Health inspection·June 11, 2023

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 observation, interview, and record review, the facility failed to provide personal care assistance in a dignified manner for Resident #14. This affected one resident (#14) of 27 residents reviewed for dignity. The facility census was 64. Findings include: Review of the medical record for Resident #14 revealed an admission date of 05/13/20. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, morbid severe obesity due to excess calories, diabetes mellitus type 2 with diabetic nephropathy, foot drop, essential primary hypertension, and major depressive disorder recurrent. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had intact cognition. Resident #14 required extensive two staff assistance for bed mobility, extensive one staff assistance for toileting, was dependent on two staff assistance for transfers, and was dependent on one staff physical assistance for bathing. The assessment indicated Resident #14 was occasionally incontinent of urine and frequently incontinent of bowel. Review of the care plan completed 04/18/23 revealed Resident #14 had an activities of daily living (ADL) self-care performance deficit related to impaired mobility. Interventions included to provide physical assistance with bathing, hygiene, toileting, eating, dressing, and transfers, and to provide transfers with physical assist of two staff using a mechanical lift. Observation on 06/11/23 at 8:14 A.M. from the hallway into Resident #14's room revealed State Tested Nursing Assistants (STNAs) #517 and #560 providing personal care to Resident #14 after completing a mechanical lift transfer to the bed. Resident #14 was uncovered wearing a brief in the bed. STNA #560 stood on Resident #14's left side of the bed and STNA #517 stood on Resident #14's right side of the bed. The privacy curtain was not pulled, and the room entrance door was not closed. At the time of the observation, STNA #560 looked up from the personal care assistance being provided and requested identification of this surveyor who was standing in the hallway near Resident #14's room entrance door. After identification was provided, STNA #560 directed STNA #517 to close the privacy curtain for Resident #14. STNA #560 then walked to Resident #14's room entrance door and started to close the door. Interview at the time of the observation with STNA #560 confirmed Resident #14 was transferred to bed using the mechanical lift and personal care was in process of being provided without closing Resident #14's privacy curtain or the room entrance door. STNA #560 stated privacy was required when providing all personal care to residents. 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: 366047 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 366047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rae Ann Geneva 839 W Main Street Geneva, OH 44041 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)