Health inspection·May 6, 2025

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 medical record review, hospital records, facility policy review and staff interviews, the facility to complete a timely investigation and self-reported incident following an injury of unknown origin for one resident (Resident #243). This had the potential to affect all 51 residents residing at the facility. Findings include: Review of the medical record for Resident #243 revealed an admission date of 02/11/25. Diagnoses included but were not limited to type II diabetes mellitus with hyperglycemia, Alzheimer's dementia, unspecified disorder of muscle, Trisomy 21, severe intellectual disabilities, adjustment disorder, dysphagia, localization-related idiopathic epilepsy and epileptic syndromes with seizures, tremors, and hearing loss. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE] revealed Resident #243 had a severe cognitive impairment. Resident #243 was noted to rarely be understood. Resident #243 was noted to use a wheelchair, required moderate assistance for ADLs. Resident #234 was also noted to receive antipsychotics, antidepressants and anticonvulsants. Review of the care plan dated 02/12/25 for Resident #243 revealed he was at risk for falls related to weakness. Interventions included non-skid footwear (02/12/25), helmet to be worn during waking hours (04/11/25), keeping bed in lowest position and call light in reach (02/12/25). A focus dated 02/12/25 revealed Resident #243 was noted to have an ADL self-care performance deficit and requires staff assistance for bed mobility, dressing and transfers. Resident #243 was noted to have behavioral problems such as getting in and out of wheelchair, sitting on the floor and crawling on the floor and attempting to pull himself up with furniture. Resident #243 was noted to refuse to wear helmet and hipsters (04/25/25). Interventions were to anticipate and meet resident needs, explain all procedures before starting and allow the resident to express himself, and ensure resident safety. Resident #243 noted to have impaired cognitive function or impaired thought process related to development delays. Interventions were to ask yes/ no questions, speak clearly and slowly. Resident #243 was also noted to be at risk for falls due to poor communication/ comprehension and unsteady gait. Interventions were hipsters to be worn (04/08/25), helmet to be worn (04/16/25), offer pillow under head when laying on couch (04/23/25). Review of the weekly skin evaluation dated 04/19/25 at 7:46 A.M. revealed Resident #243 had a bruise above his left eye. No further details were listed. Review of the nursing progress note dated 04/19/25 timed at 12:50 P.M. written by Licensed Page 1 of 4 366085 366085 05/06/2025 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 Practical Nurse #533 revealed Resident #243 was noted to have a bruise above his left eye during shift change. Neuro checks were started. The on-call nurse, physician, and the resident's guardian were notified. Review of the general progress note dated 04/21/25 timed at 12:29 P.M. revealed the interdisciplinary team met to review Resident #243. Resident #243 was noted to have discoloration to the left periorbital area with 50% dark brown and 50% green colored. Skin was intact, no noted edema noted. Resident #243 was unable to verbalize how this occurred due to diagnosis of Trisomy 21, Alzheimer's dementia, and severe cognitive impairment. Review of the weekly skin evaluation dated 04/26/25 for Resident #243 revealed noted bruising over left eye. No further details were listed. Review of the 04/28/25 general progress noted timed at 9:22 A.M. revealed Resident #243 was noted to have two black eyes and a painful and swollen left hand. An x-ray of Resident #243's skull and left hand were ordered. Review of the general progress note dated 04/28/25 and timed at 10:52 A.M. for Resident #243 revealed IDT team noted 50% green and 50% brown discoloration to the resident's right periorbital (eye) area. Resident #243's skin was noted to be intact to the right periorbital area and the resident's left hand was edematous with intact skin. Resident #243 was also noted to be unable to state what occurred. A head-to-toe skin assessment revealed no further areas of concern. Review of the weekly skin assessment dated [DATE] and timed 1:42 P.M. for Resident #243 revealed various stages of bruising to bilateral eyes and bilateral knees were noted. Review of the portable x-ray result dated 04/28/25 for Resident #234 revealed an acute non-displaced fifth proximal phalanx fracture and no definite displaced or depressed calvaria fracture. Nondisplaced fracture is possible and computed tomography (CT) scan was recommended. Review of the CT scan report dated 04/28/25 for Resident #234 revealed no gross fracture of dislocation of hip joints, no fracture of dislocation of the left hand or wrist, no evidence of acute intracranial hemorrhage, no gross fracture or dislocation of the cervical