Health inspection·July 16, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the medical record, interview with staff and review of the facility policy the facility failed to ensure Resident #16, who was dependent on staff for activities of daily living (ADL), was shaved, had his fingernails trimmed and was showered per his preference. This affected one resident (Resident #16) of three residents reviewed for showers. The facility census was 50. Residents Affected - Few Findings included: Review of the medical record revealed Resident #16 was admitted to the facility on [DATE]. Diagnoses included left side hemiplegia, cerebral infarction, anxiety disorder, depression and paralytic gait. Review of the plan of care dated 02/27/24 revealed Resident #16 had a self-care deficit related to weakness. Interventions included he needed one assist with grooming and hygiene. Further review of the plan of care dated 03/01/24 revealed Resident #16 had an ADL self-care performance deficit related to decreased mobility function activity intolerance. Interventions included to check his nail length, trim and clean on bath day and as needed and he required staff assistance with a shower twice a week and as necessary Review of the quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #16 had intact cognition and had upper body impairment on one side. Resident #16 required moderate assistance for bathing and personal hygiene. Review of the Shower Schedules revealed Resident #16 was to receive a shower on Mondays and Thursday on day shift. Review of the medical record from 06/01/24 to 07/08/24 revealed no documentation Resident #16 refused to be shaved, have his nails trimmed or be showered. On 07/08/24 at 10:00 A.M. an interview with Resident #16 revealed showers are not getting done. He stated he was to receive a shower on dayshift on Mondays and Thursday but most of the time he does not get his shower on Mondays and was never given a reason why. He stated they never shave him or trim his fingernails. Observation at this time revealed his fingernails were long and jagged and he had long hair growth on his face. Observation on 07/09/24 at 8:05 A.M. revealed Resident #16 had not been shaved or had his fingernails trimmed eve though his shower day was on 07/08/24. Page 1 of 5 366085 366085 07/16/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/09/24 at 8:05 A.M. an interview with Resident #16 revealed he had not received a shower the day before even though it was his scheduled shower day. On 07/09/24 at 8:15 A.M. an interview with State Tested Nursing Assistant #264 revealed she did not give Resident #16 a shower because she had run out of time. She stated she was scheduled on showers from 6:30 A.M. to 2:30 P.M. then she was scheduled to work on the 300 Hall at 2:30 P.M. She stated she had 12 showers to do and another resident wanted a shower because he had a doctor's appointment and he did not get one the night before. She stated she did not have time to do Resident #16. She stated she told the nurse she did not get his shower done. On 07/09/24 at 8:20 A.M. an interview with Licensed Practical Nurse # 212 confirmed the nails of Resident #16 were long and he needed shaved. She was also not aware he had not received his shower the day before. Review of the facility policy titled, Care of Fingernails/Toenails, dated 10/10 revealed the purpose was to clean the nail bed, to keep the nails trimmed and to prevent infections. Nail care included daily cleaning and regular trimming. Review of the facility policy titled, Shaving a Resident, dated 10/10 revealed the purpose was to promote cleanliness and to provide skin care; notify the supervisor if the resident refused. Review of the facility policy titled, Shower/Tub Bath, dated 10/10 revealed the purpose was to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. This deficiency represents non-compliance investigated under Complaint Number OH00155220. 366085 Page 2 of 5 366085 07/16/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interview with staff the facility failed to ensure medication was obtained from the pharmacy after admission in a timely manner for Resident #48. This affected one resident ( Resident #48) of three residents reviewed for medications. The facility census was 50. Residents Affected - Few Findings included: Review of the medical record revealed Resident #48 was admitted to the facility on [DATE]. Diagnoses included low pain, osteomyelitis, diabetes, insomnia, anxiety disorder, arthropathy, depression, polyneuropathy, dementia, lumbar vertebrae fracture, and benign prostatic hyperplasia. Review of the physician's orders revealed Resident #48 had an order for zolpidem tartrate (sedative/hypnotic) 5 milligrams at bedtime for insomnia dated 06/14/24. Review of the Five-Day Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #48 had intact cognition. Review of the Electronic Medication Administration Record (EMAR) progress note dated 06/16/24 at 3:33 A.M. revealed the facility was waiting for pharmacy to deliver the zolpidem tartrate for Resident #48. Review of the EMAR progress note dated 06/17/24 at 9:33 P.M. revealed the facility was waiting on a prescription from the