Health inspection·May 10, 2023

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review the facility failed to ensure the fall prevention care plan and resulting interventions were updated for Resident #35. This affected one resident (#35) of four residents reviewed for accidents. The facility census was 54. Findings include: Review of the medical record for Resident #35 revealed an admission date of 12/16/22. Diagnoses included Parkinson's, a history of falling, muscle wasting, and atrophy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #35 had impaired cognition. The resident required extensive assistance of two staff for bed mobility, transfers, toilet use, and personal hygiene. The resident required supervision for locomotion. Review of the fall risk assessments dated 05/02/23, 04/28/23, 04/25/23, 04/20/23, and 03/09/23 revealed the resident was at high risk for falls. Review of the plan of care dated 01/15/23 revealed Resident #35 was at risk for falls due to deconditioning, gait/balance problems, and psychoactive drug use. Interventions included: 02/27/23 - Floor mat to the right side of the bed. 02/27/23 - Every 30-minute check. 03/18/23 - Offer to assist resident with toileting more frequently throughout the shift. 03/09/23 - Resident to wear nonskid footwear while in bed. 04/19/23 - Rearrange furniture in the room to make common items more accessible to the resident. Review of physician orders for May 2023 identified orders for a mat to floor on right side of bed every shift for safety had been ordered 02/27/23. Review of the nurse's note dated 04/27/23 at 11:46 A.M. revealed the nurse was called to the room and found Resident #35 laying on his right side on right side of bed in front of his wheelchair. There were no injuries. Review of the fall investigation dated 04/27/23 revealed Resident #35 had an unwitnessed fall. The resident stated he wanted the rubber mat up. The immediate action taken were neuro checks, and the resident was educated on the importance of calling for assistance. Review of the nurse's note dated 05/02/23 at 9:15 A.M. revealed Resident #35 was observed on the floor on his knees in his bedroom. The resident said he was trying to get a piece of food off the floor and slid out of his chair. There were no injuries. Review of the fall investigation dated 05/02/23 revealed the immediate intervention was the floor was cleaned and it was reiterated to the resident to ring for help when he needed something. On (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 2 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 - Few 05/03/23 the interdisciplinary team (IDT) team met to discuss residents fall and the new intervention was medication review. The care plan was updated. Observation on 05/07/23 at 1:06 P.M. revealed a fall mat was on the floor on the right side of the bed as ordered. Resident #35 tripped over it and almost fell while transferring himself from the wheelchair to the bed. The resident was wearing sneakers. Interview on 05/09/23 at 8:30 A.M. with Resident #35 revealed he felt the fall mat made it more likely for him to fall because it tripped him up. He felt non-slip strips would help more. Interview on 05/09/23 at 11:59 A.M. with Licensed Practical Nurse (LPN) #222 revealed it would be better for Resident #35 if the fall mat was moved out of the way when he was up. Interview on 05/10/23 at 11:11 A.M. with Regional Director of Clinical Operations #252 verified the care plan regarding fall prevention needed to be updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 3 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on record review, interview, and facility policy review the facility failed to ensure discharges were thoroughly documented in the medical record. This affected one resident (#55) of four residents reviewed for discharge. The facility census was 54. Findings include: Review of the medical record for Resident #55 revealed an admission date of 11/08/21 and a discharge date of 02/03/22. Diagnoses included congestive heart failure (CHF), dementia, depression, and anxiety. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/10/21, revealed Resident #55 had impaired cognition. He required extensive assistance of two people for bed mobility, transfers, and toilet use, extensive assistance of one person for dressing and hygiene and supervision and set-up help for eating. Review of the discharge care plan dated 11/16/21 revealed Resident #55's plan was to discharge home. Review of the physician order dated 02/03/22 revealed an order to discharge home without home health care. Interview on 05/10/23 at 8:39 A.M. with Social Service Designee (SSD) #214 revealed she had no knowledge of the discharge plan or process for Resident #55 because she was not working at the facility at the time. Interview on 05/10/23 at 8:39 A.M. with the Administrator confirmed there was no other information regarding the discharge plan for Resident #55 in the medical record. Interview on 05/10/23 at 10:44 A.M. with Licensed Practical Nurse (LPN) #211 revealed Resident #55 insisted on discharge. He did not want home health care because he didn't think it was necessary. She confirmed he refused to sign his order summary on discharge. Interview on 05/10/23 at 12:63 P.M. with Certified Occupational Therapy Assistant (COTA) #256 revealed she completed a therapy evaluation for Resident #55 and would have placed any recommendations in the social service discharge summary. Review of the undated facility policy titled Resident Transfer and Discharge Policy and Procedure revealed the facility would ensure discharges were documented in the medical record and included any information relevant to the next care provider. This deficiency represents non-compliance investigated under Complaint Number OH00139577. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 4 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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, and facility policy review the facility failed to ensure Resident #26 received routine showers per preference and as scheduled. This affected one resident (#26) of four residents reviewed for showers/activity of daily living care. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record for Resident #26 revealed an admission date of 11/28/22. Diagnoses included Parkinson's disease, glaucoma, diabetes, and heart disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, dressing, and toilet use and limited assistance of one person for hygiene. Review of the facility shower schedule revealed Resident #26 was scheduled to receive a shower every Wednesday and Sunday. Review of the shower sheets for Resident #26 revealed the resident received a shower on 03/05/23, 03/15/23, 03/22/23, 03/26/23, 04/05/23, 04/09/23, 04/11/23, 04/15/23, 04/19/23, and 04/24/23. Review of the State Tested Nurse Aide (STNA) tasks revealed Resident #26 received a shower 04/03/23, 04/05/23, 04/17/23, 04/18/23, 04/19/23 and 04/24/23. Interview on 05/07/23 at 9:23 A.M. with Resident #23 revealed he only received a shower once every two weeks and would prefer to shower at least once a week. Interview on 05/10/23 at 12:55 P.M. with the Administrator confirmed Resident #26 was not getting showers based on the shower schedule, and the information reviewed was inconsistent. She could not confirm which days Resident #26 received showers. Interview on 05/10/23 at 2:03 P.M. with Registered Nurse (RN) #252 confirmed it is the resident's right to receive a shower when they choose to. Review of the facility policy titled Activities of Daily Living, supporting, dated March 2018, revealed residents who needed assistance with hygiene would obtain the necessary services according to their preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 5 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, and facility policy review the facility failed to ensure interventions were in place to promote healing of a pressure ulcer for Resident #28. This affected one resident (#28) of two residents reviewed for pressure ulcers. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record for Resident #28 revealed an admission date of 11/29/18. Diagnoses included anxiety, stroke affecting the right dominant side, depression, and gastric ulcer. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 required extensive assistance of two people for bed mobility, total assistance of two people for transfers and toilet use, total assistance of one person for dressing and hygiene and extensive assistance of one person for eating. She had a stage three pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) to the coccyx. Review of the care plan dated 03/20/23 revealed Resident #28 had impaired skin integrity due to the stage three pressure ulcer to her coccyx. Interventions included an air mattress at a setting of two, elevating her heels off the surface of the mattress as tolerated, and offloading boots as tolerated while in bed. Observation on 05/08/23 at 11:38 A.M. revealed Resident #28 was lying in bed. Her heels were not off loaded, and she was not wearing offloading boots. Her air mattress was set at four. Interview at the time of the observation with Licensed Practical Nurse (LPN) #211 revealed the offloading boots were not in her room, her heels were not offloaded, and the bed was set at four. Review of the facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, revealed the nurse would document current treatments and the physician would guide the plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 6 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 observation, record review, and interview the facility failed to maintain interventions to prevent Resident #258's fall. This affected one resident (#258) out of three residents reviewed for falls. The facility census was 54. Findings include: Review of the medical record revealed Resident #258 was admitted on [DATE] with diagnoses including follicular lymphoma, cancer of esophagus, chronic kidney disease, anemia, high blood pressure, and esophageal reflux disease. A review of Resident #258's fall assessment dated [DATE] indicated he was at moderate risk for falls. A review of Resident #258's clinical record indicated he sustained a fall on 04/30/23. There was no plan of care initiated to attempt to prevent falls until 05/07/23. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #258 had balance problems during transition indicated transfers between bed and chair were not steady and only able to stabilize with staff assistance. A plan of care was triggered to be initiated to prevent falls. A review of Resident #258's fall investigation dated 04/30/23 indicated Resident #258 was found sitting on the floor. Resident #258 indicated he was attempting to adjust his bed. The fall investigation indicated Resident #258 was attempting to ambulate without assistance. The interdisciplinary team meeting dated 05/01/23 indicated Resident #258's fall was discussed and an additional intervention was initiated to use his call light to alert staff when he needed help. A review of Licensed Practical Nurse (LPN) #253's witness statement dated 04/30/23 indicated the aide informed her Resident #258 was found seated on the floor beside his bed in his room. The fall was unwitnessed, and Resident #258 was in bed prior to the fall. LPN #253's witness statement indicated it was unknown if: Resident #258's bed was in the locked position, if Resident #258 was wearing nonskid socks or shoes, when Resident #258 was last toileted, if Resident #258 was incontinent at the time of the incident, when Resident #258 last ate, if Resident #258 had inflicted self-injury, if Resident #258 exhibited behaviors that placed him at risk for this type of incident. An observation of Resident #258 on 05/09/23 at 9:05 A.M. indicated he was seated in bed with the bed in a high position. Resident #258's over-the-bed table had his breakfast tray placed on the table. The over-the bed table was unable to be placed over his bed for him to eat his breakfast due to the bed was in the high position. An interview with Resident #258 on 05/09/23 at 9:08 A.M. indicated he was unable to verbalize the details of the fall on 04/30/23 and was having difficulty communicating verbally. An observation at 9:10 A.M. on 05/09/23 revealed State Tested Nurse Aide (STNA) #213 entered Resident #258's room and lowered the height of his bed so the over-the-bed table could be positioned over Resident #258's lap so he could reach and eat his breakfast meal. STNA #213 verified Resident #258's bed was not in the low position. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 7 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 An interview with STNA #213 on 05/09/23 at 9:20 A.M. stated she was unaware Resident #258 had a risk for falls or that he had sustained a fall on 04/30/23. When asked how she was informed if a resident was at risk for falls or had sustained a fall, STNA #213 responded the STNA working the previous shift would inform her during shift-to-shift report. STNA #213 indicated there was no interventions on Resident #258's care [NAME] located on the electronic point of care [NAME]. STNA #213 indicated there was a graph of the residents assigned to her with x's marked under different areas for each resident. STNA #213 indicated she did not know what the x's were used to represent on the care [NAME]. An interview with Regional Director of Clinical Operations (RDCO) #252 on 05/09/23 at 10:00 A.M. verified the above findings. An interview with STNA #235 on 05/10/23 at 8:56 A.M. verified the electronic care [NAME] the STNA staff used to locate information and care interventions about the residents assigned to her had no documentation if a resident had a risk for falls or a history of falls. STNA #235 stated Resident #258 was not at risk for falls and was unaware he had sustained a fall recently. An interview with Licensed Practical Nurse (LPN) #211 (MDS Nurse) on 05/10/23 at 10:04 A.M. indicated the standard interventions for the facility included to maintain resident's bed in a low position and develop and individualized plan of care to attempt to prevent falls for residents assessed as a risk of falling. LPN #211 verified the above findings. The facility policy and procedure titled Falls - Clinical Protocol, revised 03/2018, indicated the staff would identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. The staff with input from the physician would implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk for falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 8 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 0692 Provide enough food/fluids to maintain a resident's health. 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, and facility policy review the facility failed to follow recommendations to ensure Resident #12 maintained weight or did not continue to lose weight. This affected one resident (#12) of seven resident reviewed for weight loss. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record for Resident #12 revealed an admission date of 12/13/22. Diagnoses included lymphoma, diabetes, hypertension, and hyperlipidemia. Review of the quarterly Minimum Data Assessment (MDS) dated [DATE] revealed Resident #12 was moderately cognitively impaired. He required extensive assistance of two people for bed mobility, total assistance of two people for transfers, extensive assistance of one person for dressing, toilet use and hygiene and supervision and set up help for eating. He was not on a weight loss regime and had no mouth pain or missing teeth. Review of the care plan dated 04/15/23 revealed Resident #12 had a nutritional problem due to diagnosis of diabetes. Interventions included maintaining weight and evaluating and making diet changes as needed. Review of the nutritional note date 02/10/23 revealed Resident #12 had a significant weight loss of 7.5 percent in two months. He was to start weekly weights. Review of the medical record revealed he was weighed on 02/22/23, 03/15/23, and 04/07/23. Interview on 05/09/23 at 2:16 P.M. with Dietitian #254 revealed she identified a significant weight loss for Resident #12 and recommended weekly weights. She verified there was no documented evidence weekly weights had been obtained. She revealed she sees residents with significant weight loss weekly or reviews weights weekly. She last saw Resident #12 on 04/15/23. Interview on 05/10/23 at 1:04 A.M. with Licensed Practical Nurse (LPN) #222 revealed the Medication Administration Record (MAR) would include when weekly weights should be obtained. She confirmed there was no evidence of weekly weights for Resident #12 on the MAR. Review of the facility policy titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated September 2017, revealed the facility would identify necessary interventions to address weight loss and monitor nutritional status in response to the interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 9 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to follow infection control standards for Resident #28 during wound care to prevent possible cross-contamination of germs. This affected one resident (#28) out of three residents reviewed for wound care. The facility census was 