Health inspection·May 21, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #9 was on Plavix. The SRI was unsubstantiated for abuse. There was no documented evidence that PCP #600 was notified of the bruising and unknown injury. Review of the incident report dated 04/28/25 and completed by LPN #404 revealed Resident #9 had scattered discoloration noted during her shower. She had large discoloration to her right side including right forearm, right breast and right inner thigh. She also had bruising to her left upper arm. Resident #9 was unaware when it had happened and denied pain. The immediate action indicated that the Director of Nursing (DON) and Administrator were notified. There was no documented evidence that PCP #600 was notified of the bruising. Interview on 05/20/25 at 7:53 A.M. with Resident #9 revealed she denied any abuse or that staff was rough during her care. She had no recollection of the incident on 04/28/25 regarding the bruising but stated, probably bumped something as she revealed, I bruise easy, always have. Interview on 05/20/25 at 4:08 P.M. with the DON verified there was no documented evidence that PCP #600 was notified of Resident #9's unknown injury (bruising to her right side including right forearm, right breast, right inner thigh and bruising to her left upper arm) that was discovered on 04/28/25. She revealed she was unsure why the nurse did not contact PCP #600 as she stated, it should have been done. Review of the facility policy labeled, Anticoagulation- Clinical Protocol, dated November 2018, revealed the staff and physician would monitor for possible complications in residents who were being anticoagulated and manage related problems. The policy revealed if a resident showed signs of excessive bruising, hematuria (blood in urine), or other evidence of bleeding the nurse would discuss the situation with the physician before giving the next scheduled dose of medication. The policy also revealed the physician would order measures to address any complications. Review of the facility policy labeled, Change in a Resident's Condition or Status, dated February 2021, revealed the facility promptly notified the resident, and the resident's physician of changes in the resident's medical/mental condition or status. The policy revealed the nurse would notify the resident's physician when there was an accident or incident involving the resident, discovery of injuries of unknown source, and/or need to alter resident's medical treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 2 of 33 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 05/21/2025 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)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to ensure as needed (PRN) psychotropic medication was reviewed by a practitioner after 14 days for necessity and appropriateness. This affected one (Resident #33) out of five residents reviewed for psychotropic medications. The facility census was 66. Findings include: Review of the medical record for Resident #33 revealed an admission date of 03/20/19 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder recurrent, adjustment disorder with anxiety, and vascular dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 had severe cognitive impairment. Review of the care plan last reviewed on 03/12/25 revealed Resident #33 had potential for adverse effects from antianxiety medications and used PRN antianxiety medications for anxiety. Interventions included administering medications as ordered by a physician and monitoring/documenting side effects and effectiveness. Review of the physician orders for Resident #33 revealed a routine order dated 09/23/24 for Vistaril (a sedative/hypnotic which is a psychotropic) 25 milligrams (mg) twice daily for anxiety or agitation. Another order was added on 04/01/25 for Vistaril 25 mg every six hours PRN for anxiety or agitation. There was no duration ordered for the psychotropic. Review of the pharmacy recommendation dated 04/07/25 revealed a pharmacist requested Resident #33's PRN order for Vistaril 25 mg every six hours for anxiety be reviewed by a practitioner after 14 days as required for psychotropics. The physician did not review the medication as recommended until 05/08/25 when the physician ordered the medication to continue for three months due to anxiety. Review of the Medication Administration Record (MAR) for April 2025 indicated the PRN Vistaril order was administered on 04/07/25 and 04/29/25. Further review of the physician orders for Resident #33 revealed the PRN Vistaril order dated 04/01/25 which had no duration was changed on 05/09/25 to Vistaril 25 mg every six hours PRN for anxiety or agitation for a duration of three months. Review of the physician progress notes from 04/01/25 to 05/08/25 revealed no review of the PRN psychotropic after 14 days as required. Interview on 05/21/25 at 12:17 P.M. with Director of Nursing (DON) verified Resident #33's PRN psychotropic medication (Vistaril) was not reviewed by the physician within 14 days as required. The DON confirmed the pharmacist recommendation on 04/07/25 was not addressed timely until 05/08/25 in which the psychotropic medication continued until then. Review of the facility policy, Antipsychotic Medication Use, revised December 2016, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 3 of 33 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 05/21/2025 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)

F 0605 Level of Harm - Minimal harm or potential for actual harm residents would not receive PRN doses of psychotropic medications unless the medication was necessary to treat a specific condition documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days required the practitioner to document the rationale for the extended order, and the duration of the PRN order would be indicated within the order. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 4 of 33 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 05/21/2025 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)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to complete an annual Minimum Data Set (MDS) assessment in the required timeframe (within 366 days from the previous comprehensive assessment) for Resident #22. This affected one (Resident #22) out of 11 residents reviewed for comprehensive MDS assessments. The facility census was 66. Findings include: Review of the medical record for Resident #22 revealed an admission date of 05/13/20 with diagnoses including chronic obstructive pulmonary disease and diabetes mellitus type two. Review of the MDS assessments for Resident #33 revealed the last comprehensive assessment completed was an annual MDS assessment dated [DATE]. There was no comprehensive assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #22 had no comprehensive assessment completed since 04/01/24 within the required timeframe. Review of the facility policy, Comprehensive Assessments, revised March 2022, revealed comprehensive assessments were conducted in accordance with criteria and timeframes establish in the Resident Assessment Instrument (RAI) User Manual, and Annual assessments were completed at least every 366 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 5 of 33 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 05/21/2025 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)

F 0638 Assure that each resident’s assessment is updated at least once every 3 months. Level of Harm - Minimal harm or potential for actual harm Based on record reviews and interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments in the required timeframe (within 92 days from the previous assessment). This affected nine (Residents #11, #20, #21, #22, #26, #29, #41, #42 and #60) out of 11 residents reviewed for quarterly MDS assessments. The facility census was 66. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 07/31/11 and diagnoses included Parkinsonism, dementia and diabetes mellitus (DM) type two. Review of the MDS assessments for Resident #11 revealed the last quarterly assessment completed was dated 12/31/24. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #11 had no quarterly assessment completed after 12/31/24 within the required timeframe. 2. Review of the medical record for Resident #20 revealed an admission date of 01/09/16 and diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and hypertensive heart disease. Review of MDS assessments for Resident #20 revealed an annual assessment was completed dated 01/03/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #20 had no quarterly assessment completed after 01/03/25 within the required timeframe. 3. Review of the medical record for Resident #21 revealed an admission date of 09/03/15 and diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, COPD and chronic pain syndrome. Review of MDS assessments for Resident #21 revealed a significant change assessment was completed dated 01/03/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #21 had no quarterly assessment completed after 01/03/25 within the required timeframe. 4. Review of the medical record for Resident #22 revealed an admission date of 05/13/20 and diagnoses included COPD and DM type two. Review of MDS assessments for Resident #22 revealed the last quarterly assessment completed was dated 01/02/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #22 had no quarterly assessment completed after 01/02/25 within the required timeframe. 5. Review of the medical record for Resident #26 revealed an admission date of 01/09/22 and diagnoses included hypertensive heart disease, dementia and Alzheimer's disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 6 of 33 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 05/21/2025 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)

