Health inspection·October 3, 2023

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the quarterly MDS assessment, dated 08/15/23, for Resident #47 revealed she was cognitively intact. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Resident #47 was totally dependent on staff for assistance with transfers and toilet use. Resident # 47 was independent with eating. Interview on 09/24/23 at 2:14 P.M., with Resident #47 revealed she had never met with the care team and had a care conference to discuss her plan of care. 4. Review of Resident #233 revealed she was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (COPD), hypercalcemia, DM2, tachycardia, respiratory failure with hypoxia, opioid dependence, depression, hyperlipidemia, obesity, and cognitive communication deficit. Review of the new admission MDS for Resident #233, dated 08/27/23 revealed she was cognitively intact. Further review of the MDS assessment revealed she required limited assistance from staff with bed mobility, transfers, toilet use, and personal hygiene. Resident #233 revealed she was independent with eating. Interview on 09/26/23 09:06 A.M., with Resident #233 revealed she had never had a care conference to discuss her plan of care with the care team at the facility. Interview on 09/27/23 at 3:02 P.M., with the Social Service Director (SSD) #84 confirmed the last care conference for Resident #18 was completed on 03/29/22. SSD #84 confirmed Residents #28, #47, and #233 have never had a care conference following their admission to the facility. SSD #84 confirmed the facility should schedule care conferences for new admissions to the facility and quarterly during the Resident assessment. Review of the facility policy titled, Resident Participation, dated 2016, revealed the resident or resident representative are encouraged to participate in the resident's assessment and in the development and implementation of a Resident's plan of care. Further review of the facility policy revealed, a comprehensive care plan is developed within seven days of completing a resident assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 2 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure a resident was provided the assistance to obtain a pair of shoes. This affected one (#64) of 24 residents sampled during the annual survey. The facility census was 83. Residents Affected - Few Findings included: Review of Resident #64's medical record revealed an admission date of 12/14/22. His diagnoses included atherosclerotic heart disease, essential tremor, intellectual disabilities, osteoarthritis, cervical disc degeneration of the cervical region, intervertebral disc degeneration of the lumbar region, chronic pain syndrome, ischemic cardiomyopathy, personal history of traumatic brain injury, occlusion and stenosis of the bilateral carotid arteries, hypothyroidism, type II diabetes, with diabetic neuropathy, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and needed supervision for activities of daily living. Review of Resident #64's podiatry visit note dated 08/15/23 revealed under footwear evaluation the resident was counseled on proper footwear. The details included wearing well-fitting comfortable shoes. It noted he was in a risk category of loss of protective sensation with weakness, deformity, pre-ulcer, or callus but no history of ulceration. Review of the funds balance revealed on 10/02/23 the resident had $1,600.59, which was sufficient to cover the cost of a pair of new shoes. Observations on 09/26/23 at approximately 11:30 A.M. and again on 10/02/23 at 2:10 P.M., revealed Resident #64 was wearing non-skid socks and had a soft pair of slip-on house shoes next to the bed. Interview on 09/26/23 at approximately 11:30 A.M., with Resident #64 stated he wanted diabetic shoes, but no one had ordered him any. Resident #64 stated the only shoes he had were two pair of soft house shoes. Resident #64 stated someone had given him a pair of shoes that did not fit. Resident #64 stated one of the shoes did not have a shoestring, so they were given to another resident. Interview on 10/02/23 at 12:47 P.M., with the Administrator revealed the facility did not get Resident #64 any diabetic shoes due to the podiatrist not writing an order for them. The Administrator stated the podiatrist would be the one to request the shoes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 3 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. 4. Observation on 09/25/23 at 11:15 A.M., revealed a strong and foul smelling odor was noted in one of the residential hallways and identified as coming from Resident #36's room. Residents Affected - Some Interview on 09/25/23 at 11:15 A.M., with Occupational Therapist #41 verified there was a strong odor in the hallway radiating from Resident #36's room. Interview on 09/25/23 at 11:29 A.M., with Resident #36 stated he had some old rotted food he forgot about in his room and it spilled. Review of the policy titled, Quality of Life-Homelike Environment, dated May 2017 stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy revealed the facility and staff shall maximize the characteristics of the facility to reflect a homelike setting including a clean, sanitary, and orderly environment. The policy stated, staff shall provide person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146517, OH00146416, OH00146414, and OH00146234. Based on observation, resident interviews, staff interviews, record review, and policy review, the facility failed to provide a home like environment in maintaining resident's rooms in good condition. This affected four (#03, #21, #36, and #233) of 83 residents residing in the facility. The facility census was 83. Findings include: 1. Review of Resident #03's medical record revealed an admission date of 03/19/08, with diagnoses including atrial fibrillation, gastroesophageal reflux disease (GERD), diabetes mellitus 2, and hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment, dated 07/12/23, revealed Resident #03 had severely impaired cognition. Further review of the MDS assessment revealed he required supervision assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Observation on 10/03/23 at 10:11 A.M., revealed Resident #03's bathroom entry wall was busted with exposed dry wall, the window seal had a cracked edge with pieces missing, the air conditioning unit was broken with the facing hanging off, all along with the wall was chipped paint with scratches along the wall, the walls were stained with a substance that appeared as if it was running down the wall, around the bottom of the wall was stains of black/brown unknown substance and along the floor of the