Health inspection·June 5, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the fingernails on Resident #205's bilateral hands were assessed and treated timely. This finding affected one (Resident #205) of one resident reviewed for activities of daily living (ADL). Residents Affected - Few Findings include: Review of Resident #205's medical record revealed the resident was admitted on [DATE] with diagnoses including end stage renal disease, displaced comminuted fracture of the shaft of the right humerus and lack of coordination. Review of Resident #205's ADL care plan dated 05/15/25 revealed to check the resident's nail length. Trim and clean on bath days and report any changes to the nurse. Review of Resident #205's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition and the resident was dependent for toileting, showering/bathing as well as partial/moderate assistance for personal hygiene. Review of Resident #205's Weekly Skin Assessment form dated 05/19/25 did not address the resident's fingernails. Review of Resident #205's Weekly Skin Assessment form dated 05/27/25 did not address the resident's fingernails. Observation on 06/02/25 at 11:21 A.M. revealed Resident #205's fingernails on the bilateral hands appeared yellowed and thickened with debris underneath of the nails. Interview on 06/03/25 at 2:24 P.M. with Resident #205 revealed staff did not address his fingernails. Interview on 06/03/25 at 2:28 P.M. with Licensed Practical Nurse (LPN) Unit Manager (UM) #857 of Resident #205's fingernails revealed the resident's fingernails on his bilateral hands appeared yellowed and thick with debris underneath of the nails. Interview on 06/04/25 at 7:39 A.M. with LPN Wound Nurse (WN) #819 revealed she had assessed Resident #205 weekly while completing wound care on his second right toe. LPN WN #819 confirmed she did not notice the thick yellowed fingernails on the resident's bilateral hands or the debris underneath of Page 1 of 6 366085 366085 06/05/2025 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0676 the resident's fingernails. Level of Harm - Minimal harm or potential for actual harm Review of the Care of Fingernails/Toenails policy dated 10/2010 revealed the purpose of the procedure was to clean the nail bed, to keep the nails trimmed, and to prevent infections. Watch for and report any changes in the color of the skin around the nail bed, blueness of the nails, and any signs of poor circulation, cracking of the skin, evidence of ingrown nails, infections, pain or if the nails were too hard or too thick to cut with ease. Residents Affected - Few 366085 Page 2 of 6 366085 06/05/2025 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and facility policy review, the facility failed to ensure residents received trauma-informed care that accounted for the resident's experiences and preferences in order to minimize or eliminate triggers that may cause re-traumatization of the residents. This affected one resident (Resident #15) of one resident reviewed for behavioral and emotional care. The facility census was 49. Residents Affected - Few Findings include: Review if the medical record for Resident #15 revealed an initial admission date of 03/20/25 and a re-entry date of 05/20/25. Diagnoses included type two diabetes mellitus, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, primary hypertension, chronic stage three kidney disease, anxiety disorder, heart failure, cognitive communication deficit, depression, muscle wasting and atrophy, and post-traumatic stress disorder (PTSD). Review of the admission minimum data set (MDS) 3.0 assessment completed on 03/27/25 revealed Resident #15 had moderately impaired cognition and no noted behaviors. Further review of the MDS revealed Resident #15 had psychiatric and/or mood disorders listed, including anxiety disorder, depression, and PTSD. Review of the assessment titled Discharge Planning Review completed on 04/17/25 revealed the trauma review section had all boxes marked as not applicable for all listed trauma categories, including physical assault, sexual assault, captivity, serious injury or harm, and other very stressful events. Review of the Social Services Assessment completed on 04/17/25 upon admission revealed Resident #15's psychosocial adjustment factors included a distressed mood, homelessness or housing concerns, financial concerns, deficits in communication, and deficits in controlling body function. Review of the follow-up Social Services Assessment completed on 05/19/25 upon re-entry revealed the psychosocial assessment was blank and did not contain any assessment data or selections under social factors. Review of the Social Services Progress Notes from 03/20/25 through 06/04/25 revealed no notes related to Residents diagnosis of PTSD, how it impacted her daily living, identified or reported triggers, or interventions to prevent re-traumatization. Review of the care plan with last review date completed 04/08/25 revealed no care plan related to PTSD. Review of the open care plan initiated 03/19/25 with next review date due 07/05/25 revealed a care plan problem was created on 04/10/25 by MDS Coordinator #837 indicating Resident #15 had a past traumatic event; however, the traumatic event was not specified, emotional triggers or stressors were not identified, and there were no person-centered specific interventions to mitigate triggers. Interview on 06/02/25 at 11:40 A.M. of Resident #15 conducted revealed Resident #15 had PTSD from being physically abused by a spouse. A second interview on 06/03/25 at 4:28 P.M. with Resident #15 confirmed a 10-year history of physical abuse with subsequent PTSD and night terrors. Resident #15 reported that emotional triggers included being forced or coerced to do anything against her will, having anything wrapped around her, and anything that may feel restricting to her body or her movement, such as wearing that get caught up and twisted under her. Resident #15 further revealed night terrors continue while at the facility. 