Inspection·May 13, 2021

F 0684 nose. Level of Harm - Minimal harm or potential for actual harm Observation on 05/11/21 at 2:30 P.M. revealed Resident #19 was in bed and the Band-Aid was missing from her nose. There was a dime sized reddened area on her left lateral nose which had a little active bleeding. Resident #19 was dabbing the area with a tissue. Residents Affected - Few Review of Resident #19's current physician orders did not reveal any orders for wound care to the resident's left lateral nose. Review of Resident #19's progress notes from 05/01/21 to 05/12/21 did not reveal any documentation of the resident's left lateral nose wound. Interview on 05/12/21 at 9:43 A.M. with the Director of Nursing (DON) confirmed the resident's medical record did not contain evidence of wound care or assessments of Resident #19's right lateral nose wound care. The DON indicated the resident picked at her nose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365291 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hall of Fame Rehabilitation and Nursing Center 2714 13th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #32's indwelling urinary catheter was maintained per best practice guidelines. This affected one of one resident reviewed for urinary catheters. Findings include: Review of Resident #32's medical record revealed the resident was admitted on [DATE], discharged to the hospital on [DATE] and readmitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder, difficulty in walking and morbid obesity. Review of Resident #32's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited intact cognition and had an indwelling urinary catheter. Review of Resident #32's current physician orders revealed an order dated 04/06/21 to change the sixteen french Foley (urinary) catheter for dysfunction and an order to irrigate the catheter if it became occluded with 60 milliliters of normal saline as needed. Review of Indwelling Catheter Care (https://medlineplus.gov/ency/patientinstructions/000140.htm) best practice guidelines updated 05/04/21 revealed catheter care should be completed twice a day to keep the catheter clean and free of germs that can cause an infection. Review of Resident #32's progress notes from 04/01/21 to 05/12/21 and the resident's physician orders did not reveal evidence catheter care was completed per best practice guidelines. Interview on 05/12/21 at 11:33 A.M. with the Director of Nursing (DON) confirmed Resident #32's medical record did not have evidence the resident's indwelling Foley urinary catheter was cleaned and maintained per best practice guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365291 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hall of Fame Rehabilitation and Nursing Center 2714 13th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 manufacturer recommendations, observations and interviews the facility failed to ensure all insulin containers were properly dated, and used and disposed of according to manufacture guidelines. This affected four of five residents (Resident #5, #6, #26 and #27) whose insulin products were stored in two of three medication carts. Findings Include: An observation on 05/11/21 at 3:48 P.M. of the second floor medication cart was conducted with Licensed Practical Nurse (LPN) #813. Resident #6's Lantus Flexpen (insulin pen) was labeled with an open date of 04/04/21 and Resident #6's Humalog insulin vial was labeled with an open date of 04/01/21. LPN #813 verified insulin is to be discarded after 28 days from the date opened. Observation on 05/11/21 at 3:58 P.M. of first floor cart, medication cart two, with LPN #862 revealed Resident #26's opened Novalog (insulin) flexpen had a pharmacy ship date of 03/29/21 and was not dated when it had been opened and there was an open Basaglar (insulin) Flexpen shipped from pharmacy on 01/11/21 and was not dated when opened. Resident #27's open Lantus (insulin) Flexpen shipped on 03/23/21, and was labeled with an open date of 04/01/21. Resident #5's open Novalog (insulin) flexpen was dated with an open date of 02/27/21 and the Levemir (insulin) flexpen was labeled with an open date of 04/02/21. Interview at that time with LPN #862 verified these insulin products were to be dated when opened and discarded after 28 days from the date opened. Interview on 05/12/21 at 10:25 A.M. with Director of Nursing (DON) verified insulin products were to be dated when opened and discarded after 28 days once opened. Review of the manufacturer recommendations for Humalog, Novolag, Basaglar and Lantus insulin solutions revealed flexpens/vials in use more than 28 days should be discarded due to deterioration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365291 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hall of Fame Rehabilitation and Nursing Center 2714 13th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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** 2. Medical record review for Resident #29 revealed the latest re-entry admission on [DATE]. Diagnoses included end stage renal (kidney) disease with dialysis, quadriplegia, stage four pressure ulcer of the sacral region, Alzheimer's disease, diabetes mellitus, diabetic