Health inspection·April 16, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the memorandum QSO-24-08-NH and facility policy review, the facility failed to utilize enhance barrier precautions (EBP) when indicated for Residents #9 and #34. This affected two residents (#9 and #34) out of three residents reviewed for the donning of EBP. The facility reported 11 residents (#9, #10, #16, #18, #34, #36, #46, #48, #51, #53, and #54) who were identified on EBP. The facility census was 65. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #34 revealed an admission date of 04/01/25 with diagnoses including osteomyelitis (a bone infection, typically caused by bacteria) of vertebra, chronic ulcer of right foot, and diabetes. Review of the April 2025 physician orders revealed Resident #34 had an order to access and flush her Med Port (a device implanted under the skin to provide long-term access to a large vein near the heart for possible intravenous access) with normal saline 0.9 percent intravenously 10 milliliters (ml) prior to antibiotic, daptomycin (antibiotic) sodium chloride intravenous solution 500 milligram (mg) per 50 ml per Med Port every day and utilize EBP. Review of the care plan dated 04/03/25 revealed Resident #34 was on intravenous antibiotics due to osteomyelitis. Interventions included follow up with labs, monitor temperature, and treatment as ordered. There was nothing regarding EBP in the comprehensive care plan. Observation on 04/14/25 at 11:11 A.M. revealed Licensed Practical Nurse (LPN) #601 entered #34's room to administer her intravenous antibiotic. On the outside of the doorframe indicated Resident #34 was on EBP and a blue bag hung on the door that included gloves, gown, and masks. LPN #601 proceeded to perform hand hygiene, apply gloves and did not don a gown. LPN #601 leaned over Resident #35 causing her uniform to come in direct contact with Resident #34. She proceeded to flush her Med Port with normal saline, start the administration of her daptomycin (antibiotic) 500 mg intravenously, doffed her gloves and performed hand hygiene. Interview on 04/14/25 at 11:20 A.M. with LPN #601 verified Resident #34 was on EBP and she had only donned gloves and no gown. She verified she had come in direct contact with Resident #34 and should have worn a gown during the administration of her intravenous antibiotic. Interview on 04/14/25 at 2:40 P.M. with the Director of Nursing (DON) verified Resident #34 was to be on EBP due to her Med Port and wound. She revealed that it had been an issue with staff remembering to utilize EBP despite the signage on the doorframe and bag with personal protective equipment (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 3 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 04/16/2025 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)