Legends Care Rehabilitation and Nursing Center

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure there was a phone available for residents to use. This affected one (Resident #55) out of three residents reviewed for telephone communication. The facility census was 52 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure care conferences were held timely. This affected one (Resident #55) out of three residents reviewed for care conferences. The facility census was 52 residents.

Inspectors wroteBased on record review, interview, facility investigation review, and policy review, the facility failed to timely report an allegation of misappropriation to all required entities. This affected one resident (Resident #73) out of three residents reviewed for misappropriation of narcotics. Facility census 65.

Inspectors wroteBased on record review, interview, facility investigation review, and policy review, the facility failed to ensure a thorough investigation was completed for missing narcotic medication. This affected one resident (Resident #73) out of three residents reviewed for misappropriation of narcotics. Facility census was 65.

Inspectors wroteBased on interview, record review, observation, and hospital record review, the facility failed to ensure surgical wound dressing orders were in place and provided as ordered, and failed to ensure post operative intervention was place to prevent blood clots. This affected three residents (#70, #71 and #72) our of three residents reviewed wound care, and two residents (#70 and #71) out of three residents reviewed for anticoagulant medication. The facility census was 65.

Inspectors wroteBased on observation, interview with staff, and review of facility policy, the facility failed to maintain a sanitary kitchen and failed to properly date food items when opened. This affected all the residents in the facility except three residents (Resident #2, #18 and #57) who did not eat their meals from the kitchen. Findings Include:Observations of the kitchen during the initial tour with [NAME] #114 on 01/20/26 at 8:25 A.M. revealed the following concerns:a. [...]

Inspectors wroteBased on review of the medical record and interview with staff, the facility failed to ensure the concerns of the family of Resident #58 were addressed timely. This affected one resident (Resident #58) of three reviewed for change in condition. Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE] were he later passed away. Review of the face sheet for Resident #58 revealed Family Member #250 was the emergency contact. [...]

Inspectors wroteBased on review of the medical record and interview with staff the facility failed to notify the family of Resident #58 when he was ordered a psychotropic medication. This affected one resident (Resident #58) of three reviewed for medication administration. Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition. [...]

Inspectors wroteBased on review of the medical record and interview with staff the facility failed to notify the family of Resident #58 when he was ordered a psychotropic medication. This affected one resident (Resident #58) of three reviewed for medication administration. Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition. [...]

Inspectors wroteBased on review of the medical record, review of the fall investigation, interview with the staff, and review of facility policy, the facility failed to ensure Resident #58 had fall inventions in place. This affected one resident (Resident #58) of three reviewed for falls. Findings Include: Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE]. Review of the Morse Falls assessment dated [DATE] revealed Resident #58 was a high risk for falls. [...]

Inspectors wroteBased on observation, review of the medical record, interview with staff, and review of facility policy, the facility failed to maintain and medication error rate of less than five percent (%). Nine medications were given in error out of 25 opportunities for error, to equal an error rate of 36%. This affected one resident (Resident #18) out of four observed for medication administration. Findings Include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included lupus, acute respiratory failure, moderate protein-calorie malnutrition, gastrostomy status, and dysphagia. Review of the January 2026 physician's orders revealed Resident #18 had orders due at 9:00 A.M. [...]

Inspectors wroteBased on review of the medical record and interview with staff, the facility failed to ensure radiologic study recommendations were scheduled and addressed in a timely manner for Resident #58. This affected one resident (Resident #58) of three reviewed for a change in condition. Findings Include:Review of the medical record revealed Resident #58 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction, chronic obstructive pulmonary disease, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy and vision loss. Resident #58 was sent to the emergency room on [DATE]. Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #58 had intact cognition. Review of the Progress Note dated 09/15/25 at 4:18 P.M. revealed Resident #58 was resting in bed. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, medical record review, review of hospital records, review of facility Self-Reported Incidents (SRI), review of facility abuse investigations, review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, review of the facility policy titled Resident Rights, and interviews, the facility failed to ensure Resident #23 and Resident #38 were free from incidents of resident to resident physical and verbal abuse. This resulted in Immediate Jeopardy and actual harm beginning on 02/04/25 at approximately 8:30 P.M. when Resident #38 was abused by Resident #15, a resident who was identified to not like other residents in his space or touching his things. [...]

Inspectors wroteBased on closed record review, facility policy review and interview, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for Resident #60, who was found unresponsive, without a pulse/heartbeat and was identified to have advance directives reflecting the resident was a Full Code status. This resulted in Immediate Jeopardy and serious life-threatening harm/death on [DATE] when staff failed to initiate CPR or call 911 for medical services assistance when the resident was found unresponsive. Resident #60 subsequently passed away. This affected one resident (#60) of three residents reviewed for death in the facility. The facility census was 53 residents. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to notified the resident's family/responsible party and the physician timely upon the death of two residents (#60 and #61). This affected two residents (#60 and #61) of three residents reviewed for death. The facility census was 53.

