daughter had not been informed of the bruises and when she observed them on 04/24/24 they appeared to be yellow and healing. Review of photographs provided by Resident #37's daughter dated 04/24/24 timed 1:20 P.M. revealed scattered yellow bruises to Resident #37's right arm that appeared to be healing. The photographs did not appear to be consistent with injuries caused by someone grabbing Resident #37's arm. Observation on 05/07/24 at 11:23 A.M. of Resident #37 revealed scattered yellow bruises on Resident #37's right upper arm and darker scattered bruises on Resident #37's left upper arm. Resident #37 was not interviewable and was unable to say how the bruises occurred. Observation of Resident #37 on 05/07/24 at 11:26 A.M. with State Tested Nursing Assistant (STNA) #241 confirmed the scattered bruises; however, STNA #241 stated she was unsure how the bruises occurred. Interview on 05/07/24 at 11:34 A.M. with STNA #221 revealed she had observed the bruising on Resident #37's arm approximately two weeks prior and had reported it to Licensed Practical Nurse (LPN) #229. STNA #221 stated Resident #37 was unable to state how the bruises had occurred. Telephone interview on 05/08/24 at 7:39 A.M. with LPN #229 revealed she informed the Administrator of Resident #37's bruises on 05/06/24. LPN #229 stated the Administrator stated she would have the Director of Nursing (DON) look at Resident #37 the following morning. Interview on 05/08/24 at 1:05 P.M. with Administrator revealed she had not been made aware of Resident #37's bruises until 05/06/24 by LPN #229. The Administrator stated she had informed the DON that evening and the DON would observe the bruises the next morning. The Administrator denied she had been informed of Resident #37's bruises prior to 05/06/24. Interview on 05/08/24 at 1:35 P.M. with the DON revealed she had been made aware of the bruises to Resident #37's arm on the evening of 05/06/24 and stated she had observed Resident #37 on the morning of 05/07/24. The DON stated Resident #37's bruises appeared to be faded yellow and were healing. The DON stated Resident #37 had a fall on 04/24/24 and the bruises were likely from the fall. The DON was shown pictures sent from Resident #37's daughter that were dated 04/24/24 timed 1:20 P.M. which showed faint yellow bruises to the resident's right arm. The DON was made aware the picture was taken several hours prior to Resident #37's fall. The DON confirmed there was no documentation of the bruises prior to 04/24/24 and no documented bruising after 04/24/24 until the shower sheet date 04/25/24, which did not include any specific description. Follow-up telephone interview on 05/08/24 at 1:55 P.M. with Resident #37's daughter revealed went to the facility on the afternoon of 04/24/24 and had discussed her concerns regarding the bruises on 366085 Page 12 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #37's arm with the Administrator. Resident #37's daughter stated she had shown the pictures from 04/24/24 to the Administrator at that time and stated the Administrator told her she would look into the situation. This deficiency represents non-compliance investigated under Complaint Number OH00152859 and OH00153683. 366085 Page 13 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide adequate intervention and update Resident #61's care plan related to the resident's known use of a bed remote control to prevent a fall with injury. This affected one resident (#61) of four reviewed for person centered care planning. The facility census was 58. Actual harm occurred on 04/20/24 at approximately 2:30 A.M. when Resident #61, who had impaired cognition and a history of using the bed remote control to place her bed in the highest position without having the cognitive ability to lower the bed, was found on the floor yelling out in pain with both of her legs bent behind her with bones protruding from the skin. Resident #61's bed was noted in the high position when she was found on the floor. The resident was transferred to the hospital and subsequently passed away. Review of the Coroner's Report dated 04/22/24 revealed the cause of death as hypovolemic shock (sudden loss of blood or fluid), bilateral femur fractures and fall from bed. Findings include: Review of Resident #61's closed medical record revealed an admission date of 05/22/22. The resident passed away on 04/22/24. Resident #61's diagnoses included muscle weakness, falls and obesity. Review of Resident #61's care plan dated 01/23/23 revealed Resident #61 had self-care deficits with interventions including two staff assist with bed mobility. The care plan also reflected Resident #61 was at risk for falls with an intervention to keep bed in lowest position. Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 had impaired cognition and required moderate assistance with toileting, bathing, personal hygiene, and bed mobility. Review of progress note dated 04/20/24 authored by Licensed Practical Nurse (LPN) #202 revealed Resident #61's bed was observed to have been in a high position. Review of progress note dated 04/20/24 authored by Licensed Practical Nurse (LPN) #202 revealed an aide stated she needed assistance because Resident #61 was on the floor and was in need of an ambulance. Upon LPN #202 entering Resident #61's room, Resident #61 was observed with her head toward the foot of the bed and her legs were bent back in an unnatural position. Resident #61's bed was in the high position. Review of progress note dated 04/22/24 authored by the Director of Nursing (DON) revealed on 04/20/24 at approximately 2:36 A.M. Resident #61 was observed on the floor with her head toward the foot of the bed and both legs were bent back in an unnatural position. Resident #61's bed was noted to be in the highest position. The note further indicated Resident #61 manipulated the bed remote herself. The progress note indicated prior to the fall Resident #61's bed was in the lowest position. Review of the facility's updated fall investigation revealed Resident #61's bed was in the high position. Resident #61 was last seen at approximately 2:10 A.M. and the bed was in the lowest position at that time. 366085 Page 14 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0689 Level of Harm - Actual harm Residents Affected - Few Review of the revised care plan dated 04/22/24 revealed Resident #61 had an actual fall with major injury with interventions including keeping bed in lowest position and do not leave the bed remote within Resident #61's reach. Review of Coroner's report dated 04/22/24 revealed cause of death as hypovolemic shock (sudden loss of blood or fluid), bilateral femur fractures and fall from bed. Interview on 05/01/24 at 12:08 P.M. with Resident #61's daughter revealed she was at the facility to collect Resident #61's belongings because the resident fell at the facility, was sent to the hospital, and subsequently passed away. Resident #61's daughter stated on 04/20/24 Resident #61 fell out of bed and broke both of her femurs. Resident #61's daughter stated Resident #61 was not able to get out of bed on her own and required staff assistance to move in bed. Interview on 05/01/24 at 2:19 P.M. with State Tested Nursing Assistant (STNA) #221 revealed Resident #61 was able to use the bed controls and used them to place her bed in a high position and once in the high position the resident could not lower the bed. Interview on 05/02/24 at 5:35 A.M. with Licensed Practical Nurse (LPN) #202 revealed she was present on the evening of 04/19/24 through 04/20/24 from approximately 6:30 P.M. to 7:00 A.M. LPN #202 stated at approximately 2:36 A.M. on 04/20/24, the STNA told her Resident #61 was on the floor. LPN #202 immediately entered Resident #61's room and observed Resident #61 on the floor with both of her legs bent behind her and her bones were sticking out and she was yelling out in pain. LPN #202 asked Resident #61 what happened, and Resident #61 had told her she needed to go to the bathroom. LPN #202 told Resident #61 she was not able to get up by herself and Resident #61 stated Oh I forgot. LPN #202 did not move Resident #61 and immediately called 911. Telephone interview on 05/02/24 at 12:59 P.M. with STNA #266 revealed she was present on 04/19/24 through 04/20/24 from approximately 10:30 P.M. to 7:00 A.M. STNA #266 stated she was charting at the nurses' station at approximately 2:30 A.M. when she heard Resident #61 yell out I'm gonna fall, and then Resident #61 yelled I'm on the floor. STNA #266 immediately went into Resident #61's room and observed Resident #61 on the floor with her legs completely behind her. STNA #266 stated STNA #269, and LPN #202 also responded. STNA #266 stated Resident #61 was not capable of turning herself in bed, but she could get her legs off the bed which may have caused the fall out of bed. STNA #266 stated Resident #61 was known on previous occasions to move her bed to the high position and not be able to put it back down. Telephone interview on 05/05/24 at 9:50 A.M. with STNA #269 revealed she was the assigned aide for Resident #61 on 04/19/24 through 04/20/24 from 10:30 P.M. to 6:30 A.M. STNA #269 stated she had provided care for Resident #61 approximately five minutes prior to her fall on 04/20/24. STNA #269 had repositioned Resident #61 and placed the bed in the lowest position. STNA #269 stated Resident #61 often moved her bed into a high position and then could not put it back down. Interview on 05/06/24 at 3:14 P.M. with Director of Nursing (DON) confirmed Resident #61's care plan was updated after her fall on 04/20/24 to include keeping the bed remote control out of Resident #61's reach. The DON also confirmed Resident #61 had a history of using the remote control to place the bed in the highest position without the ability to lower the bed. There was no evidence during the investigation, the facility implemented comprehensive and individualized interventions prior to the fall that occurred on 04/20/24 to address this safety/fall risk in order to prevent the fall from occurring. 