Inspection·February 28, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy, the facility failed to Resident #10 was treated in a dignified manner. This affected one resident (#10) of three residents reviewed for dignity. The facility identified 12 residents (#3, #4, #8, #10, #11, #13, #15, #16, #25, #30, #34, and #39) as smokers. The facility census was 40. Findings Include: Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and tobacco use. Review of Resident #10's care plan dated 12/08/22 with a revision date of 12/14/22 revealed Resident #10 is a smoker. Interventions included but were not limited to instructing the resident about the facility policy on smoking, location, times, safety concerns. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact and was independent for activities of daily living (ADL). Review of Resident #10's progress notes from 11/28/23 through 12/10/23 revealed no concerns related to behaviors regarding the smoking policy. Review of the nurses note dated 12/11/23 at 1:45 P.M. revealed maintenance was in Resident #10's room to repair toilet and found a Ziploc baggie with white powder behind the toilet which was immediately removed from the room, and the local police department (PD) was notified. PD arrived on site and confiscated the white powder for further testing and questioned the resident. Resident #10 denied that he knew anything about the substance that was found. The Nurse Practitioner (NP) was notified, and new orders received to obtain a urine drug screen at this time. All parties were notified. Review of the nurses' note dated 12/11/23 at 2:00 P.M. revealed urine obtained for drug screen and tested. Urine tested positive for tetrahydrocannabinol (THC), oxycodone (OXY), and cocaine. The NP was notified of the results, and new orders were received to discontinue OXY and the order for Resident #10 to go on leave of absence by himself. Resident #10 was aware of the above orders and all questions were answered. Review of the social services note dated 12/11/23 at 4:28 P.M. revealed Social Service Designee (SSD) #226 and Director of Nursing (DON) spoke to Resident #10 about resident's smoking privileges have been revoked due to failure to comply with smoking policy. The resident voiced understanding. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 365291 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 02/28/2024 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)