Health inspection·December 18, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to exercise reasonable care for the protection of Resident #50's personal property from loss or theft. This affected one resident (#50) of one resident reviewed for personal property. The facility census was 67. Findings include: Review of the medical record for Resident #50 revealed an admission date of 12/30/21. Diagnoses included congestive heart failure (CHF), legal blindness, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had intact cognition. Review of the Resident Grievance/Concern Log dated October 2023 through December 2023 revealed no missing items reported by Resident #50. Interview on 12/11/23 at 2:14 P.M. with Resident #50 revealed she had a black sweater with her name written on it, and the sweater went missing about a month ago. Resident #50 stated she reported it to staff, had not heard anything else about it and it was not replaced. Interview on 12/13/23 at 4:50 P.M. with Laundry and Housekeeping Supervisor (LHS) #858 revealed when clothing went missing it was part of his responsible to try to locate the missing item that included following up with the resident to get more details, searching laundry, and other residents' closets to make sure it didn't get mistakenly placed in another's resident's closet. LHS #858 stated it took a day or two to search and if unable to locate the missing item he then turned it over in a concern form to the Administrator and typically the item was replaced. LHS #858 stated they were pretty good about finding missing items unless the item went missing weeks prior to them knowing about. LHS #858 stated he learned of Resident #50's missing black sweater about two weeks ago. LHS #858 stated he looked for it in laundry and searched in other residents' closets. LHS #858 stated he also tried to find something similar in laundry but was unable to find Resident #50's sweater. LHS #858 stated after two days of searching he turned it over to the Administrator and was not sure if the sweater was replaced. LHS #858 stated he didn't have any updates on the sweater. Interview on 12/13/23 at 5:13 P.M. with the Administrator revealed she had given the concern to LHS #858, but she did not log it onto the concern log. The Administrator stated she believed it was reported on 11/30/23 or some time at the end of November 2023. The Administrator stated LHS #858 informed her he couldn't find it but was going to continue to look for it. The Administrator stated LHS #858 did the concern form and LHS #858 still had it. The Administrator stated she had not followed up with LHS #858 so she will just replace Resident #50's sweater. Review of the facility policy titled Lost and Found, revised January 2008 revealed the facility shall assist all personnel and residents in safe guarding their personal property. 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 12/18/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on record review and interview, the facility did not ensure to implement policies and procedures to include screening of all employees against the State of Ohio Nurse Aide Registry (NAR) to identify if an employee had a finding concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. This had the potential to affect all 67 residents living in the facility. The facility census was 67. Residents Affected - Many Findings include: Review of the personnel files for the Administrator, Dietary Aide (DA) #680 and #828, Dietary Manager (DM) #613, Maintenance Assistant (MA) #885, Activities Assistant (AA) #630, Receptionist #614 and Housekeepers (HK) #600, #623, #650, #806, #811, #843, #871, #872, #874, and #879 revealed no evidence they were screened against the State of Ohio NAR. A review of the Ohio Nurse Aide Registry checks run on 12/18/23, during the annual survey, for the Administrator, DA #680 and #828, DM #613, MA #885, AA #630, Receptionist #614 and HK #600, #623, #650, #806, #811, #843, #871, #872, #874, and #879 revealed no evidence of reported abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property for these personnel. Interview with Human Resources (HR) #638 and the Assistant Director of Nursing (ADON) #896 on 12/14/23 at 3:45 P.M. verified there was no evidence the Administrator, DA #680 and #828, DM #613, MA #885, AA #630, Receptionist #614, and HK #600, #623, #650, #806, #811, #843, #871, #872, #874, and #879 were screened against the State of Ohio NAR. HR #638 stated she was unaware all employees needed checked against the Ohio NAR. HR #638 stated only state tested nursing assistants had been checked against the NAR since her start date of 07/19/23. ADON #896 revealed she was unaware all employees needed to be checked against the Ohio NAR. A review of the policy titled; Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 01/12/18, revealed the facility will do the following prior to hiring a new employee: check the Ohio NAR and any other registries for unlicensed persons prior to the use of that individual in the facility. 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 12/18/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a complete and accurate care plan for Resident #7. This affected one resident (#7) of 27 residents reviewed for care plans. The facility census was 67. Findings include: Review of Resident #7's medical record revealed an admission date of 08/01/22. Diagnoses included aphasia following cerebrovascular disease, spastic hemiplegia, peripheral vascular disease, benign prostatic hyperplasia with lower urinary tract symptoms and urinary tract infection Resident #7 was prescribed anticoagulant therapy of apixaban five milligram tablet two times a day by mouth for a diagnoses of cerebrovascular disease and peripheral vascular disease. Review of Resident #7's nurse progress notes indicated he was resistant to care including incontinence care. Review of Resident #7's physician's orders indicated Resident #7 had been prescribed antibiotic therapy on two occasions since admission for urinary tract infections. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had moderately impaired cognition, was taking an anticoagulant medication and was incontinent of bladder on occasion. Review of Resident #7's revised care plan dated 07/18/23 revealed the care plan did not include the use of and potential risks of the use of anticoagulant therapy nor did it include resistence to and/or refusal of care and risk of urinary tract infections and/or use of antibiotic therapy. During an interview on 12/18/23 at 11:49 A.M. with the Director of Nursing (DON), the DON verified the care plan did not include the use of and potential risks of the use of anticoagulant therapy and did not include the risk of UTI and/or use of antibiotic therapy or resistence to and/or refusal of care. The DON said this was because the MDS nurse's assessment data was incomplete and/or in-progress in Resident #7's medical record. 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 12/18/2023 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 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, interview, and record review the facility failed to ensure oxygen tubing was changed at least weekly for Resident #8 and #47 who were receiving oxygen therapy. This affected two residents (Residents #8 and #47) of the 22 residents (Residents #5, #6, #8, #9, #10, #14, #15, #19, #20, #23, #24, #28, #29, #30, #31, #35, #46, #47, #59, #66, #221, and #273.) the facility identified as receiving oxygen therapy. The facility census was 67. Residents Affected - Few Findings include: 1. Review of Resident #8's medical records revealed an admission date of 10/02/23. Diagnoses included obstructive sleep apnea, morbid obesity, chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. Review of the December 2023 physician orders revealed an order for oxygen at four liters/minute via nasal cannula (a tube with two prongs inserted in nasal openings to deliver oxygen). continuously to maintain an oxygen level of 92% and change oxygen tubing every Saturday on night shift and as needed. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed intact cognition and a dependence on oxygen. Review of a chest x-ray for Resident #8 dated 12/01/23 revealed pulmonary congestion and a bilateral lower lobe infiltrate. Review of the Treatment Administration Records (TAR) dated 12/01/23 to 12/11/23 revealed the nasal cannula tubing was signed off as changed on 12/09/23. Observation on 12/11/23 at 10:54 AM revealed Resident #8 sitting in a wheelchair with oxygen being delivered at four liters per minute via nasal cannula. The label on the nasal cannula/oxygen tubing was dated 12/03/23. Interview on 12/11/23 at 2:00 PM with Licensed Practical Nurse (LPN) #837 verified the date of 12/03/23 on Resident #8's nasal cannula/oxygen tubing. LPN #837 stated the oxygen tubing should be changed and dated weekly. 2. Record Review for Resident #47 revealed an admission date of 03/19/21. Diagnoses included chronic obstructive pulmonary disease (COPD), depression and anxiety. Review of physician orders for December 2023 revealed there were no orders for oxygen tubing maintenance. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had intact cognition and a primary medical condition of COPD. Observation on 12/11/23 at 11:15 AM revealed Resident #47 sitting in a chair next to the bed. There was an oxygen machine with the nasal cannula tubing attached to it and the machine was not running. Resident #47 revealed the oxygen was only used as needed and that was why there was no oxygen being used at the time of the observation. The date on the nasal cannula tubing was 12/03/23. Interview on 12/11/23 at 2:00 PM with Licensed Practical Nurse (LPN) #837 verified the date of (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 12/18/2023 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 0695 Level of Harm - Minimal harm or potential for actual harm 12/03/23 on Resident #47's oxygen tubing. LPN #837 stated the oxygen tubing should be changed and dated weekly. A review of the policy titled Departmental (Respiratory Therapy)-Prevention of Infection, dated November 2011, revealed oxygen cannula and tubing should be changed every seven days and as needed. Residents Affected - Few 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 12/18/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interviews, review of the call light detail report, call light policy, nursing staff schedules, payroll based journal (PBJ), nursing staff punch detail, the staffing tool and the facility assessment, the facility failed to respond to call lights in a timely manner for Resident #8, #32, #50 and #221, and failed to meet the minimum staffing requirement for all quarters of fiscal year 2023. This affected four residents (#8, #32, #50, and #221) of five residents reviewed for sufficient staffing and call light response times, and had the potential to affect all residents living in the facility. The facility census was 67. Findings include: 1. Interview on 12/11/23 at 11:09 A.M with Resident #14 stated sometimes there were not enough staff and call light response times were 20 minutes. Interview on 12/11/23 at 11:12 A.M. with Resident #221 stated call light response times were anywhere between 30 minutes to one hour and