F 0638 Level of Harm - Minimal harm or potential for actual harm Review of MDS assessments for Resident #26 revealed an annual assessment was completed dated 12/31/24. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #26 had no quarterly assessment completed after 12/31/24 within the required timeframe. Residents Affected - Some 6. Review of the medical record for Resident #29 revealed an admission date of 05/10/23 and diagnoses included degeneration of nervous system due to alcohol, COPD and hypertensive heart disease. Review of MDS assessments for Resident #29 revealed the last quarterly assessment completed was dated 12/31/24. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #29 had no quarterly assessment completed after 12/31/24 within the required timeframe. 7. Review of the medical record for Resident #41 revealed an admission date of 12/30/20 and diagnoses included epilepsy, dementia, DM type two and congestive heart failure. Review of MDS assessments for Resident #41 revealed the last quarterly assessment completed was dated 01/03/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #41 had no quarterly assessment completed after 01/03/25 within the required timeframe. 8. Review of the medical record for Resident #42 revealed an admission date of 12/26/23 and discharge date of 05/05/25. Diagnoses included hypertensive heart disease and dementia. Review of MDS assessments for Resident #42 revealed an annual assessment was completed dated 01/02/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #42 had no quarterly assessment completed after 01/02/25 within the required timeframe. 9. Review of the medical record for Resident #60 revealed an admission date of 09/06/24 and diagnoses included hypertensive heart disease, chronic pain syndrome and asthma. Review of MDS assessments for Resident #60 revealed the last quarterly assessment completed was dated 01/08/25. There was no quarterly assessment completed thereafter as required. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #60 had no quarterly assessment completed after 01/08/25 within the required timeframe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 7 of 33 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 05/21/2025 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)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and facility policy review, the facility failed to complete and submit Minimum Data Set (MDS) assessments within the required timeframes. This affected 11 (Residents #11, #20, #21, #22, #26, #29, #41, #42, #60, #62 and #70) out of 11 residents reviewed for MDS assessments. The facility census was 66. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 07/31/11 and diagnoses included Parkinsonism, dementia and diabetes mellitus (DM) type two. Review of the quarterly MDS assessment for Resident #11 with an ARD (assessment reference date) of 12/31/24 revealed it was completed on 02/13/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 12/31/24. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #11's assessment was not completed timely. 2. Review of the medical record for Resident #20 revealed an admission date of 01/09/16 and diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia and hypertensive heart disease. Review of the annual MDS assessment for Resident #20 with an ARD date of 01/30/25 revealed it was completed on 03/06/25 and the CAA (care area assessment) completed on 03/06/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after the ARD on 01/30/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #20's assessment and CAA were not completed timely. 3. Review of the medical record for Resident #21 revealed an admission date of 09/03/15 and diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side, COPD and chronic pain syndrome. Review of the significant change MDS assessment for Resident #21 with an ARD date of 01/03/25 revealed it was completed on 02/04/25 and the CAA completed on 02/04/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after determination of change in resident status on 01/03/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #21's assessment and CAA were not completed timely. 4. Review of the medical record for Resident #22 revealed an admission date of 05/13/20 and diagnoses included COPD and DM type two. Review of the quarterly MDS assessment for Resident #22 with an ARD date of 01/02/25 revealed it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 8 of 33 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 05/21/2025 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)

F 0640 Level of Harm - Minimal harm or potential for actual harm was completed on 02/26/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 01/02/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #22's assessment was not completed timely. Residents Affected - Some 5. Review of the medical record for Resident #26 revealed an admission date of 01/09/22 and diagnoses included hypertensive heart disease, dementia and Alzheimer's disease. Review of the annual MDS assessment for Resident #26 with an ARD date of 12/31/24 revealed it was completed on 02/14/25 and the CAA completed on 02/14/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after the ARD on 12/31/24. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #26's assessment and CAA were not completed timely. 6. Review of the medical record for Resident #29 revealed an admission date of 05/10/23 and diagnoses included degeneration of nervous system due to alcohol, COPD and hypertensive heart disease. Review of the significant change assessment with an ARD date of 11/25/24 revealed it was completed on 01/15/25 and the CAA completed on 01/15/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after determination of change in resident status on 11/25/24. Review of the quarterly MDS assessment for Resident #29 with an ARD date of 12/31/24 revealed it was completed on 02/14/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 12/31/24. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #29's assessments and CAA were not completed timely. 7. Review of the medical record for Resident #41 revealed an admission date of 12/30/20 and diagnoses included epilepsy, dementia, DM type two and congestive heart failure. Review of the quarterly MDS assessment for Resident #41 with an ARD date of 01/03/25 revealed it was completed on 02/03/25 and submitted on 03/20/25. The assessment was not completed within the required timeframe which was within 14 days after the ARD of 01/03/25, and it was not submitted timely which was within 14 days after completion on 02/03/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #41's assessment was not completed or submitted timely. 8. Review of the medical record for Resident #42 revealed an admission date of 12/26/23 and discharge date of 05/05/25. Diagnoses included hypertensive heart disease and dementia. Review of the annual MDS assessment for Resident #42 with an ARD date of 01/02/25 revealed it was completed on 02/19/25 and the CAA completed on 02/19/25. The assessment and CAA were not completed within the required timeframe which was within 14 days after the ARD of 01/02/25. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 9 of 33 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 05/21/2025 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)

F 0640 Level of Harm - Minimal harm or potential for actual harm Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #42's assessment and CAA were not completed timely. 9. Review of the medical record for Resident #60 revealed an admission date of 09/06/24 and diagnoses included hypertensive heart disease, chronic pain syndrome and asthma. Residents Affected - Some Review of the admission MDS assessment for Resident #60 with an ARD date of 09/12/24 revealed it was completed on 10/04/24 and the CAA completed on 10/04/24. The assessment and CAA were not completed within the required timeframe which was within 14 calendar days after admission on [DATE]. Review of the quarterly MDS assessment for Resident #60 with an ARD date of 01/08/25 revealed it was completed on 03/13/25. The assessment was not completed within the required timeframe, which was 14 days after the ARD of 01/08/25. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #60's assessments were not completed timely. 10. Review of the medical record for Resident #62 revealed an admission date of 12/29/24 and discharge date of 02/04/25. Diagnoses included metabolic encephalopathy and COPD. Review of the admission MDS assessment for Resident #62 with an ARD date of 01/05/25 revealed it was completed on 01/13/25 and the CAA completed on 01/13/25. The assessment and CAA were not completed within the required timeframe which was within 14 calendar days after admission on [DATE]. Review of the discharge return not anticipated MDS assessment for Resident #62 dated 01/30/25 revealed it was completed on 03/26/25. The assessment was not completed within the required timeframe which was within 14 days after discharge on [DATE]. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #62's assessments were not completed timely. 11. Review of the medical record for Resident #70 revealed an admission date of 04/01/25 and diagnoses included intraspinal abscess and granuloma, DM type two and chronic pain syndrome. Review of the admission MDS assessment for Resident #70 with an ARD date of 04/08/25 revealed it was completed on 04/29/25 and the CAA completed on 04/29/25. The assessment and CAA were not completed within the required timeframe which was within 14 calendar days after admission on [DATE]. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Resident #70's assessment was not completed timely. Review of the facility policy, Comprehensive Assessments, revised March 2022 revealed comprehensive assessment were conducted in accordance with criteria and timeframes establish in the Resident Assessment Instrument (RAI) User Manual including admission assessments which must be completed by day 14. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 10 of 33 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 05/21/2025 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)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and facility policy review, the facility failed to provide residents and representatives with a written summary of the baseline care plan. This affected two (Residents #76 and #77) of two residents reviewed for baseline care plans. The facility census was 66. Findings include: 1. Review of the medical record for Resident #76 revealed an admission date of 02/18/25 and discharge date of 03/07/25. Diagnoses included nonrheumatic aortic valve stenosis, nonrheumatic mitral valve insufficiency, pulmonary hypertension, nonrheumatic tricuspid valve insufficiency, chronic obstructive pulmonary disease, atrial fibrillation, and congestive heart failure (CHF). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #76 was rarely or never understood. The baseline care plan dated 02/18/25 included Resident #76's use of antibiotics for a urinary tract infection, diuretics due to CHF, cognitive status and needs for activities of daily living assistance. Review of the family conference form dated 02/21/25 revealed there was a conference held with Resident #76's family to discuss the resident's care. However, there was no evidence Resident #76, and the resident's representative received a written summary of the baseline care plan. Review of the nursing progress notes from February 2025 to March 2025 revealed no indication Resident #76 and the resident's representative received a written summary of the baseline care plan. Interview on 05/20/25 at 4:03 P.M. with MDS Coordinator #333 verified Resident #76 and the resident's representative did not receive a written summary of the baseline care plan. 2. Review of the medical record for Resident #77 revealed an admission date of 02/04/25 and discharge date of 02/21/25. Diagnoses included myocardial infarction type two, malignant neoplasm of prostate, severe protein-calorie malnutrition, pulmonary fibrosis, and chronic kidney disease stage two. Review of the admission MDS assessment dated [DATE] revealed Resident #77 had moderate cognitive impairment. The baseline care plan dated 02/05/25 included Resident #77's fall risk, plan for discharge, advanced care planning, wound prevention, cognitive status and needs for activities of daily living assistance. Review of the family conference form dated 02/06/25 revealed there was a conference held with Resident #77's family to discuss the resident's care. However, there was no evidence Resident #77, and the resident's representative received a written summary of the baseline care plan. Review of the nursing progress notes for February 2025 revealed no indication Resident #77 and the resident's representative received a written summary of the baseline care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 11 of 33 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 05/21/2025 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)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 05/21/25 at 10:04 A.M. with MDS Coordinator #333 verified Resident #77 and the resident's representative did not receive a written summary of the baseline care plan. Review of the facility policy, Care Plans - Baseline, revised March 2022, revealed residents and/or representatives are provided a written summary of the baseline care plan in a language the resident/representative can understand. Event ID: Facility ID: 366047 If continuation sheet Page 12 of 33 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 05/21/2025 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)

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** 2. Review of the medical record revealed Resident #140 was admitted to the facility on [DATE] with diagnoses including PTSD, recurrent major depressive disorder, generalized anxiety disorder, congestive heart failure, chronic obstructive pulmonary disease, and alcohol dependence with unspecified alcohol use disorder. Review of the baseline care plan dated 05/13/25 revealed Resident #140 was new to the nursing facility, had adjustment issues related to admission, had the potential for bleeding, was ordered physical therapy (PT) and occupational therapy (OT), had the potential for skin impaired skin integrity, had skin impairments noted on admission, was admitted on a regular diet, was admitted with anti-anxiety medications, was dependent on the facility's activities staff for activities and social interaction, was at risk for falls, and was at risk for nutritional problems related to class three morbid obesity. There was no information found in the baseline care plan related to Resident #140's diagnosis of PTSD. Interview with the Director of Nursing (DON) on 05/19/25 at 4:26 P.M. verified there were no care plans used for trauma informed care, to obtain information on the resident's triggers, and confirmed there was no information on Resident #140's Kardex. Interview on 05/20/25 at 2:24 P.M. revealed SSD #318 will be doing a brief trauma assessment for residents with PTSD/trauma going forward, did not complete one until yesterday 05/19/25 for Resident #140 and had a meeting with the resident and the resident's family, but typically the assessments should be completed within 48 hours of admission so it could be reflected on the baseline care plan, but in this case, that did not get done prior to the baseline care plan being completed, so trauma care was not on the residents baseline care plan, but should have been. Review of Residents 140's Brief Trauma Questionnaire revealed it was completed on 05/19/25 at 3:59 P.M. Interview with the MDS Coordinator #333 on 05/20/25 at 4:03 P.M. confirmed that the resident did not have a baseline care plan in place within the first 48 hours for PTSD. The care plan was initiated on 05/16/25. Based on record reviews, interviews and facility policy review, the facility failed to implement a comprehensive care plan to include trauma-informed care for Residents #25 and #140. This affected two (Residents #25 and #140) out of two residents reviewed for trauma-informed care. The facility reported two (Residents #25 and #140) who had trauma related diagnoses. The facility census was 66. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of the quarterly MDS assessment completed 01/11/25 revealed Resident #25 had moderate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 13 of 33 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 05/21/2025 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)

F 0656 cognitive impairment. Level of Harm - Minimal harm or potential for actual harm Review of the physician orders effective May 2025 revealed no orders related to trauma-informed care other than to consult psychotherapies. Residents Affected - Few Review of the assessments for Resident #25 revealed no trauma screening or assessments completed since admission. Review of the nursing progress notes from May 2024 to May 2025 revealed no documentation relevant to Resident #25's trauma or trauma-informed care. Review of the physician progress notes from psychiatric services on 11/18/24, 12/09/24, 01/14/25, 02/10/25, 03/10/25 and 05/05/25 revealed no documentation relevant to Resident #25's trauma or trauma-informed care. Review of the care plan dated 02/18/17 and last updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. The resident had depression, anxiety, and a history of alcohol abuse, who demonstrated behaviors related to maintaining personal space. There was no reference in the care plan relevant to Resident #25's trauma including triggers and trauma-informed care. Review of the nursing assistant Kardex for Resident #25 effective 05/19/25 indicated no information relevant to trauma-informed care. Interview on 05/19/25 at 4:26 P.M. with the Director of Nursing (DON) verified there were no assessments used for trauma informed care and no information on Resident #25's trauma, triggers or needed interventions to care for the resident's PTSD which included in the care plan, Kardex and progress notes. Interview on 05/20/25 at 1:52 P.M. with Resident #25 denied any staff had discussed or asked questions related to the PTSD or trauma. Interview on 05/20/25 2:24 P.M. with Social Services Director (SSD) #318 verified there was no trauma assessment completed for Resident #25 to contribute to trauma-informed care. SSD #318 indicated a trauma assessment should have been completed within 48 hours after admission so it would reflect on the baseline care plan and then into the comprehensive care plan thereafter. Resident #25 had no trauma assessment completed upon admission and none afterwards so therefore it was not included in the care plan. Review of the facility policy, Trauma Informed Care, revised March 2019, revealed trauma-informed care was culturally sensitive and person-centered. Review of the facility policy, Using the Care Plan, revised August 2006, revealed the care plan would be used in developing the resident's daily care routines and available to staff who have responsibility for providing care or services to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 14 of 33 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 05/21/2025 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, interviews and facility policy review, the facility failed to revise care plans for Residents #3 and #25 to include the use and monitoring of seat belts and alarms as restrictive devices and failed to complete comprehensive care plans within the required timeframe (within 21 days after admission) for Residents #60 and #70. This affected four (Residents #3, #25, #60 and #70) out of four residents reviewed for comprehensive care plan completion and revision. The facility census was 66. