Health inspection·August 17, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her to slap another resident and/ or that she felt staff ever treated her and/ or other residents in a disrespectful manner. 2. Review of medical record for Resident #40 revealed an admission date of 03/03/22 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension, moderate intellectual disability, and major depression. Review of nursing notes dated 05/01/23 to 08/17/23 for Resident #40 revealed no incidents that involved staff treating him in a disrespectful manner. Interview on 08/17/23 at 11:23 A.M. with STNA #613 revealed there was one aide (STNA #606) that worked at the facility that she felt was rude and disrespectful to the residents. She revealed there was one time approximately one month ago she overheard STNA #606 (who was in Resident #40's room) tell him, No wonder why your mother gave you up. She revealed she did not report this incident as she felt the facility was aware how STNA #606 talked to the residents as management did not ever do anything about the way she treated residents when it had been previously reported. She revealed she felt STNA #606 used a form of humiliation such as when a resident was incontinent of bowel or urine, instead of just assisting with incontinence care she would make a huge deal and state, not again, and/ or really you did this again. She revealed she felt she scolded and/ or shamed the residents and that the way she talked to them was not right. She revealed she also felt management knew about how STNA #606 treated the residents and stated, I do not know how she (STNA #606) still has a job. Interviews on 08/17/23 at 11:45 P.M. and 1:43 P.M. with Resident #40 denied any incidents that staff including STNA #606 had treated him in a disrespectful manner. Interview on 08/17/23 at 12:06 P.M. with Administrator and Director of Nursing revealed they were not aware of the above allegations. They revealed staff had never reported the incidents; therefore, an investigation was never completed. They verified staff should have immediately reported the incidents. 3. Review of medical record for Resident #32 revealed an admission date of 08/07/23 with diagnoses including surgical aftercare following surgery due to neoplasm to the nervous system, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, hypertension, and major depression. Review of the Admission/ Medicare Five-Day MDS assessment dated [DATE] revealed Resident #32 had intact cognition and no behaviors. He required extensive assist of staff with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of a witness statement dated 08/16/23 at 3:00 P.M. and completed by the Director of Nursing revealed Licensed Practical Nurse (LPN) #610 notified the Director of Nursing that Resident #32 had a complaint regarding STNA #606's care. The statement revealed he stated he did not want STNA #606 to care for him anymore. The statement revealed he had asked STNA #606 to make his bed and put him in bed. The statement revealed she told him he had to wait as other residents had been up longer and those residents needed to go to bed first. The statement revealed the Director of Nursing told him that a float aide would provide his care and that she would follow up with the Administrator regarding the incident. There was no further investigation completed. Review of the nursing notes dated 08/07/23 to 08/17/23 for Resident #32 revealed no incidents were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 2 of 8 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 08/17/2023 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)

F 0550 documented that Resident #32 felt he was treated in an undignified/disrespectful manner. Level of Harm - Minimal harm or potential for actual harm Interview on 08/17/23 at 11:24 A.M. with Resident #32 revealed a couple days ago STNA #606 was assigned his hall and he had asked her to make his bed and lay him back down as he was in pain and hurting. He revealed STNA #606 was rude and got upset at him for asking. He revealed STNA #606 stated, she had other people to deal with and that he had only been up in his chair since 8:00 A.M. and other residents had been up longer than him, and he would just have to wait. He revealed he waited two hours as she had not returned; therefore, rang his call light. He revealed STNA #606 answered his call light and raised her voice as she was upset that he had rang his light. He revealed she stated she was taking him off her list to take care of since he kept ringing and asking to lay down. He revealed he felt her tone was rude and that she was disrespectful. He revealed he had reported the incident to the Director of Nursing who stated she would handle the situation as well as he requested STNA #606 not to take care of him again because he revealed staff should never talk to a resident in that manner. Residents Affected - Some Interview on 8/17/23 at 11:33 A.M. with the Director of Nursing revealed on 08/16/23 Resident #32 told her the concerns he had when he asked STNA #606 to make his bed and assist in lying him down, but STNA #606 told him she had several residents to care for prior to him. She revealed he stated he had waited two hours and that she had still had not assisted him. She revealed he had not stated anything regarding taking him off the list because he rang or asked too much. She revealed STNA #606 was no longer on duty by the time he had reported the incident to her and that she had planned to follow up with STNA #606 the next time she was at work. She revealed she had filled out a witness statement but had not completed a self-reported incident (SRI), investigation and/ or any additional follow up as she was awaiting to speak with STNA #606 her next assigned day to get her story. 