physician for the zolpidem tartrate for Resident #48. Review of the physician's progress note revealed the physician was in the facility on 06/17/24 and nobody notified her to write a prescription for Resident #48's' zolpidem tartrate. Review of the EMAR progress note dated 06/18/24 at 8:07 P.M. revealed the facility was waiting on a prescription from the physician for the zolpidem tartrate for Resident #48. Review of the pharmacy delivery sheets dated 06/25/24 revealed Resident #48 received 30 tablets of zolpidem tartrate. Review of the list of medication in the facility's emergency drug kit revealed there were two tablets of zolpidem tartrate in stock. Review of the June 2024 medication administration record revealed Resident #48 was never administered a dose of zolpidem tartrate while he was at the facility from 06/14/24 to 06/25/24. On 07/10/24 at 5:30 P.M. an interview with the Director of Nursing revealed she was not aware there was an issue with the zolpidem tartrate for Resident #48 until she started looking at other medications for Resident #48 and realized he had not been getting it. This deficiency represents non-compliance investigated under Complaint Number OH00155220 and continued non-compliance from the survey dated 06/18/24. 366085 Page 3 of 5 366085 07/16/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, interview with staff, and review of the facility policy the facility failed to maintain a medication error rate of less than five percent. Two medication errors occurred within 31 opportunities for error resulting in a medication error rate of 6.5 percent. This affected one resident (Resident #1) of three observed for medication administration. The facility census was 50. Residents Affected - Few Findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included asthma, depression, arthritis, falls, prediabetes, shortness of breath, palpitations and anxiety disorder. Review of the July 2024 medication administration record revealed Resident #1 had an order for duloxetine 30 milligrams (mg) and to administer 60 mg in the morning for depression. She did not have an order for Zoloft 50 mg. Observation of medication administration on 07/09/24 at 7:30 A.M. revealed Resident #1 had a card of duloxetine with the order for two duloxetine 30 mg tablets however Licensed Practical Nurse (LPN) # 250 had only placed one 30 mg tablet in the medication cup. LPN #250 also administered one tablet of Zoloft 50 mg however the name on the card was for the other resident ( Resident #2) who lived in the same room as Resident #1. LPN #250 started to go into the room of Resident #1 to administer the medication when she was stopped by the surveyor and asked to verify the medication with the orders. An interview at 7:35 A.M. LPN #250 verified the duloxetine order was for two 30 mg tablets for a total of 60 mg and verified she did not look at the name on the card for the Zoloft 50 mg and was going to administer the medication to Resident #1 who did not have an order for Zoloft had the surveyor not stopped her from giving Resident #1 the Zoloft. Review of the facility policy titled, Administering Medications. dated 12/12 revealed medication would be administered in a safe and timely manner and as prescribed. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. This deficiency represents non-compliance investigated under Complaint Number OH00155220. 366085 Page 4 of 5 366085 07/16/2024 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview with staff and review of the facility policy the facility failed to ensure staff performed hand hygiene during medication administration. This affected one resident ( Resident #2) of three observed for medication administration. The facility census was 50. Residents Affected - Few Findings included: Observation on 07/09/24 at 7:37 A.M. revealed Licensed Practical Nurse (LPN ) #250 administered medications, eye drops (resident self-administered), inhaler, nasal spray to Resident #1, came out of the residents room into the hallway to the medication cart and put the items away in the medication cart and set up medications for Resident #2 then went back into the room, administered the medication to Resident #2, went into the bathroom and got a pair of gloves and put them on to administer her insulin in her left arm. She administered the insulin, left the room, and threw her gloves away in the trash can on the medication cart in the hallway. She never washed her hands after administering medication to Resident #1, prior to administering medication to Resident #2, or after removing her gloves in the hallway. On 07/09/24 at 7:43 A.M. an interview with LPN #250 confirmed she had not performed proper hand hygiene while administering medications. Review of the facility policy titled, Handwashing/Hand Hygiene, dated 08/15 revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol hand rub containing at least 62 percent alcohol or soap and water before preparing or handling medication, after contact with objects (medical equipment) in the immediate vicinity of the resident, and after removing gloves. This deficiency represents non-compliance investigated under Complaint Number OH00154417. 366085 Page 5 of 5