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 08/28/03 with diagnoses of hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, speech and language deficits following cerebrovascular disease, chronic kidney disease and vascular dementia. Review of a physician order dated 09/17/24 indicated Resident #3 had a Velcro seat belt to the wheelchair for positioning and safety. Review of the quarterly Minimum Data Set (MDS) assessment completed 03/19/25 revealed Resident #3 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #3 had impaired cognition with fluctuation including poor decision making, poor impulse control and a communication problem so staff had to anticipate needs. Resident #3 also had potential for falls related to limited mobility, impaired balance and coordination due to right-sided hemiplegia. Staff were to anticipate Resident #3's needs, be sure a call light was in reach and apply a Velcro seat belt to the wheelchair for positioning and safety. There was no plan of care to monitor the seat belt as necessary, appropriate or least restrictive. Observation on 05/18/25 at 9:50 A.M. revealed Resident #3 sitting in a wheelchair watching television with a seat belt secured with Velcro at the waist. Review of the Treatment Administration Record (TAR) from April 2025 to May 2025 revealed Resident #3's seat belt was in place each shift. Interview on 05/19/25 at 4:35 P.M. with the Director of Nursing (DON) verified Resident #3 had a Velcro seat belt ordered, and the care plan only referenced the seat belt as a fall intervention without any plan for monitoring or assessing the device as necessary, appropriate or least restrictive. Interview on 05/20/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #364 verified Resident #3 wore a seat belt daily while up in the wheelchair and had it for several months, and it was used to prevent the resident from getting up unassisted. 2. Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type two, dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder (PTSD). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 15 of 33 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 05/21/2025 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a physician order dated 09/17/24 indicated Resident #25 had an alarming Velcro seat belt to the wheelchair for positioning and safety. Another physician order dated 03/17/25 specified an additional pressure alarm was applied to the wheelchair for safety. Review of the Quarterly MDS assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. Resident #25 also had potential for falls related to limited range of motion of the right lower extremity, poor balance and poor safety awareness. Staff were to be sure a call light was in reach and maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The alarming Velcro seat belt was not addressed in the plan of care, and there was no plan to monitor either the seat belt or pressure alarm as necessary, appropriate or least restrictive. Review of the TAR from April 2025 to May 2025 revealed Resident #25's seat belt and additional pressure alarm was in place each shift. Interview on 05/19/25 at 4:35 P.M. with the DON verified Resident #25 had an alarming Velcro seat belt and pressure alarm ordered, and the care plan did not address these devices as being in place or removed, nor any plan for monitoring or assessments. Observation on 05/20/25 at 1:37 P.M. with CNA #364 of Resident #25 verified there was no physician ordered seatbelt or pressure alarm in place for safety or positioning. Interview at the time of the observation with CNA #364 could not state when or why the devices were not in place. An interview on 05/20/25 at 1:52 P.M. with Resident #25 denied remembering when the alarm or seat belt was last used or whether being able to release the seat belt when it was in place. Interview on 05/20/25 at 1:54 P.M. with Registered Nursing (RN) #431 confirmed both the seat belt and pressure alarm devices were not in place as ordered and were signed off on the TAR as being checked and in place as safety interventions. RN #431 indicated the devices were removed some time ago but could not identify when but remembered it was because Resident #25 was no longer trying to get up without assistance. Review of the progress notes from September 2024 to May 2025 revealed no documentation to identify the removal of the alarming seat belt or pressure alarm for Resident #25. Observation on 05/21/25 at 12:13 P.M. of Resident #25 being transported to the dining room via wheelchair revealed no visible seat belt or alarming device in place. 3. Review of the medical record for Resident #60 revealed an admission date of 09/06/24 with diagnoses including hypertensive heart disease, chronic pain syndrome and asthma. Review of the admission MDS assessment dated [DATE] revealed it was completed on 10/04/24. The care area assessment and care plan were completed on 10/04/24. This was outside of the required timeframe for completing comprehensive care plans. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Residents #60's care plan was completed late, outside of the required 21 days after admission timeframe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 16 of 33 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 05/21/2025 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of the medical record for Resident #70 revealed an admission date of 04/01/25 with diagnoses including intraspinal abscess and granuloma, diabetes mellitus type two and chronic pain syndrome. Review of the admission MDS assessment dated [DATE] revealed it was completed on 04/29/25. The care area assessment and care plan were completed on 04/29/25. This was outside of the required timeframe for completing comprehensive care plans. Interview on 05/19/25 at 10:26 A.M. with MDS Coordinator #333 verified Residents #70's care plan was completed late, outside of the required 21 days after admission timeframe. Review of the facility policy, Using the Care Plan, revised August 2006, revealed the care plan was used in developing the resident's daily care routines and was available to staff who have responsibility for providing care or services to residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 17 of 33 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 05/21/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews and facility policy review, the facility failed to properly monitor and maintain safety interventions which were in place for Resident #25. This affected one (Resident #25) out of two residents reviewed for safety interventions. The facility census was 66. Findings include: Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type two, dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder. Review of the quarterly Minimum Data Set (MDS) assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Review of a physician order dated 09/17/24 indicated Resident #25 had an alarming Velcro seat belt to the wheelchair for positioning and safety. Another physician order dated 03/17/25 specified an additional pressure alarm was applied to the wheelchair for safety. Review of the assessments for Resident #25 revealed there were none completed for either the alarming seat belt on 09/17/24 or the pressure alarm on 03/17/25, and none thereafter to determine necessity and appropriateness. Review of the care plan updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. Resident #25 also had potential for falls related to limited range of motion of the right lower extremity, poor balance, poor safety awareness, and a history of falls. Staff were to be sure a call light was in reach and maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The alarming Velcro seat belt was not addressed in the care plan. Review of the progress notes from September 2024 to May 2025 revealed no documentation to justify the use of either the alarming seat belt or pressure alarm for Resident #25 or to monitor those devices. Review of the Treatment Administration Record (TAR) from April 2025 to May 2025 revealed Resident #25's seat belt was checked every shift for placement and functioning, and the pressure alarm was checked twice daily for placement and functioning for safety. Review of the nursing assistant [NAME] (summary of resident information) for Resident #25 effective 05/19/25 indicated to maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The physician ordered seat belt was not listed on the [NAME] to inform nursing assistants of the safety order. Interview on 05/19/25 at 4:35 P.M. with the Director of Nursing (DON) verified Resident #25 had an alarming Velcro seat belt and pressure alarm ordered without any assessments to ensure it was necessary and appropriate. The care plan did not address these devices with any plan for monitoring or assessments. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 18 of 33 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 05/21/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/20/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #364 of Resident #25 verified there was no physician ordered seatbelt or pressure alarm in place for safety or positioning. Interview at the time of the observation with CNA #364 could not state when or why the devices were not in place. An interview on 05/20/25 at 1:52 P.M. with Resident #25 denied remembering when the alarm or seat belt was last used. Interview on 05/20/25 at 1:54 P.M. with Registered Nursing (RN) #431 confirmed both the seat belt and pressure alarm devices were not in place as ordered and were signed off on the TAR as being checked and in place as safety interventions. RN #431 indicated the devices were removed some time ago but could not identify when but remembered it was because Resident #25 was no longer trying to get up without assistance. A second review of the progress notes from September 2024 to May 2025 revealed no documentation to identify the removal of the alarming seat belt or pressure alarm for Resident #25. Observation on 05/21/25 at 12:13 P.M. of Resident #25 being transported to the dining room via wheelchair revealed no visible seat belt or alarming device in place. Review of the facility policy, Managing Falls and Fall Risk, revised March 2018, revealed position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy, and staff will document each resident's response to interventions intended to reduce falls or the risks of falling. If interventions were successful in preventing falling, staff would continue the interventions or reconsider whether the measures were still needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 19 of 33 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 05/21/2025 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)