4. Interview on 08/17/23 at 9:06 A.M. with Dining Assistant/ Activities #603 revealed she felt STNA #606 treated residents in a disrespectful manner as she frequently raised her voice at them. She revealed STNA #606 would place the resident's desserts out of reach and even when a resident asked and/ or attempted to get the dessert STNA #606 would not allow them to have it as she would state in a rude tone, they had to eat their other food first before the dessert. Also, she revealed when residents wanted to leave the dining room because they were finished, STNA #606 would raise her voice at them and tell them in a rude tone to hold on, just wait. She revealed it was difficult to provide exact examples, but she just felt STNA #606 was rude to the residents. She revealed she knew management was aware as they had witnessed STNA #606 being rude to the residents themselves. She stated she was aware staff had told them how STNA #606 talked to the residents, and that she felt management did not do anything regarding the allegations. Interview on 08/17/23 at 10:55 A.M. with STNA #608 revealed the facility had one aide (STNA #606) that was very rude and not the nicest to the residents. She revealed she had overheard STNA #606 get frustrated and yell at the residents. She stated, she will just say mean things to them. She was unable to provide specifics examples and revealed management was aware that she treated residents in a disrespectful manner as it had been reported numerous times, but nothing ever happened. Interview on 08/17/23 at 11:17 A.M. with STNA #611 revealed there was one aide (STNA #606) that she had never personally witnessed STNA #606 be rude to the residents, but several residents had complained that she was not nice to them. She revealed Resident #32 recently complained about how he was treated by her and reported to the Director of Nursing, and that he no longer wanted her to take care of him. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 3 of 8 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 08/17/2023 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 08/17/23 at 11:20 A.M. with STNA #612 revealed there was one aide (STNA #606) that was rude and disrespectful all the time to the residents. She revealed STNA #606 gets upset at residents anytime they ask her to do anything for them. She revealed she raises her voice at the residents and had an attitude like they were a bother to her. She revealed staff including herself have reported it to management including the Director of Nursing, but nothing ever happened. She was unable to provide dates and times of when she reported the incidents. She revealed several residents no longer wanted STNA #606 to take care of them. She revealed most have discharged , but Resident #32 still resided at the facility. Interview on 08/17/23 at 12:06 P.M. with Administrator and Director of Nursing revealed that none of the above allegations were reported to them besides the incident on 08/17/23 regarding Resident #32 and that they had not investigated the incidents since they revealed they were unaware. Review of Ohio Gateway revealed no SRIs had been filed from the facility since 08/16/21. Review of the facility policy, Resident Rights, dated 2012, revealed resident rights were extremely important and were necessary because they protect a vulnerable population. The policy revealed each facility must train its staff, particularly STNA's, but also to make sure those rights were followed and always maintained. The policy revealed every resident had the right to be treated with dignity, privacy, and respect. The policy revealed any staff who witnesses and suspects abuse should report it to his/ or her supervisor. This deficiency represents non-compliance investigated under Complaint Number OH00145009. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 4 of 8 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 08/17/2023 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy the facility did not ensure allegations of potential staff to resident abuse were reported to the state agency. This affected one resident (Resident #32) out of five residents reviewed for abuse and had the potential to affect all 66 residents residing at the facility. Findings include: Review of the medical record for Resident #32 revealed an admission date of 08/07/23 with diagnoses including surgical aftercare following surgery due to neoplasm to the nervous system, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, hypertension, and major depression. Review of the Admission/ Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and no behaviors. He required extensive assist of staff with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of a witness statement dated 08/16/23 at 3:00 P.M. and completed by the Director of Nursing revealed Licensed Practical Nurse (LPN) #610 notified the Director of Nursing that Resident #32 had a complaint regarding State Tested Nurse Aide (STNA) #606's care. The statement revealed he stated he did not want STNA #606 to care for him anymore. The statement revealed he asked STNA #606 to make his bed and put him in bed. The statement revealed she told him he had to wait as other residents had been up longer and those residents needed to go to bed first. The statement revealed the Director of Nursing told him that a float aide would provide his care and that she would follow up with the Administrator regarding the incident. There was no further investigation completed. Review of nursing notes dated 08/07/23 to 08/17/23 for Resident #32 revealed no incidents were documented that Resident #32 had made an allegation of potential abuse and/ or was not treated with dignity and respect. Interview on 08/17/23 at 11:24 A.M. with Resident #32 revealed a couple days ago STNA #606 was assigned his hall and that he asked her to make his bed and lay him back down as he was in pain and hurting. He revealed STNA #606 was rude and got upset at him for asking. He revealed STNA #606 stated, she had other people to deal with and that he had only been up in his chair since 8:00 A.M. and other residents been up longer than him and he would just have to wait. He revealed he waited two hours as she had not returned; therefore, rang his call light. He stated STNA #606 answered his call light and raised her voice as she was upset that he had rang his light. He revealed she stated she was taking him off her list to take care of since he kept ringing and asking to lay down. He stated he felt her tone was rude and that she was disrespectful. He revealed he reported the incident to the Director of Nursing who stated she would handle the situation as well as he requested STNA #606 not to take care of him again because he revealed staff should never talk to a resident in that manner. Interview on 8/17/23 at 11:33 A.M. with the Director of Nursing (DON) revealed on 08/16/23 that Resident #32 told her his concerns that he had asked STNA #606 to make his bed and assist in laying him down, but that STNA #606 told him she had several residents to care for prior to him. She stated he had stated he had waited two hours and that she had still had not assisted him. She stated he had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 5 of 8 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 08/17/2023 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)