54. Residents Affected - Few Findings include: Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, aphasia, anxiety, dysphagia, gastronomy tube, central pain syndrome, poly neuropathy, obesity, osteoarthritis, coagulation deficit, hearing loss, anemia, fatty liver, kidney cyst, peripheral vascular disease, depression, myasthenia gravis, uterine cancer, and hyperlipidemia. Resident #28 developed the coccyx wound in the facility on 10/06/21. A review of Resident #28's wound assessment dated [DATE] indicated the presence of a stage III pressure ulcer (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed, slough may be present but does not obscure the depth of tissue loss, may include undermining and tunneling) located on the coccyx and measuring 1.9 centimeters (cm) by 1.5 cm by 0.5 cm deep. The coccyx wound had undermining at the one o'clock position for a maximum of 0.4 cm with scant clear exudate. The coccyx wound had 100 percent granulation (pink or beefy red tissue with a shiny, moist granular appearance). The skin surrounding the wound was healthy and pink. The wound treatment recommendation was to use collagen and cover with foam dressing and offload the wound by turning. The wound status had improved. Resident #28's physician order, dated 05/01/23, indicated to cleanse the coccyx wound with wound cleanser, pat dry, apply collogen, and cover with a foam dressing daily and as needed. An observation on 05/09/23 at 9:40 A.M. of Licensed Practical Nurse (LPN) #249 perform Resident #28's wound treatment revealed concerns with following infection control standards. LPN #249 entered Resident #28's room and did not wash her hands and placed the wound treatment supplies directly on Resident #28's over-the-bed table without sanitizing the surface of the table or placing a barrier on the table to place the supplies. LPN #249 proceeded to remove the foam dressing from the manufacturer's packaging and set the dressing back on the over-the-bed table. LPN #249 washed her hands and applied a pair of disposable gloves. LPN #249 carried the wound treatment supplies from the over-the-bed table and placed the supplies directly on Resident #28's bed linens without placing a clean barrier on the bed. LPN #249 proceeded to cleanse Resident #28's coccyx wound with wound cleanser and patted the wound dry with gauze. LPN #249 did not wash her hands or remove her gloves after cleaning the coccyx wound. LPN #249 proceeded to apply the collagen powder to the wound with a cotton swab and then covered the wound with a foam dressing. LPN #249 repositioned Resident #28 on her left side and gathered the soiled/used wound supplies and placed them in the trash receptacle. LPN #249 proceeded to leave Resident #28's room without removing the soiled supplies from Resident #28's room. An interview with LPN #249 on 05/09/23 at 9:50 A.M. verified the above findings. The facility policy and procedure titled Handwashing/Hand Hygiene, revised 08/2019, indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections in the facility. Use of alcohol-based hand rub containing at least 62 percent alcohol; or, alternatively, soap, and water in the following situations: • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 10 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 0880 Before and after coming on duty. Level of Harm - Minimal harm or potential for actual harm • Before and after direct contact with residents. Residents Affected - Few • Before preparing and handling medications. • Before performing any non-surgical invasive procedures. • Before and after handling an invasive device. • Before donning sterile gloves. • Before handling clean or soiled dressings, gauze pads, etc. • Before moving from a contaminated body site to a clean body site during resident care. • After contact with a resident's intact skin. • After contact with blood or body fluids. • After handling used dressings, contaminated equipment, etc. • After contact with objects in the immediate vicinity of the resident. • After removing gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 11 of 12 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 366326 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Geneva Center for Rehabilitation and Nursing 1140 South Broadway 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 0880 • Level of Harm - Minimal harm or potential for actual harm Before and after entering isolation precaution settings. • Residents Affected - Few Before assisting a resident with their meal. • Before and after eating or handling food. • After personal use of the toilet or conducting your personal hygiene. The facility policy and procedure titled Wound Care, revised 10/2010, indicated to use a disposable cloth to establish a clean field on the resident's over-the-bed table. Place all items to be used during the procedure on the clean field. Arrange the supplies so they can be easily reached. Wash and dry hands thoroughly. Position the resident and place a disposable cloth next to the resident to serve as a barrier to protect the bed linen and other body sites. Donn an exam glove to remove the soiled dressing and discard the glove with the soiled dressing in appropriate receptacle. Wash and dry hands thoroughly. Donn another set of disposable gloves. Cleanse the wound with a gauze pad. Apply treatments as indicated. Dress the wound. Place initials and date on the wound treatment with tape. Remove disposable cloth next to the resident and discard in the designated container. Wash hands. Saturate the field with alcohol and wipe the over-the-bed table before placing the table in reach of the resident. Wash and dry hands before leaving the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366326 If continuation sheet Page 12 of 12