366085 Page 3 of 6 366085 06/05/2025 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 06/04/25 at 11:57 A.M. with Certified Nurse Aides (CNA) #852 revealed no knowledge of Resident #15's PTSD diagnosis or any triggers that caused Resident #15 emotional stress. Interview on 06/04/25 at 3:52 P.M. with CNA #810 revealed an awareness that Resident #15 had a diagnosis of PTSD, but had no knowledge of underlying causes, triggers, or specific interventions to prevent additional stress or re-traumatization. Interview on 06/04/25 at 3:59 P.M. with CNA #864 revealed a belief Resident #15 may have acquired PTSD while in another facility due to something that may have happened there but uncertainty about what caused the PTSD or what could trigger Resident #15's PTSD symptoms. Further interview revealed one potential intervention might be for Resident #15 to have no male caregivers but could not confirm that was a PTSD related intervention. 366085 Page 4 of 6 366085 06/05/2025 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, record review and interview, the facility failed to ensure medications were administered as ordered. A total of 31 medications were administered with two errors for a medication error rate of 6.45%. This finding affected two (Residents #19 and #40) of three residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident #19's medical record revealed the resident was admitted on [DATE] with diagnoses including type two diabetes, morbid obesity and chronic obstructive pulmonary disease. Review of Resident #19's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed moderate cognitive impairment. Review of Resident #19's physician orders revealed an order dated 04/13/24 to administer Humalog via a KwikPen sq (subcutaneous) and inject as per sliding scale. Using a Humalog KwikPen, inject four units for a sliding scale of 200 to 250; six units for a sliding scale of 251 to 300; eight units for a sliding scale of 301 to 350; 10 units for a sliding scale of 351 to 400 and twelve units for a sliding scale of 401 to 450 before meals and at bedtime for diabetes. Call the physician for a blood sugar greater than 450. Observation on 06/02/25 at revealed Licensed Practical Nurse (LPN) #827 obtained Resident #19's blood sugar with a result of 293. LPN #827 administered six units of Humalog short acting insulin via a Humalog KwikPen to Resident #19. LPN #827 did not dial up a two unit air shot prior to dialing up the six units to administer to the resident. Interview on 06/02/25 at 11:14 A.M. with LPN #827 confirmed she did not dial up a two unit air shot for Resident #19's Humalog insulin prior to administering six units to the resident. Review of the Instructions for Use Humalog KwikPen injection including pulling the pen cap straight off, check the liquid in the pen, select a new needle, push the capped needle straight onto the pen and twist the needle on until it was tight, pull off the outer needle shield, prime the pen by turning the dose knob to select two unit, hold the pen with the needle point up and tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with needle point up and push the dose knob in until it stop and the zero was observed in the dose window, select the required dose and administer to the resident. 2. Review of Resident #40's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including anxiety disorder, schizophrenia and depression. Review of Resident #40's Quarterly MDS 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #40's physician orders revealed an order dated 02/05/25 to administer Vitamin E oral capsule 100 units, give one capsule by mouth one time a day for a supplement. Observation on 06/03/25 at 8:01 A.M. revealed LPN Wound Nurse (WN) #819 administered four 366085 Page 5 of 6 366085 06/05/2025 Legends Care Rehabilitation and Nursing Center 2311 Nave Road SE Massillon, OH 44646

F 0759 medications to Resident #40 including Vitamin E 180 mg (milligrams) or 400 iu (international units). Level of Harm - Minimal harm or potential for actual harm Interview on 05/03/25 at 8:27 A.M. with LPN WN #819 confirmed she did not administer the correct dose of Vitamin E to Resident #40 during the medication administration. Residents Affected - Few A total of 31 medications were administered with two errors for a medication error rate of 6.45%. Review of the Administering Medications policy revised 12/2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. 366085 Page 6 of 6