F 0609 Level of Harm - Minimal harm or potential for actual harm not stated anything regarding taking him off the list because he rang or asked too much. She revealed STNA #606 was no longer on duty by the time he had reported the incident to her and that she had planned to follow up with STNA #606 the next time she was at work. She revealed she had filled out a witness statement but had not completed a self-reported incident, investigation and/ or any additional follow up as she was awaiting to speak with STNA #606 her next assigned day to get her story. Residents Affected - Few Review of Ohio Gateway revealed no SRI was filed from the facility since 08/16/21 including after the DON was notified of this surveyor's interview with Resident #32 on 08/17/23 of his alleged allegation of potential abuse; an SRI was still not filed. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 01/12/18, revealed residents have the right to be free from abuse, and neglect. The policy revealed it is the facilities policy to investigate all alleged violations involving abuse and neglect. The policy revealed the facility would immediately notify the administrator and the Ohio Department of Health as rights were extremely important and were necessary because they protect a vulnerable population. The policy revealed each facility must train its staff, particularly STNA's, but also to make sure those rights were followed and always maintained. The policy revealed every resident had the right to be treated with dignity, privacy, and respect. The policy revealed any staff who witnesses and suspects abuse should report it to his/ or her supervisor. This deficiency represents non-compliance investigated under Complaint Number OH00145009. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 6 of 8 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 08/17/2023 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)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy the facility did not ensure allegations of potential staff to resident abuse were thoroughly investigated in a timely manner. This affected one resident (Resident #32) out of five residents reviewed for abuse and had the potential to affect all 66 residents residing at the facility. Residents Affected - Few Findings include: Review of the medical record for Resident #32 revealed an admission date of 08/07/23 with diagnoses including surgical aftercare following surgery due to neoplasm to the nervous system, hemiplegia and hemiparesis following cerebral infarction affecting the right non-dominant side, hypertension, and major depression. Review of the Admission/ Medicare Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had intact cognition and no behaviors. He required extensive assist of staff with bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of a witness statement dated 08/16/23 at 3:00 P.M. and completed by the Director of Nursing revealed Licensed Practical Nurse (LPN) #610 notified the Director of Nursing that Resident #32 had a complaint regarding State Tested Nurse Aide (STNA) #606's care. The statement revealed he stated he did not want STNA #606 to care for him anymore. The statement revealed he asked STNA #606 to make his bed and put him in bed. The statement revealed she told him he had to wait as other residents had been up longer and those residents needed to go to bed first. The statement revealed the Director of Nursing told him that a float aide would provide his care and that she would follow up with the Administrator regarding the incident. There was no further investigation completed. Review of nursing notes dated 08/07/23 to 08/17/23 for Resident #32 revealed no incidents were documented that Resident #32 had made an allegation of potential abuse and/ or was not treated with dignity and respect. Interview on 08/17/23 at 11:24 A.M. with Resident #32 revealed a couple days ago STNA #606 was assigned his hall and that he asked her to make his bed and lay him back down as he was in pain and hurting. He revealed STNA #606 was rude and got upset at him for asking. He revealed STNA #606 stated, she had other people to deal with and that he had only been up in his chair since 8:00 A.M. and other residents been up longer than him and he would just have to wait. He revealed he waited two hours as she had not returned; therefore, rang his call light. He stated STNA #606 answered his call light and raised her voice as she was upset that he had rang his light. He revealed she stated she was taking him off her list to take care of since he kept ringing and asking to lay down. He stated he felt her tone was rude and that she was disrespectful. He revealed he reported the incident to the Director of Nursing who stated she would handle the situation as well as he requested STNA #606 not to take care of him again because he revealed staff should never talk to a resident in that manner. Interview on 8/17/23 at 11:33 A.M. with the Director of Nursing (DON) revealed on 08/16/23 that Resident #32 told her his concerns that he had asked STNA #606 to make his bed and assist in laying him down, but that STNA #606 told him she had several residents to care for prior to him. She stated he had stated he had waited two hours and that she had still had not assisted him. She stated he had not stated anything regarding taking him off the list because he rang or asked too much. She revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 7 of 8 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 08/17/2023 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)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few STNA #606 was no longer on duty by the time he had reported the incident to her and that she had planned to follow up with STNA #606 the next time she was at work. She revealed she had filled out a witness statement but had not completed an investigation and/ or any additional follow up as she was awaiting to speak with STNA #606 her next assigned day to get her story. Review of the facility policy, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated 01/12/18, revealed residents have the right to be free from abuse, and neglect. The policy revealed it is the facilities policy to investigate all alleged violations involving abuse and neglect. The policy revealed the facility would immediately notify the administrator and the Ohio Department of Health as rights were extremely important and were necessary because they protect a vulnerable population. The policy revealed each facility must train its staff, particularly STNA's, but also to make sure those rights were followed and always maintained. The policy revealed every resident had the right to be treated with dignity, privacy, and respect. The policy revealed any staff who witnesses and suspects abuse should report it to his/ or her supervisor. This deficiency represents non-compliance investigated under Complaint Number OH00145009. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 8 of 8