Inspection·August 11, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Review of Resident #34's point click care (PCC) computer documentation revealed the urine albumin/creatinine ration was collected on 07/27/23 at 1:40 A.M. and completed on 07/27/23 at 9:57 A.M. Review of Resident #34's progress note dated 07/27/23 at 10:57 A.M. authored by LPN #808 indicated the lab test results were sent to the physician and no new orders were obtained. Residents Affected - Few Resident #34's urine lab test result dated 07/27/23 revealed the wrong lab test completed for the resident as it should have been for a UA plus culture and sensitivity (C&S). Review of Resident #34's physician orders revealed an order dated 07/29/23 to obtain a UA due to complaints of dysuria. The treatment administration records (TARS) revealed the order was documented as completed on 07/29/23 and 07/30/23. Review of Resident #34's progress note dated 07/29/23 at 11:45 A.M. authored by RN DON indicated the laboratory company was called to pick up a urine specimen due to complaints of dysuria. Review of Resident #34's progress note dated 07/29/23 at 3:18 P.M. authored by RN DON indicated the UA lab test results were received which was positive for leukocytes with moderate bacteria. The facility was waiting on the C&S lab test to determine the appropriate antibiotic to use for the UTI. Review of Resident #34's progress note dated 07/30/23 at 2:39 P.M. authored by RN DON indicated bactrim antibiotic ordered for seven days. Review of Resident #34's progress note dated 07/31/23 at 11:50 P.M. authored by RN #809 indicated she was called to the resident's room, and she appeared confused and not quite herself. Her blood pressure was 140/85 with a heart rate of 70 and respirations of 18 and a pulse oximetry of 95% (percent) on room air. Review of Resident #34's change in condition progress note dated 08/01/23 at 5:50 A.M. indicated the resident had altered mental status and uncontrolled pain. Review of Resident #34's progress note dated 08/01/23 at 2:00 P.M. indicated the hospital reported the resident was admitted for blurry vision, altered mental status and UTI. Review of Resident #34's hospital paperwork dated 08/01/23 indicated the resident was treated for a UTI; however, she was found to be more confused and disoriented over the midnight with a headache and blurry vision in both eyes. She was admitted for a possible cerebrovascular accident (CVA or stroke). Interview on 08/11/23 at 7:36 A.M. with RN DON indicated she sent Resident #34's urine specimen for a UA plus C&S lab test on 07/29/23 and she started the resident on antibiotics on 07/30/23. Interview on 08/11/23 at 7:40 A.M. with LPN Assistant Director of Nursing (ADON) confirmed the facility had been having difficulty obtaining lab results from their current laboratory and was in the process of having a meeting with them. Interview on 08/11/23 at 9:10 A.M. with Lab #810 indicated the facility sent an outdated urine specimen for Resident #34 and they were unable to use the urine for a UA plus C&S lab test on 07/13/23. She stated the order had to be canceled and the facility had to resend another urine. She stated new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365291 If continuation sheet Page 2 of 3 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 08/11/2023 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 orders for a UA plus C&S lab tests were placed on 07/19/23 and 07/20/23. Lab #810 indicated on 07/26/23 an order was placed for a urine creatinine ratio lab test. She indicated they did not receive any additional urine specimens after 07/13/23 for a UA plus C&S lab test but the laboratory did receive a urine specimen for a creatinine test on 07/26/23 which was resulted on 07/27/23. Interview on 08/11/23 at 9:35 A.M. with LPN #808 indicted he sent a urine specimen to the laboratory for Resident #34 on 07/13/23 and was unaware it was canceled. He said he had ordered an UA with C&S lab test on 07/26/23 and it was completed by the lab on 07/27/23 as an albumin/creatinine ratio lab test in error. LPN #808 stated he knew he put the lab test in as a UA plus C&S. An additional interview on 08/11/23 at 9:43 A.M. with RN DON confirmed Resident #34's UA plus C&S lab test was ordered and sent to the lab on 07/13/23 and the facility was unaware the test was canceled on 07/14/23. She confirmed Resident #34's UA plus C&S lab test results were not obtained until another urine specimen was sent to the lab on 07/29/23 and the result of the lab test was obtained by the facility on 07/29/23 which delayed the resident's care for complaints of pain and dysuria. This deficiency represents non-compliance investigated under Complaint Number OH00145202. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365291 If continuation sheet Page 3 of 3