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 record review, interview, observation and review of the facility policy, the facility failed to clean Resident #10's Continuous Positive Airway Pressure (CPAP) (machine used to treat sleep apnea) equipment and mask as recommended. This affected one (Resident #10) out of one resident reviewed for use of CPAP. This had the potential to affect two (Residents #9 and #10) who had orders for CPAPs. The facility census was 66. Residents Affected - Few Findings include: Review of the medical record for Resident #10 revealed an admission date of 11/03/21 with diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, diabetes and hypertension. Review of the undated care plan revealed Resident #10 had diagnoses of COPD and obstructive sleep apnea. Resident #10 utilized a BiPap (Bilevel positive airway pressure) with oxygen every night. Interventions included oxygen therapy as ordered, head of bed elevated as tolerated, and monitor for difficulty breathing. There was nothing in the care plan regarding cleaning of respiratory equipment. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had intact cognition. She required oxygen therapy and was on a non-invasive mechanical ventilator. Review of the nursing notes dated 04/01/25 to 05/18/25 revealed no documentation regarding Resident #10's CPAP equipment and/or mask was cleaned. Review of the Treatment Administration Record (TAR) for April 2025 and May 2025 revealed there were no orders/documentation regarding the cleaning of Resident #10's CPAP equipment and/or mask. Review of the May 2025 Physician Orders revealed Resident #10 had an order to wear a CPAP when sleeping at night and as needed during the day. There were no orders regarding cleaning of CPAP equipment and/or mask. Interview on 05/18/25 at 10:58 A.M. with Resident #10 revealed she wore a CPAP at night and was concerned as the staff never cleaned her CPAP equipment and/or mask. She revealed she was concerned about getting an infection due to the equipment being dirty. Observation on 05/18/25 at 10:58 A.M. revealed Resident #10's CPAP machine was sitting on her dresser with her mask hanging on a clip on the wall. Observations on 05/19/25 at 9:30 A.M., 05/19/25 at 11:59 A.M., and 05/20/25 at 7:56 A.M. revealed no indication Resident #10's CPAP machine, equipment and mask were cleaned. Interview on 05/20/25 at 2:00 P.M. with Licensed Practical Nurse (LPN) #304 revealed she was the nurse assigned to care for Resident #10 and was frequently on her unit. She revealed she was unsure who cleaned the CPAP equipment and/or mask as nothing was on the TAR to indicate the floor nurse was to clean it. She verified she had not cleaned the equipment when she was assigned to Resident #10. Interview on 05/20/25 at 2:04 P.M. with LPN #312 revealed when she was first asked if she handled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 20 of 33 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 05/21/2025 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cleaning of CPAP equipment and/or masks she stated, well that is the question as she stated she was going to transfer the cleaning to Respiratory/Registered Nurse (RN) #360 as she had too much to manage with the wounds and medical records. When this surveyor attempted to clarify the cleaning of the CPAP equipment, LPN #312 revealed there was no official cleaning schedule and/or procedure that she followed. She verified she had no documentation in regard to when Resident #10's CPAP equipment and/or mask was cleaned in the last two months. Interview on 05/20/25 at 2:05 P.M. with MDS Coordinator/LPN #333 verified there was nothing in the care plan regarding cleaning the CPAP equipment and/or mask. She revealed the care plan should have indicated she utilized a CPAP not a BiPap. Interview on 05/20/25 at 2:15 P.M. with the Director of Nursing (DON) verified the facility did not have a system in place regarding when the CPAP equipment and/or masks were getting cleaned. She verified there was no documentation regarding the cleaning of Resident #10's CPAP equipment and/or mask. She revealed there should have been an order placed on the TAR indicating how the equipment was to be cleaned, how often it should have been cleaned and the nurse documenting when it was cleaned. Review of the facility policy, Care of the BiPap/ CPAP Equipment, dated 01/17/09, revealed the objective of the policy was to decrease the risk of infections and maintain a clean environment. The procedure revealed to rinse the tubing and the mask in warm, soapy water, using mild detergent, soak the mask and large boar tubing for 20 minutes in a one-to-three-part solution of white vinegar and water, and hang both the mask and tubing on a clean towel to air dry. The headgear, tubing and mask should be washed once a week and as needed. This deficiency represents non-compliance investigated under Complaint Number OH00165776. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 21 of 33 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 05/21/2025 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)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #140 was admitted to the facility on [DATE] with diagnoses including PTSD, anxiety disorder, congestive heart failure, chronic obstructive pulmonary disease, and alcohol dependence with unspecified alcohol use disorder. Residents Affected - Few Review of the baseline care plan dated 05/13/25 revealed Resident #140 was new to the nursing facility, had adjustment issues related to admission, had the potential for bleeding, was ordered physical therapy (PT) and occupational therapy (OT), had the potential for skin impaired skin integrity, had skin impairments noted on admission, was admitted on a regular diet, was admitted with anti-anxiety medications, was dependent on the facility's activities staff for activities and social interaction, was at risk for falls, and was at risk for nutritional problems related to class three morbid obesity. There was no information found in the baseline care plan related to Resident #140's diagnosis of PTSD. The interview with the DON on 05/19/25 at 4:26 P.M. verified there were no care plans related to Resident #140's trauma informed care, no evidence the facility obtained information on resident's triggers, and verified there was no information related to trauma-informed care on the Kardex. Interview with SSD #318 on 05/20/25 at 2:24 P.M. will be doing a brief trauma assessment for residents with PTSD/trauma going forward, did not complete one until yesterday, 05/19/25, for Resident #140 and had a meeting with the resident and the resident's family, but typically the assessments should be completed within 48 hours of admission so it is reflected on the baseline care plan, but in this case, that did not get done prior to the baseline care plan being completed, so trauma care was not on it, but it should have been. Review of Residents #140's Brief Trauma Questionnaire confirmed it was completed on 05/19/25 at 3:59 P.M. Interview on 05/20/25 at 3:43 P.M. with the [NAME] verified there was no evidence of staff training on trauma-informed care, but the trauma assessment and staff training were being implemented to take place this Thursday, 05/22/25. Interview with the MDS Coordinator #333 on 05/20/25 at 4:03 P.M. confirmed that Resident #140 did not have a baseline care plan in place within the first 48 hours for PTSD. The pare plan was initiated on 05/16/25. Review of the facility policy titled, Trauma Informed Care, revised in March 2019, revealed all staff are to be provided with in-service training about trauma, its impact on health, and PTSD in the context of the healthcare setting, nursing staff are to be trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. The facility supports a culture of emotional well-being and physical safety for staff, residents and visitors. Trauma-informed care is culturally sensitive, and person-centered caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers and implement universal screening of residents for trauma. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 22 of 33 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 05/21/2025 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)