Inspectors wroteBased on resident and staff interview, observation, medical record review, review of the Self-Reported Incident (SRI) and investigation, and review of the facility policy, the facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse. This affected two (Residents #15 and #38) of three residents reviewed for abuse. The facility census was 53.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff were competent and compliant with implementing cardiopulmonary resuscitation per the physician orders and failed to ensure the resident's time of death was called by the physician for accuracy. This affected two residents (#60 and #61) of three residents reviewed for Advanced Directives. The facility census was 53.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, review of pest control invoices, review of pest control logs, interview with staff, and review of the facility policy the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 51 residents who received meals from the kitchen. Two residents (#31 and #33) were identified by the facility as receiving nothing by mouth. The facility census was 53.

Inspectors wroteBased on review of the medical record, review of the facility's Self-Reported Incident (SRI), interview with staff and family, and review of the facility policy the facility failed to ensure Resident #53 was treated with dignity and respect during care by a facility staff member. This affected one resident (#53) of three residents reviewed for dignity and respect. The facility census was 53.

Inspectors wroteBased on review of the medical record and interview with staff the facility failed to ensure an ultrasound was scheduled for Resident #53 in a timely manner. This affected one resident (#53) of three residents reviewed for care and services. The facility census was 53.

Inspectors wroteBased on observation, review of the meal ticket, interview with staff, and review of facility policy the facility failed to ensure Resident #34 received to correct physician's ordered diet. This affected one resident (#34) of three residents reviewed for diet orders. The facility census was 53.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on review of the medical record, interview with the staff, interview with the resident and review of the facility policy the facility failed to ensure an allegation of mistreatment was reported to the Ohio Department of Health (ODH). This affected one resident (Resident #49) of six reviewed for abuse. The facility census was 57.

Inspectors wroteBased on review of the medical record, interview with the staff, interview with the resident and review of the facility policy the facility failed to thoroughly investigate an allegation of mistreatment. This affected one resident (Resident #49) of six reviewed for abuse. The facility census was 57.

Inspectors wroteBased on review of the medical record, review of the hospital records and interview with staff the facility failed to ensure Resident #60 was not unnecessarily transferred to a hospital. This affected one resident (Resident #60) of three reviewed for hospitalization. The facility census was 57.

Inspectors wroteBased on review of the medical record, review of the ostomy company invoice and interview with staff the facility failed to ensure ostomy and drainage tube care was provided to Resident #60. This affected one resident (Resident #60)of three reviewed for ostomy care. The facility census was 57.

Inspectors wroteBased on review of the medical record, review of the emergency medication kit list, review of the hospice notes and interview with staff the facility failed to ensure an effective pain management program was implemented for Resident #58. This affected one resident (Resident #58) of three reviewed for pain management. The facility census was 57.

Inspectors wroteBased on review of the medical record and interview with staff the facility did not ensure the application of a negative pressure wound therapy machine was accurately documented in the medical record for Resident #60. This affected one resident (#60) of three residents reviewed for wound care documentation. The facility census was 57.

Inspectors wroteBased on review of written complaints, review of facility investigation, review of staffing schedule and employee timecard punches, and interview, the facility failed to ensure a resident representative complaint was thoroughly investigated related to a staff member being impaired. This affected one resident (#12) of three residents reviewed. The facility census was 57.

Inspectors wroteBased on observation, review of the medical record and interviews with staff the facility failed to ensure facility staff wore personal protective equipment (PPE) while providing care in a droplet isolation room. This affected one resident ( Resident #54) of two residents reviewed for isolation precautions and had the potential to affect six additional residents (#6, #12, #17, #32, #40, and #56) residing on the same unit. The facility census was 58.

Inspectors wroteBased on review of the medical record and interview with the staff the facility failed to notify the physician or Nurse Practitioner Resident #46 was out of her insulin. This affected one resident (Resident #46) of three reviewed for insulin use. The facility census was 58.

Inspectors wroteBased on medical record review, review of the pharmacy delivery sheets, and interviews with staff and resident, the facility did not ensure routine insulin was available to administer to Resident #46 according to the physician orders. This affected one resident (Resident #46) of three residents reviewed for insulin administration. The facility census was 58.

