Inspection·January 27, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and staff interview the facility failed to ensure supplemental oxygen delivery devices were changed weekly and stored properly. This affected three residents (Residents #12, #24 and #28) of three residents reviewed for supplemental oxygen use. The facility identified 10 residents currently utilizing supplemental oxygen (Residents #4, #11, #12, #14, #22, #24, #28, #30, #34 and #37). Residents Affected - Few Findings include: 1. Review of Resident #12's medical record revealed an admission date of [DATE] with diagnoses that included pneumonia, congestive heart failure and hypertension. Physician's orders on [DATE] indicated the use of supplemental oxygen at two liters per minute (lpm) per nasal canula by oxygen concentrator. Additional orders indicated to change nasal canula every night shift on Sunday. An additional order on [DATE] identified the use of DuoNeb (aerosolized medication for shortness of breath) 0.5-2.5 milligrams (mg) per milliliter (ml) via nebulizer every six hours as needed for shortness of breath from [DATE] for five days until [DATE]. Review of the Treatment Administration Record (TAR) revealed the oxygen tubing and nasal canula documented as changed on [DATE] and [DATE]. Observation on [DATE] at 10:05 A.M. revealed Resident #12 sitting in a wheelchair in her room. An oxygen concentrator was observed with the oxygen tubing and nasal canula draped on the oxygen concentrator without being stored in a protective plastic storage bag. Additional observation revealed a medication nebulizer lying on the night stand without being in a protective plastic storage bag. The nasal canula, oxygen tubing, and nebulizer and tubing was dated [DATE]. 2. Review of Resident #24's medical record revealed an admission date of [DATE] with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus and vascular dementia. Physician's orders on [DATE] indicated the use of supplement oxygen at two lpm per nasal canula as needed for shortness of breath. An additional order on [DATE] indicated the use of DuoNeb 0.5-2.5 mg/ml via nebulizer every six hours as needed. Observation on [DATE] at 10:10 A.M. revealed Resident #24 was out of her room. An oxygen concentrator with oxygen tubing and nasal canula was observed. The nasal canula was draped on top of the concentrator without being in a protective plastic storage bag. A medication nebulizer was observed sitting on the night stand without being in a protective plastic storage bag. (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 2 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 01/27/2025 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)