half. Interview on 12/11/23 at 2:17 P.M. with Resident #50 revealed she felt they were not enough staff because the call light response times were sometimes 30 minutes to 45 minutes long. Resident #50 stated one time while waiting she had urinated on herself. Interview on 12/11/23 at 4:17 P.M. with Resident #32 stated there were long wait times before call lights were answered, sometimes over an hour. Review of the call light detail report dated 12/01/23 through 12//07/23 revealed Resident #50's call light response time was 48 minutes and 22 seconds on Tuesday 12/05/23 at 4:20 A.M. Resident #32's call light response time was 42 minutes and 54 seconds on 12/05/23 at 6:18 A.M. Resident #221's call light response times were 33 minutes and 32 seconds on Saturday 12/02/23 at 7:40 A.M., 41 minutes and nine seconds on 12/02/23 at 9:07 A.M., 52 minutes and 54 seconds on 12/02/23 at 4:46 P.M., 52 minutes and 54 seconds on Monday 12/04/23 at 5:25 P.M., 35 minutes and 55 seconds on 12/05/23 at 1:33 A.M., 43 minutes and two seconds on 12/05/23 at 6:03 A.M., 47 minutes and 58 seconds on Wednesday 12/06/23 at 5:34 A.M., 37 minutes and 13 seconds on 12/06/23 at 5:44 P.M., 32 minutes and 40 minutes on 12/06/23 at 7:35 P.M., and 49 minutes and 26 seconds on Thursday 12/07/23 at 4:59 P.M. An interview was conducted on 12/18/23 at 11:49 A.M. with the Director of Nursing (DON) who stated anyone can answer call lights but pretty much the nurses and aides answered the call lights. The DON stated the expectation of call light response time was between 10 to 15 minutes. The DON verified the long call light response times on the call light detail report for Resident #32, #50, and #221. The DON stated Resident #221 had never complained to her about long call light response times and so she needed to look into what was going on the early morning of 12/05/23. Follow up interview on 12/18/23 at 12:52 P.M. with the DON revealed on the early morning of 12/05/23 the facility had one aide who came in late and another aide left early without communicating with staff. The DON stated her and three other staff members of the management team all hit the floor helping with patient care, and she assumed that was why the call light response times were long that morning. (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 12/18/2023 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 2. Review of the payroll based journal (PBJ) Staffing Data CASPER Report from the Centers for Medicare and Medicaid Services (CMS) revealed for Quarter three 2023 (April 1 to June 30) the facility triggered for excessively low weekend staffing. Review of the third quarter (04/01/23 through 06/30/23) fiscal year 2023 PBJ, nursing schedules, nursing punch detail and staffing tool revealed staffing levels did not meet the minimum staffing requirement of 2.50 hours per resident per day (ppd) of direct care for the following Saturdays and Sundays dated 04/16/23 at 2.34 ppd, 05/06/23 at 2.41 ppd, 05/07/23 2.45 ppd, and 06/25/23 2.46 ppd. Interview on 12/18/23 11:49 A.M. with the Director of Nursing (DON) verified the amount of direct care staff in the facility on those days did not meet the minimum staffing requirement of 2.50 for those days and stated she assumed it was related to call offs. Review of the call light detail report for 04/15/23, 04/16/23, 05/06/23, 05/07/23, 06/24/23, and 06/25/23 revealed Resident #50's call light response time was 39 minutes and 13 seconds on 04/16/23 at 6:29 PM and 33 minutes on 05/07/23 at 4:57 P.M. Resident #32's call light response time was 49 minutes and 54 seconds on 06/24/23 at 1:32 A.M. Resident #14's call light response time was 38 minutes and 53 seconds on 06/25/23 at 1:05 A.M. Interview on 12/18/23 at 3:33 P.M. with the DON and Assistant Director of Nursing (ADON) revealed initially when the call light was activated it would transmit to the aides' pager, then after seven minutes it would go to the nurse, and after so long an email was sent to the Administrator. The DON verified the long call light response times for Resident #14, #32 and #50 and stated she would have to look into it. The DON stated her expectation during change of shift was for staff to answer the call lights. Follow-up interview on 12/18/23 at 4:09 P.M. with the DON and ADON revealed regarding the call light response time on 04/16/23 for Resident #50 may have been related to a Covid-19 outbreak and staff taking longer to attend to call lights because of donning and doffing personal protective equipment (PPE). The DON stated on 05/07/23 at 4:57 P.M. was a mealtime. The DON stated on 06/24/23 and 06/25/23 they had four residents who were ill and required more assistance from staff so that could be why call light response times were long. The DON stated they try to adjust staffing to meet the resident acuity needs but call offs occured which affected how many staff were available to provide direct care. Review of the facility policy titled Answering the Call Light, revised March 2021, revealed the purpose of this procedure was to ensure timely responses to the resident's requests and needs. Review of the Facility Assessment, updated 05/30/23, revealed 6:00 A.M. to 9:00 A.M. and 6:00 P.M. to 9:00 P.M. were the peak hours to consider in regards to staffing and resource needs, and Covid-19 residents have additional staffing needs. The Facility Assessment indicated the facility would be staffed everyday to meet the acuity needs of the residents for an average census of 55 to 65 residents. This deficiency represents non-compliance investigated under Complaint Number OH00149023. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 8 of 8