F 0699 Level of Harm - Minimal harm or potential for actual harm Based on record reviews, interviews and facility policy review, the facility failed to adequately train staff on trauma related care and provide trauma-informed care to Residents #25 and #140. This affected two (Residents #25 and #140) out of two residents reviewed for trauma-informed care. The facility reported two (Residents #25 and #140) who had trauma-related diagnoses. The facility census was 66. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of the quarterly Minimum Data Set (MDS) assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. The resident had depression, anxiety, and a history of alcohol abuse, who demonstrated behaviors related to maintaining personal space. There was no reference in the care plan relevant to Resident #25's trauma including triggers and trauma-informed care. Review of the physician orders effective May 2025 revealed no orders related to trauma-informed care other than to consult psychotherapies. Review of the assessments for Resident #25 revealed no trauma screening or assessments completed since admission. Review of the nursing progress notes from May 2024 to May 2025 revealed no documentation relevant to Resident #25's trauma or trauma-informed care. Review of the physician progress notes from psychiatric services on 11/18/24, 12/09/24, 01/14/25, 02/10/25, 03/10/25 and 05/05/25 revealed no documentation relevant to Resident #25's trauma or trauma-informed care. Review of the nursing assistant Kardex for Resident #25 effective 05/19/25 indicated no information relevant to trauma-informed care. Interview on 05/19/25 at 4:26 P.M. with the Director of Nursing (DON) verified there were no assessments used for trauma-informed care and no information on Resident #25's trauma, triggers or needed interventions to care for the resident's PTSD which included in the care plan, Kardex and progress notes. Interview on 05/20/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #364 stated believing of hearing that Resident #25 had PTSD but was unaware of any information relevant to it such as cause, triggers or interventions needed to reduce anxiety or approach care. Interview on 05/20/25 at 1:52 P.M. with Resident #25 denied talking to any staff related to the PTSD or trauma. Interview on 05/20/25 at 1:54 P.M. with Registered Nursing (RN) #431 revealed no knowledge of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 23 of 33 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 05/21/2025 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)

F 0699 Resident #25's trauma and care needs related to PTSD. Level of Harm - Minimal harm or potential for actual harm Interview on 05/20/25 2:24 P.M. with Social Services Director (SSD) #318 verified there was no trauma assessment completed for Resident #25 to contribute to trauma-informed care. SSD #318 indicated a trauma assessment should have been completed within 48 hours after admission so it would reflect on the baseline care plan and then into the comprehensive care plan thereafter. Resident #25 had no trauma assessment completed upon admission and none afterwards so therefore it was not included in the care plan. Residents Affected - Few Interview on 05/20/25 at 3:43 P.M. with the DON confirmed an inability to provide evidence the facility staff had received training related to trauma-informed care, trauma assessments, screening tools or strategies to address residents' triggers, but it was scheduled to be implemented on 05/22/25. Review of the facility policy, Trauma Informed Care, revised March 2019, revealed all staff were provided training about trauma, its impact on health, and PTSD in the context of the healthcare setting. Nursing staff were trained in screening tools, trauma assessment and how to identify triggers associated with re-traumatization. The facility supports a culture of emotional well-being and physical safety for staff, residents and visitors. Trauma-informed care was culturally sensitive and person-centered. Caregivers were taught strategies to help eliminate, mitigate or sensitively address a resident's triggers, and the facility implemented universal screening of residents for trauma. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 24 of 33 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 05/21/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on record review, review of insulin manufacture guidelines, observation, interview and review of facility policy, the facility failed to ensure insulin was dated after opening and failed to ensure insulin was disposed of per manufacture guidelines. This affected four (Residents #8, #11, #63, and #131) out of nine (Residents #5, #8, #11, #12, #41, #47, #63, #129, and #131) that had their insulin on the East and/or North medication cart. This had the potential to affect 12 (Residents #5, #8, #10, #11, #12, #41, #46, #47, #63, #129, #131, and #179) that had orders for insulin. The facility census was 66. Findings include: 1. Review of the medical record for Resident #11 revealed an admission date of 12/09/14 with diagnoses including dementia, diabetes and hypertension. Review of the May 2025 physician's orders revealed Resident #11 had an order dated 11/22/24 for Lantus solution (insulin) 100 units per milliliter (ml) inject eight units subcutaneously (SQ) once a day due to diabetes. Review of the care plan revealed Resident #11 had the potential for hypoglycemia and/or hyperglycemia related to diabetes. Interventions included Accu checks (blood sugar checks) as ordered, diabetic medications as ordered and monitoring for side effects and effectiveness. 2. Review of the medical record for Resident #63 revealed an admission date of 01/21/25 with diagnoses including diabetes, hypertension and congestive heart failure. Review of the May 2025 physician's orders revealed Resident #63 had an order for Lispro injection solution (insulin) 100 units per ml inject SQ per sliding scale for diabetes. Review of the care plan dated 02/13/25 revealed Resident #63 had diabetes. Interventions included diabetes medications as ordered by the physician, and monitoring side effects and effectiveness. 3. Review of medical record for Resident #131 revealed an admission date of 05/15/25 with diagnoses including malignant neoplasm of bronchus or lung, and diabetes. Review of the May 2025 physician's orders revealed Resident #131 had an order for Lantus solution peninjector (insulin) 100 units per ml inject 20 units SQ one time a day due to diabetes. Review of the undated care plan revealed Resident #131 had diabetes. Interventions included diabetes medications as ordered by the physician, and monitoring, documenting, and reporting signs of hypoglycemia and hypoglycemia to the physician. 4. Review of the medical record for Resident #8 revealed an admission date of 10/02/23 with diagnoses including diabetes and congestive heart failure. Review of the May 2025 physician's orders revealed Resident #8 had an order for Degludec insulin solution pen-injector 100 units per ml inject 50 units SQ one time a day due to diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 25 of 33 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 05/21/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the undated care plan revealed Resident #8 had diabetes and was insulin dependent. Interventions included diabetes medications as ordered and monitoring, documenting, and reporting signs of hypoglycemia and hypoglycemia to the physician. Observation on 05/19/25 at 7:55 A.M. of the East medication cart with Licensed Practical Nurse (LPN) #351 revealed Resident #11's Lantus insulin pen was opened but not dated as to when it was opened, and Resident #63's Lispro insulin pen was opened and dated as opened 04/15/25. Interview on 05/19/25 at 7:55 A.M. with LPN #351 verified the above findings and revealed all insulin should be dated when it is opened. She revealed she thought insulin was only good for 30 days after it was opened but was not sure. Observation on 05/19/25 at 12:13 P.M. of the North medication cart with Registered Nurse (RN) #431 revealed Resident #131's Lantus insulin pen was opened but not dated as to when it was opened. The cart also had Resident #8's Degludec insulin pen that was also opened but not dated. Interview on 05/19/25 at 12:13 P.M. with RN #431 verified the above findings and revealed all insulin should be dated when it is opened. She revealed she was unable to determine when the insulin was opened to track when it should be discarded. Review of the Lantus insulin drug manufacture guidelines, dated 08/2022, revealed after the Lantus was opened, keep at room temperature and after 28 days throw the opened Lantus away even if it has insulin in it. Review of the Degludec insulin drug manufacture guidelines, dated 11/24, revealed storage after use recommended to keep at room temperature or refrigerated for up to eight weeks. The guideline recommended to dispose after eight weeks even if there was insulin left in the pen. Review of the Lispro insulin drug manufacture guidelines, dated 2023, revealed store opened insulin pen at room temperature and throw away the pen after 28 days even if there was still insulin left in it. Review of the facility policy labeled, Administering Medications, dated April 2019, revealed when opening a multi-dose container, the date opened was to be recorded on the container. The expiration date and/or beyond use date on the medication label was checked prior to administration. Review of the facility policy labeled, Storage of Medications, dated November 2020, revealed the facility was to store all drugs and biologicals in a safe, secure, and orderly manner. There was nothing in the policy regarding ensuring insulin was dated when opened and how long insulin was good for after opening. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 26 of 33 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 05/21/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review, interviews, review of facility policy, observation, the facility failed to ensure accurate documentation on the medication administration record (MAR) for Resident #43 and the treatment administration record (TAR) for Resident #25. The facility also failed to routinely assess seat belts and alarms for necessity, appropriateness and least restrictive. This affected two (Residents #25, and #43) out of 21 medical records reviewed for accuracy, and two (Residents #3 and #25) out of two residents reviewed for restraints. The facility identified 13 residents (#4, #5, #9, #11, #16, #25, #26, #29, #33, #38, #52, #64 and #135) who had seat belts or alarms as restrictive devices. The facility census was 66. Findings included:1. Review of the medical record for Resident #43 revealed an admission date of 12/20/21 with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, indwelling urethral catheter, and neuromuscular dysfunction of the bladder. Review of the May 2025 physician's orders revealed Resident #43 had an order dated 05/16/25 for meropenem (antibiotic) intravenous solution one gram intravenously (IV) every eight hours for urinary tract infection (UTI). Review of the May 2025 MAR revealed Resident #43's order for meropenem IV was scheduled to be administered at 6:00 A.M., 2:00 P.M., and 10:00 P.M The MAR was blank on 05/17/25 at 6:00 A.M. and 05/18/25 at 2:00 P.M. indicating the meropenem was not administered. Review of undated care plan revealed Resident #43 was in IV antibiotic due to UTI that was to be administered from 05/16/25 to 05/23/25. Interventions included administering the antibiotic as ordered, and monitoring for side effects and effectiveness. Interview on 05/20/25 at 1:39 P.M. with Licensed Practical Nurse (LPN) #304 verified the MAR was blank on 05/17/25 at 6:00 A.M. and 05/18/25 at 2:00 P.M. indicating the meropenem was not administered. She revealed she did not know if Resident #43's IV antibiotic was administered. Interview on 05/20/25 at 2:15 P.M. with the Director of Nursing (DON) verified the MAR was blank on 05/17/25 at 6:00 A.M. and 05/18/25 at 2:00 P.M. indicating the meropenem was not administered. She revealed she spoke with the nurses assigned to administer the IV antibiotics and they had stated they administered the medication but did not document the MAR. Review of the facility policy labeled, Charting and Documentation, dated July 2017, revealed documentation in the medical record would be complete and accurate. 2. Review of the medical record for Resident #25 revealed an admission date of 02/18/17 with diagnoses of chronic obstructive pulmonary disease, diabetes mellitus type two, dementia, major depressive disorder recurrent, generalized anxiety disorder and post-traumatic stress disorder. Review of a physician order dated 09/17/24 indicated Resident #25 had an alarming Velcro seat belt to the wheelchair for positioning and safety. Another physician order dated 03/17/25 specified an additional pressure alarm was applied to the wheelchair for safety. Review of the quarterly Minimum Data Set (MDS) assessment completed 01/11/25 revealed Resident #25 had moderate cognitive impairment. Additional medical record review for Resident #25 revealed there were no assessments completed upon application of either the alarming seat belt on 09/17/24 or the pressure alarm on 03/17/25, and none thereafter for necessity, appropriateness or least restrictive. Review of the TAR from April 2025 to May 2025 revealed Resident #25's pressure alarm was checked twice daily at rising and bedtime, and the seat belt was checked every shift for placement and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 27 of 33 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 05/21/2025 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few functioning. The pressure alarm was not signed as being checked on 04/07/25, 04/24/25, 04/28/25 and 05/14/25 at bedtime. The seat belt was not signed as being checked on 04/03/25 on night shift, and on 04/24/25 and 04/28/25 on evening shift. Review of the care plan updated on 04/18/25 indicated Resident #25 had impaired cognition including poor memory and poor choices. Resident #25 also had potential for falls related to limited range of motion of the right lower extremity, poor balance and poor safety awareness. Staff were to be sure a call light was in reach and maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The alarming Velcro seat belt was not addressed in the plan of care, and there was no plan to monitor either the seat belt or pressure alarm as necessary, appropriate or least restrictive. Review of the nursing assistant Kardex for Resident #25 effective 05/19/25 indicated to maintain a pressure alarm to the wheelchair to alert staff to unassisted rising. The physician ordered seat belt was not noted on the Kardex. Interview on 05/19/25 at 4:35 P.M. with the DON verified Resident #25 had an alarming Velcro seat belt and pressure alarm ordered without any assessments to ensure it was not a restraint, necessary, appropriate and least restrictive. The care plan did not address these devices with any plan for monitoring or assessments. During the interview the DON was in the process of adding physician orders for nurses to monitor Resident #25's seat belt once every quarter to ensure it was not a restraint by checking to see if the resident could self-release it on command. The DON stated restrictive devices such as seat belts and alarms were to be assessed when applied and at least quarterly to ensure it was not a restraint. Review of the physician order written by the DON on 05/19/25 specified Resident #25 was able to release the seat belt on command and if not, it was to be reported. This check was to be completed daily every three months on the first of the month for three days, and it was to begin on 06/01/25. Observation on 05/20/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #364 of Resident #25 verified there was no physician ordered seatbelt or pressure alarm in place for safety or positioning. Interview at the time of the observation with CNA #364 could not state when or why the devices were not in place. An interview on 05/20/25 at 1:52 P.M. with Resident #25 denied remembering when the alarm or seat belt was last used or whether being able to release the seat belt when it was in place. Interview on 05/20/25 at 1:54 P.M. with Registered Nursing (RN) #431 confirmed both the seat belt and pressure alarm devices were not in place as ordered and were signed off on the TAR as being checked and in place as safety interventions. RN #431 indicated the devices were removed some time ago but could not identify when but remembered it was because Resident #25 was no longer trying to get up without assistance. Review of the progress notes from September 2024 to May 2025 revealed no documentation to identify the removal of the alarming seat belt or pressure alarm for Resident #25. Observation on 05/21/25 at 12:13 P.M. of Resident #25 being transported to the dining room via wheelchair revealed no visible seat belt or alarming device in place. Interview on 05/20/25 at 4:31 P.M. with the Director of Nursing (DON) verified the seat belt and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 28 of 33 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 05/21/2025 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)

F 0842 pressure alarm were not documented accurately as being in place and/or functioning. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy, Use of Restraints, revised April 2017, revealed prior to placing a resident in restraints there will be a pre-restraining assessment and review to determine the need. The assessment will be used to determine possible underlying causes of the problematic medical symptoms and if there are less restrictive interventions that may improve the symptoms. Physical restraints include devices that a resident cannot remove. When indicated the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation of the need will be documented. Residents Affected - Few Review of the facility policy, Managing Falls and Fall Risk, revised March 2018, revealed position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy, and staff will document each resident's response to interventions intended to reduce falls or the risks of falling. If interventions were successful in preventing falling, staff would continue the interventions or reconsider whether the measures were still needed. 3. Review of the medical record for Resident #3 revealed an admission date of 08/28/03 with diagnoses of hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, speech and language deficits following cerebrovascular disease, chronic kidney disease and vascular dementia. Review of a physician order dated 09/17/24 indicated Resident #3 had a Velcro seat belt to the wheelchair for positioning and safety. Additional medical record review for Resident #3 revealed there were no assessments completed upon application of the seat belt on 09/17/24 or thereafter for necessity, appropriateness or least restrictive. Review of the quarterly Minimum Data Set (MDS) assessment completed 03/19/25 revealed Resident #3 had moderate cognitive impairment. Review of the care plan updated on 04/18/25 indicated Resident #3 had impaired cognition with fluctuation including poor decision making, poor impulse control and a communication problem so staff had to anticipate needs. Resident #3 also had potential for falls related to limited mobility, impaired balance and coordination due to right-sided hemiplegia. Staff were to anticipate Resident #3's needs, be sure a call light was in reach and apply a Velcro seat belt to the wheelchair for positioning and safety. There was no plan of care to monitor the seat belt as necessary, appropriate or least restrictive. Observation on 05/18/25 at 9:50 A.M. revealed Resident #3 sitting in a wheelchair watching television with a seat belt secured with Velcro at the waist. The resident was unable to explain why a seat belt was in place, but when encouraged, pulled the seat belt apart with the left hand due to the right sided paralysis. Review of progress notes from September 2024 to May 2025 revealed no documentation to justify the use of or monitoring of the seat belt for Resident #3. Review of the Treatment Administration Record (TAR) from April 2025 to May 2025 revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 29 of 33 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 05/21/2025 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)