Inspectors wroteBased on review of nursing schedules, employee time punch review and interviews, the facility failed to ensure a registered nurse was scheduled for eight consecutive hours every day. This had the potential to affect all 53 residents.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to prevent the worsening of a surgical wound for Resident #4 and failed to ensure wound treatment was provided as ordered for Resident #4 and Resident #2. This affected two residents (#4 and #2) of four residents reviewed for non-pressure skin wounds. Actual Harm occurred on 07/21/22 when Resident #4, who was cognitively impaired, and at risk for skin breakdown was found to have a worsening ulceration of a surgical wound, located on the lower, left, lateral leg. The facility failed to provide wound care as ordered and the wound worsened and subsequently required treatment and debridement at a wound clinic. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #214, Resident #215 and Resident #216 received a timely beneficiary notice when skilled services were discontinued. This affected three of three residents reviewed for beneficiary notices.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure advanced directive orders were consistent across electronic and paper medical records. This affected two residents (Resident #5 and Resident #39) of three residents reviewed for advanced directives. The facility census was 58 residents.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident representative of a change in health status and hospital transfer. This affected one (Resident #206) of three residents reviewed for notification of change. The facility census was 58.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure care plans were revised as needed. This affected three residents (Resident #2, Resident #4 and Resident #46) of 21 residents reviewed for care planning. The facility census was 58 residents.

Inspectors wroteBased on medical record review, observation, policy review, and interview, the facility failed to ensure fall interventions were in place for one (Resident #21) of three residents reviewed for falls.

Inspectors wroteBased on record review and interviews the facility failed to assess Resident #48 before and after dialysis treatments. This affected one of two residents reviewed for dialysis. The census was 58.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure pharmacy medication review recommendations were timely addressed and followed up upon. This affected one resident (Resident #44) of six residents reviewed for unnecessary medications. The facility census was 58 residents.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure resident records were complete and accurate. This affected three residents (Resident #3, Resident #46 and Resident #54) of 21 residents reviewed for documentation. The facility census was 58 residents.

Inspectors wroteBased on record review and staff interview the facility failed to implement their abuse policy and procedure to ensure screening procedures included checking all staff members against the Nurse Aide Registry (NAR) to determine whether the employee had a finding of abuse, neglect and/or misappropriation. The facility failed to check the Director of Nursing (DON), Licensed Practical Nurse (LPN) #508, Registered Nurse (RN) #515, and Maintenance Supervisor (MS) #579. This affected four of eight new employees reviewed and had the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain acceptable infection control standards to prevent the spread of infection related to the collection of soiled laundry, the cleaning of resident rooms for residents who have Clostridium Difficle (C Diff) infections, the disposal of items in a sharps container and during blood glucose testing using a shared glucometer. This affected two residents (#17 and #22) and had the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to provide restorative ambulation services as planned, failed to complete accurate restorative assessments, failed to ensure restorative delivery records were completed in a manner which would permit a thorough assessment, and failed to address declines in participation in a timely manner. This affected one resident (#9) of two residents reviewed for activities of daily living.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #33 and Resident #50 received appropriate care and services. This affected two residents (#33 and #50) of three residents reviewed for dignity and respect.

Inspectors wroteBased on observation, record review and interview the facility failed to implement a bowel protocol for Resident #57 to address the resident's constipation and failed to ensure an assessment and treatment were implemented for Resident #29 related to a non-pressure related skin injury. This affected one resident (#57) of 27 residents interviewed related to bowel status and one resident (#29) of 27 residents observed for skin integrity.

Inspectors wroteBased on observation, record review and interview the facility failed to complete an accurate pressure ulcer assessment for Resident #8 following the resident's readmission from the hospital. This affected one resident (#8) of four residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and interview the facility failed to provide restorative nursing services for range of motion (ROM) in accordance with Resident #9's plan of care. This affected one resident (#9) of 26 residents screened for range of motion.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a timely dietary consult and failed to administer tube feeding nutrition as ordered for Resident #12 to prevent weight loss. This affected one resident (#12) of two residents reviewed for nutrition.

Inspectors wroteBased on observation, record review and interview the facility failed to deliver nutrition through a feeding tube in a manner which would prevent microbial growth. This affected one resident (#12) of one resident reviewed for enteral/feeding tubes. The facility identified three residents receiving tube feedings.

Inspectors wroteBased on record review and interview facility failed to implement a comprehensive and individualized pain management program including the administration of pain medication for Resident #48 as ordered. This affected one resident (#48) of two residents reviewed for pain.

Inspectors wroteBased on record review and interview the facility failed to ensure the justified use of psychoactive medication for Resident #38. This affected one resident (#38) of five residents reviewed for unnecessary medication use.