366085 Page 15 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0689 This deficiency represents non-compliance investigated under Complaint Number OH00153683 and OH00153514. Level of Harm - Actual harm Residents Affected - Few 366085 Page 16 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, interview and record review the facility failed to ensure adequate staffing to meet resident needs. This affected Residents #39, #43, #5, #2, #52, and had the potential to affect all residents residing in the facility. The facility census was 58. Findings include: Interview on 05/01/24 at 9:39 A.M. with Resident #39 revealed it usually took about 30 to 45 minutes for staff to respond to his call light. Interview on 05/01/24 at 10:04 A.M. with Resident #43 revealed it took staff a long time to respond to her call light, especially during the evening hours. Interview on 05/01/24 at 10:19 A.M. with State Tested Nursing Assistant (STNA) #255 revealed there were occasions when there were only two to three aides for entire building and due to lack of staff some residents who required two person assistance out of bed were not gotten up. Interview on 05/01/24 at 10:50 A.M. with STNA #237 revealed from 7:00 A.M. to 8:00 A.M. she was the only STNA present for the 400, 500 and 600 halls which included 24 residents because of a call off. STNA #237 indicated this occurred frequently and it was very difficult to answer call lights, get the residents up, serve breakfast, and provide incontinence care in a timely manner. STNA #237 stated there were times when there was not enough staff to provide timely care, or showers for residents, and there had been occasions when residents were left in bed because a second staff member was not available to assist with transferring the residents out of bed. STNA #237 stated staff discussed the staffing concerns with management, however they had been told that corporate would not allow them to have any additional staff. Observations on 05/01/24 at 1:13 P.M. revealed call lights were on outside of the rooms of Resident #5 and Resident #2. Resident #5's call light was answered at 1:31 P.M. and Resident #2's call light was answered at 1:32 P.M. Interview on 05/02/24 at 6:11 A.M. with Resident #2 revealed sometimes it took over an hour for staff to respond to her call light. Interview on 05/06/24 at 10:26 A.M. with Resident #52 revealed sometimes it took over an hour for staff to respond to her call light. Interview on 05/06/24 at 3:24 P.M. with STNA #215 revealed there were occasions when a resident required the assistance of two staff members and when that occurred call lights were not answered timely. STNA #215 stated management was aware of staffing concerns, however they had been told that corporate would not allow anymore than two aides per unit. Review of resident council minutes for February and March 2024 revealed resident complaints regarding long call light response times. This deficiency represents non-compliance investigated under Complaint Number OH00152859 and OH00153514. 366085 Page 17 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and personnel file review the facility failed to ensure medications were stored in locked compartments, labeled, and only authorized personnel had access. This affected one (#22) of three residents who were randomly observed for medications being left unattended. Facility census was 58. Findings include: Observation on 05/06/24 at 10:20 A.M. revealed Resident #22 was sleeping in bed with a medication cup on his bedside table that contained approximately 8-10 pills. Interview with Registered Nurse (RN) #246 on 05/06/24 at time of observation confirmed the medication at Resident #22's bedside. RN #246 stated he thought Resident #22 was going to take the medications once he woke up. RN #246 stated he should have remained in Resident #22's room while medications were consumed. Review of RN #446's personnel file revealed a written warning dated 05/06/24 indicating RN #246 had left medication at a resident's bedside. 