F 0842 #3's seat belt was in place each shift. Level of Harm - Minimal harm or potential for actual harm Review of the nursing assistant Kardex (summary of resident information) effective 05/19/25 indicated to apply a Velcro seat belt in the wheelchair for safety. Residents Affected - Few Interview on 05/19/25 at 4:35 P.M. with Director of Nursing (DON) verified Resident #3 had a Velcro seat belt ordered without any assessments to ensure it was not a restraint, necessary, appropriate and least restrictive. The care plan only referenced the seat belt as a fall intervention without any plan for monitoring or assessing the device to determine when or if the resident was able to self-release the seat belt. During the interview, the DON wrote a physician order for the nurses to monitor Resident #3's seat belt once every quarter to ensure it was not a restraint by checking to see if the resident could self-release it on command. The DON confirmed restrictive devices such as seat belts were to be assessed when applied and at least quarterly to ensure it was not a restraint. Review of the physician order written by the DON on 05/19/25 specified Resident #3 was able to release the seat belt on command and if not, it was to be reported. This check was to be completed daily every three months on the first of the month for three days, and it was to begin on 06/01/25. Interview on 05/20/25 at 1:37 P.M. with Certified Nursing Assistant (CNA) #364 confirmed Resident #3 wore a seat belt daily while up in the wheelchair and had for several months, and it was used to prevent the resident from getting up unassisted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 30 of 33 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 05/21/2025 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)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on record review, interview and review of facility policy, the facility failed to ensure the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings. This had the potential to affect all 66 residents residing at the facility. Residents Affected - Many Findings included: Review of QAPI meeting attendance sign in sheets dated 12/27/23, 01/16/24, 02/20/24, 03/19/24, 04/16/24, 05/22/24, 06/26/24, 07/24/24, 08/02/24, 09/25/24, 10/24/24, 11/26/24, 12/27/24, 01/23/25, 02/25/25, 03/26/25, and 04/22/25 revealed the Medical Director/Primary Care Physician (PCP) #600 did not attend the above meetings. Interview on 05/18/25 at 3:58 P.M. with Administrator verified the Medical Director/PCP #600 did not sign any of the QAPI meeting attendance sheets and she had no evidence from 12/27/23 to 04/22/25 that he attended a QAPI meeting at least quarterly. Review of the facility policy labeled, Quality Assurance and Performance Improvement (QAPI) ProgramDesign and Scope, dated February 2020, revealed the facility QAPI program was ongoing, comprehensive and addresses all care and services provided by the facility. The policy did not identify the required members including the medical director that needed to attend the QAPI meeting and/ or identify the frequency of how often the required members were to attend. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 31 of 33 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 05/21/2025 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the building floors in safe and clean condition. This had the potential to affect all 66 residents residing in the facility. Findings include: Review of a floor repair quote dated 03/22/25 revealed the quote included installation of vinyl floor tiles to the facility's front areas, halls and nurses' stations, but it did not seem to include repair to resident rooms. Observation on 05/19/25 at 1:37 P.M. of the environment revealed the following: The front foyer and entry way had various dark soiled areas with one large area near the right front entrance door. Multiple areas of the floor appear worn and scratched. There were various scuffs, and two small circular areas cracked and sunken. The carpeted area in the building front near the dining room which included the television area and around the nurses' station had multiple small and large dark stained areas. The floor which borders the front of the nurses' station outward approximately two feet slopes downward toward the nurses' station desk which posed a fall hazard to all residents who ambulated through there. Interview on 05/19/25 at 2:10 P.M. with Licensed Practical Nurse (LPN) #351 verified the floor sloped toward the nurses' station and had for quite a while, which was a fall hazard for residents. LPN #351 reported having tripped because of it but was uncertain if any residents had done the same. The floor in the Concord Hall area between the kitchen and laundry area appeared soiled, dark and worn. Throughout the rest of the hallway there were various scuff marks, scratches and worn areas of the floor with multiple dark stains and cracked floor tiles. rooms [ROOM NUMBERS] had dark soiled areas at the entrances. room [ROOM NUMBER] had various stained discolorations and floor scratches. room [ROOM NUMBER] had dark soiled areas inside the room near the bed. The floor in the Hummingbird Lane area had large dark soiled areas which appeared stained at the hallway entrance. There were multiple cracks in the floor tiles with some tiles sunken closest to where the fire doors were located. room [ROOM NUMBER] had small cracks in the floor tiles at the entrance. room [ROOM NUMBER] had dark soiled stains at the room entrance and a small crack in the floor tile near the bottom of the bed by the room door. Throughout the hallway there were multiple various scuff marks, some small and large with discolored stained areas. The floor in the Northern Lights area had multiple various scuffs and small and large dark stained discolored areas, some worn, most notably at room [ROOM NUMBER]'s entrance. room [ROOM NUMBER] had an elongated crack in the floor going across the hall from the room's entrance with the floor sunken where cracked. room [ROOM NUMBER] had a small floor area with an imprint of what appears to be tire tread from the nearby electric wheelchair. room [ROOM NUMBER] had a quite large crack in the floor tile which transversed from the room entrance into the room toward the bathroom area. The floor had sunken in some areas with the cracked tile. At the hallway entrance just inside the fire doors adjacent to rooms [ROOM NUMBERS] were multiple cracked tiles with missing pieces which covered a floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 32 of 33 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 05/21/2025 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many area of approximately 11 tiles. room [ROOM NUMBER] had floor tile crack just inside the room door and dark stained areas near the door entrance and bed. room [ROOM NUMBER]'s entrance area had approximately five cracked floor tiles. The hallway floor between rooms [ROOM NUMBERS] had approximately four cracked tiles. room [ROOM NUMBER]'s entrance had cracked floor tiles across with dark soiled stained areas and scuff marks throughout the room. The back of the hallway had multiple various cracked floor tiles with scuff marks on the floor and small dark soiled areas. room [ROOM NUMBER] had multiple cracked floor tiles and dark soiled areas. The emergency exit at the back of the hallway had chipped and cracked floor tile with pieces of the floor tiles pulled away and scattered across the doorway. Some areas of the floor were sunken or raised up due to the floor damage. Observation and interview on 05/19/25 at 2:38 P.M. with Housekeeping Director (HD) #359 of the environment verified the above observations. HD #359 indicated the floors were scrubbed at least once monthly but could not confirm it received deep cleaning routinely each month. HD #359 reported the floors were mopped daily, but denied any staffing issues which would cause a lack in routine floor deep cleaning each month. HD #359 further reported the carpeted floors were cleaned once weekly but the stains were permanent. HD #359 also acknowledged being aware of the floor sloping toward the nurses' station by the dining room, and agreed it was a fall risk for the residents. Interview on 05/19/25 at 4:08 P.M. with the Administrator confirmed knowledge of the above observations. The Administrator acknowledged discussing the floor status with the owners and a plan to obtain quotes for floor replacement but was unaware of any formal plan with dates. Review of a text message involving the facility's administration dated 05/09/25 revealed the Administrator being asked if she wanted the flooring done with an affirmative response. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366047 If continuation sheet Page 33 of 33