neuropathy, seizures, anemia, and muscle weakness. The comprehensive MDS assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 11. Scores of eight to 12 indicated moderate cognitive impairment. This MDS indicated Resident #29 required total assistance of two staff members for repositioning and transfers. Resident #29 was on a mechanical soft diet with regular consistency fluids. Dietary consults and nutritional supplements for wound healing were provided and Resident #29 had a steady weight of 136-139 pounds during the six-month review. Resident #29's diagnosis of a stage four pressure ulcer of the sacral region was dated 04/19/17. Resident #29's medical record reflected on 01/01/21 a wound vacuum, wound treatment device with suction, was ordered and placed on the sacral pressure ulcer to help heal the ulcer. Review of the treatment administration record (TAR) for the period of 01/01/21 through 03/31/21 revealed a physician order initiated on 01/01/21 to cleanse the sacrum pressure ulcer with normal saline, pat dry, apply skin prep to the peri-wound, then apply wound-pump with black foam and apply at 125 millimeters of mercury (mm/Hg) every Monday, Wednesday and Friday and as needed. The TAR failed to evidence the dressing change was completed on the scheduled dates of 01/08/21, 01/22/21, 02/05/21, and 02/10/21. The wound vacuum was then discontinued on 02/13/21. Review of Resident #29's TAR for the period 01/01/21 through 03/31/21 revealed a physician order dated 01/30/21 to cleanse the sacral wound with normal saline, apply silver alginate, cover with a foam dressing once a day. The TAR failed to evidence this treatment was completed on 02/13/21 through 02/20/21, 02/22/21, 02/26/21 and 03/11/21. The order was discontinued on 03/20/21 and rewritten for a different time administration and continued through the discontinued date of 04/30/21. Interview completed on 05/12/21 at 2:30 P.M. with the DON who verified the documentation had not evidenced the wound care was provided as required. The DON said she was very familiar with Resident #29 and had spoken with the resident and completed dressing changes may times during the four-year stay. The DON stated the dressing changes had been provided as required but staff failed to document the changes as required. The wound had improved and if the dressing changes had not been completed, Resident #1 would have notified the DON. It was stated the order to cleanse the sacral wound written on 01/30/21 was originally ordered for use if the supplies for the wound vacuum had not arrived to maintain adequate supply due to the COVID-19 pandemic and shipping backlogs. On 02/13/21 when the wound vacuum orders had been discontinued and the order to cleanse the sacral wound with normal saline, apply silver alginate and cover with a foam dressing, one time a day for sacral wound remained in effect with the transfer of the care orders. The DON stated the original order should have been written as an as needed order until 02/13/21 when it became a scheduled daily dressing change. In addition, the wound care documentation had not been completed correctly and the facility was in the process of hiring a wound care nurse at the time of the survey. These findings were verified on 05/13/21 at 12:45 P.M. with the Administrator, DON, and Regional (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365291 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/13/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hall of Fame Rehabilitation and Nursing Center 2714 13th Street NW Canton, OH 44708 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Nurse #801. Level of Harm - Minimal harm or potential for actual harm Review of the document Dressings, Dry/Clean last revised 09/2013 revealed it with the policy of the facility for staff to record the date and time of the dressing change. Residents Affected - Few Based on record review and interview, the facility failed to ensure Resident #8's medical record completely and accurately reflected the resident's falls and Resident #29's medical record accurately reflected the resident's pressure wounds. This finding affected two of 17 resident records reviewed for accurate medical records. Findings include: 1. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, bipolar disorder and schizoaffective disorder. Review of Resident #8's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment. Review of Resident #8's progress notes from 05/01/21 to 05/12/21 did not reveal documentation of the sustained on 05/01/21 and 05/05/21. Review of Resident #8's facility Incident Summary form dated 05/01/21 indicated the resident slipped trying to turn off the roommate's light and the resident had no socks on. Review of Resident #8's facility Incident Summary form dated 05/05/21 indicated the resident fell going to the bathroom and did not have non-skid socks on. Interview on 05/12/21 at 7:53 A.M. with the Director of Nursing (DON) confirmed Resident #8's medical record did not contain details of the resident's falls on 05/01/21 or 05/05/21 which included the immediate interventions implemented at the time of the falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365291 If continuation sheet Page 6 of 6