366085 Page 18 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on interview and personnel file review the facility failed to ensure staff concerns related to staff conduct were addressed. This had the potential to affect all residents residing in the facility. The facility census was 58. Residents Affected - Many Findings include: Interview on 05/02/24 at 5:35 A.M. with Licensed Practical Nurse (LPN) #202 revealed she informed the Administrator of concerns related to LPN #275 taking extended and frequent breaks and sleeping while on duty. LPN #202 stated on the evening of 04/20/24, LPN #275 was outside in the facility parking lot for three to four hours during her shift. LPN #202 stated she called the Administrator on 04/20/24 sometime after 2:30 A.M. to inform her Resident #61 had fallen and was being transported to the hospital. LPN #202 also informed the Administrator that LPN #275 was not present in the facility during the time Resident #61 had fallen; she was in the parking lot. LPN #202 stated the Administrator had been informed of LPN #275 not being present during her shifts prior to 04/20/24 and nothing had been done. Telephone interview on 05/02/24 at 9:41 A.M with State Tested Nurse Aide (STNA) #218 revealed she arrived at the facility on 04/20/24 at approximately 2:00 A.M. and she observed LPN #275 in a car in the parking lot with other people with loud music playing. STNA #218 stated LPN #275 had done that before and management was aware and had done nothing about it. STNA #218 further stated she had observed LPN #275 sleeping during her shift on several occasions and the Administrator was notified. Telephone interview on 05/02/24 at 12:59 P.M. with STNA #266 revealed arrived at the facility on 04/20/24 at approximately 10:30 P.M. STNA #266 stated she was told LPN #275 had been outside in a car for several hours. STNA #266 stated LPN #275 had done that several times before and LPN #275 was also observed sleeping during her shift on several occasions. STNA #266 stated the Administrator was aware and nothing had been done. Interview on 05/02/24 at 2:11 P.M. with the Administrator revealed on 04/20/24 around 2:30 A.M. she received a call from LPN #202 indicating Resident #61 had fallen and was being taken to the hospital. LPN #202 also told her LPN #275 was out of the building at the time of Resident #61's fall; however, the Administrator denied LPN #202 had told her it was for several hours. The Administrator also denied staff had informed her LPN #275 had been sleeping during her shifts or that she took extended breaks. The Administrator said LPN #275 was terminated due to insubordination and LPN #275 was disrespectful toward her. Follow up interview and review of LPN #275's personnel file with the Administrator on 05/02/24 at 3:00 P.M. revealed no disciplinary action or a termination letter. The Administrator stated she would check with the corporate office regarding LPN #275's termination notice. Telephone interview on 05/06/24 at 9:50 A.M. with STNA #269 revealed she had informed the Administrator several times regarding LPN #275 leaving the facility for long periods of time and sleeping while on duty. Review of LPN #275's personnel file on 05/08/24 at 1:05 P.M. with the Administrator revealed a termination letter dated 04/20/24 indicating insubordination and poor work performance. Interview with 366085 Page 19 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0835 Level of Harm - Minimal harm or potential for actual harm the Administrator, at time of review, revealed she could not state specific incidents of poor work performance. The Administrator stated just general poor work performance. This deficiency represents non-compliance investigated under Complaint Number OH00153045. Residents Affected - Many 366085 Page 20 of 21 366085 05/14/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate documentation on a Medication Administration Record (MAR). This affected one (#29) of four residents reviewed for documentation. The facility census was 58. Findings include: Review of Resident #29's medical records revealed an admission date of 01/12/24. Diagnoses included dementia, altered mental status and difficulty walking. Review of Resident #29's Minimum Data Set assessment dated [DATE] revealed Resident #29 was rarely understood and was dependent on staff for toileting, bathing and personal hygiene. Review of the MAR on 05/08/24 at 11:25 A.M., for April 2024 revealed Registered Nurse (RN) #246 documented medications as being administered on 04/24/24, 04/27/24 and 04/28/24. Review of MAR for May 2024 revealed RN #246 documented medications as being administered on 05/02/24. Review of the April and May 2024 MARs and interview on 05/08/24 at 1:05 P.M. with the Administrator confirmed RN #246 had signed off the medications for 04/24/24, 04/27/24, 04/28/24 and 05/02/24. Follow up interview on 05/09/24 at 10:05 A.M. with the Administrator revealed she had spoken with RN #246 regarding the documented medications. RN #246 had told the Administrator another nurse had actually administered the medication, however RN #246 stated he had observed the medications being given. The Administrator stated RN #246 should not have signed off medications that he had not administered. 366085 Page 21 of 21