spine, no evidence of acute fracture of facial bones, orbits or sinuses. Review of the facility self-reported incident (SRI) #259780 for Resident #243 revealed it was opened on 04/28/25 at 11:29 A.M. for an injury of unknown source which was reported by staff. Resident #243 was noted on 04/28/25 at 9:30 A.M. to be observed with two swollen eyes and a swollen hand. It was noted to be unknown how it occurred. Review of the facility's investigation of the Resident #243's injury of unknown origin, dated 04/28/25, revealed Resident #243 was noted to have two swollen eyes and a swollen left hand. Resident #243 was unable to state how it occurred due to severe cognitive impairment. Staff statements were obtained, and no staff or residents stated they had witnessed a fall or injury for Resident #243. A skin check was completed on 04/28/25 and did not reveal any other injuries. The resident's physician and guardian were notified. No alleged perpetrator was identified. The facility believed Resident #243 self-inflicted these bruises due to extensive history of placing himself to the floor on his own and crawling around on the floor. Resident #243 was noted to refuse to wear his helmet and at times had become angry when staff attempt to put the helmet back on. Resident #243 was also noted to put his 366085 Page 2 of 4 366085 05/06/2025 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 face/head on overbed table or any table or any item close to him. Pillows and blankets are to be placed under his head. Questionnaires with staff and other residents revealed no concerns. Abuse education was provided to all staff. Interview on 05/05/25 at 2:22 P.M. was attempted with Resident #243 but due to severe cognitive impairment, it was unable to be conducted to obtain useful information. Interview on 05/06/25 at 7:15 A.M. with the DON revealed on 04/19/25, Resident #243 was noted to have bruising to the left periorbital area which was 50% dark brown and 50% green in color. The skin was intact with no noted edema or evidence of pain. The DON stated they equated it to a fall or him hitting his head but was unaware of anyone who witnessed a fall or injury. The DON stated they did not open an SRI because they thought it was from Resident #243 putting his face on the table. On 04/28/25, when Resident #243 was observed with bruising to both eyes, they opened an SRI and got x-rays for his skull and left hand. Upon receiving the results, Resident #243 was sent out for a CT scan which came back normal. Phone interview on 05/06/25 at 8:25 A.M. with Licensed Practical Nurse (LPN) #533 revealed he observed Resident #243 on 04/19/25 around 6:30 A.M. with a bruise over his left eye which appeared to be fresh, purple in color, and he reported it to Registered Nurse (RN) #532. LPN #533 stated he did not notice any further bruising until 04/28/25, when he noticed bruising to both of Resident #243's eyes. LPN #533 stated he did not see Resident #243 fall and was unaware of any other staff who observed a fall for Resident #243. LPN #533 stated following observation on 04/19/25 and 04/28/25, he immediately reported it to management. Interview on 05/06/25 at 9:45 A.M. with Registered Nurse (RN) #532 revealed she became aware of the bruise above Resident #243's left eye on 04/19/25 when LPN #533 notified her. RN #532 instructed LPN #533 to write the incident up as a fall. RN #532 confirmed Resident #243 was unable to say what happened and was not aware of anyone who had observed the resident fall. RN #532 confirmed it was an injury of unknown origin since no one had witnessed it, and Resident #243 was unable to state what happened. RN #532 stated she did not notify any other management since she thought it was from a fall. When she became aware of the additional injuries on 04/28/25, management was already aware and had started an investigation. Interview on 05/06/25 at 11:23 A.M. with the Administrator and DON confirmed they were unable to provide evidence in Resident #243's medical record indicating how Resident #243's injury occurred on 04/19/25 and were unable to provide evidence an investigation of the injuries was started until 04/28/25. Review of the facility policy called; Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 10/27/17 revealed it is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident or misappropriation of resident property, including injuries of unknown source, in accordance with this policy. Facility staff should immediately report all such allegations to the Administrator/designee and to the Ohio Department of Health in accordance with the procedures in this policy. An injury is classified as an 'injury of unknown source' when both the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. 366085 Page 3 of 4 366085 05/06/2025 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0609 This deficiency represents non-compliance investigated under Control Number OH00165239. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366085 Page 4 of 4