baseboard heating unit. Interview on 10/03/23 at 10:11 A.M., with Floor Technician (FT) #79 confirmed Resident #03's room had broken window seal, broken air unit hanging off the wall, the door frame around the wall was smashed and plaster exposed, the walls were soiled with dirt and unknown brown and black substance smeared around wall and base board unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 4 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of Resident #233's medical record revealed an admission date of 07/24/23, with diagnoses including: chronic obstructive pulmonary disease, diabetes mellitus 2, opioid dependence, hypomagnesemia, hypoxemia, anxiety disorder, and acidosis. Review of the New admission MDS assessment for Resident #233 revealed she was cognitively intact. Further review of the MDS assessment revealed she required limited assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident # 233 revealed she was independent and required no assistance from staff with eating. Interview on 09/25/23 at 11:53 A.M., with Resident #233 stated the toilet runs in her bathroom and she has reported this to management. Resident #233 stated she would love to have a mirror in her bathroom over the sink and has asked management for a mirror over her sink. Observation on 09/25/23 at 11:53 A.M., revealed Resident #233's toilet sounded like running water and would continuously start then stop. The sounds continued of the toilet shutting on and off. The bathroom sink did not have a mirror located above it and the wall air conditioning unit located beside Resident #233's bed had white unpainted, cracked caulking around it. Interview and observation on 09/26/23 at 3:55 P.M., with the Director of Nursing in Resident #233's room confirmed the toilet continued to run, the bathroom did not contain a mirror and the wall around the air conditioning unit was white with exposed cracked, chipped caulking. 3. Review of Resident #21's medical record revealed an admission date of 02/23/23, with diagnoses including: schizophrenia, diabetes mellitus 2, and asthma. Review of the quarterly MDS assessment, dated 08/04/23 revealed he had impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #36's medical record revealed an admission date of 05/22/23, with diagnoses including: chronic obstructive pulmonary disease (COPD), osteoarthritis, hypertension, and chronic bronchitis. Review of the quarterly MDS assessment, dated 08/09/23, revealed he required supervision from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. Observation on 09/28/23 at 3:34 P.M., revealed Resident #21 and #36's bathroom did not have cold water available at the bathroom sink, and the electric socket in the bathroom was exposed with no cover. Interview on 09/28/23 at 3:34 P.M., with STNA #175 confirmed the cold water was not running in Resident #21 and #36's bathroom sink. SNTA #175 confirmed the electric socket in the bathroom was exposed with no cover on it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 5 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to complete a Significant Change Pre-admission Resident Review (PASARR) for Resident #24. The facility failed to complete a PASARR review for Resident #63 in a timely manner following the expiration of the Hospital Exemption Notification System ([NAME]) approved stay at the facility. The facility failed to ensure Resident #70's PASARR was completed correctly by failing to identify mental health diagnoses. This affected three (#24, #63 and #70) of three residents reviewed for PASARR. The facility census was 83. Residents Affected - Few Findings include: 1. Record review for Resident #24 revealed he was admitted to the facility on [DATE]. His diagnoses included antisocial personality, major depressive disorder, schizoaffective disorder, insomnia, bipolar disorder, depression, and altered mental status. Review of quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #24 was cognitively intact. The MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, and eating. Resident #24 was totally dependent on staff with toilet use, transfers, and personal hygiene. Further review of the MDS assessments revealed Resident # 24 had a Significant Change MDS assessment completed on [DATE] related to an acute hospital stay. Review of the Preadmission Screening and Resident Review for Resident (PASARR) for Resident #24 revealed the only PASARR in place was dated, [DATE]. The facility failed to submit a PASARR for Resident #24 related to his significant change in health dated [DATE]. 2. Record review for Resident #63 revealed she was admitted to the facility on [DATE]. Her diagnoses included acute and chronic respiratory failure, hypertensive heart disease, chronic kidney disease, depression, morbid obesity, post-traumatic stress disorder (PTSD), mood affective disorder, and anemia. Hospital discharge referral dated, for Resident # 63 revealed she was given the medication. Review of the quarterly MDS assessment for Resident #63, dated [DATE], revealed she was cognitively intact. Further review of the MDS assessment revealed she was independent and required no assistance from staff with all activities of daily living. Review of the Hospital Exemption Notification Screening ([NAME]) dated [DATE] revealed Resident #63 could reside in a skilled nursing facility for a less than thirty day stay or PASARR was completed. Review of PASARR for Resident #63, dated [DATE] revealed the facility did complete a PASARR review within the required expiration of the [NAME]. 3. Record review for Resident #70 revealed he was admitted to the facility on [DATE]. His diagnoses included dysarthria, dysphagia, intracerebral hemorrhage, essential primary hypertension, bipolar disorder, malingerer, chronic pain syndrome, anxiety disorder, insomnia, hypoglycemia, and psychoactive substance abuse. Review of the quarterly MDS assessment for Resident #70, dated [DATE], revealed he had mildly impaired cognition. Further review of the MDS assessment revealed he required supervision from staff with all activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 6 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of PASARR, dated [DATE] revealed the facility failed to identify Resident # 70's anxiety disorder or bipolar disorder. Interview on [DATE] at 4:29 P.M., with Social Service Designee (SSD) #84 confirmed Resident #24 did not have a Significant Change in Condition PASARR screening completed on [DATE]. SSD #84 confirmed Resident #63 did not have a PASARR screening completed within thirty days of admission. SSD #84 confirmed the [NAME] expired on [DATE] and the PASARR was not completed until [DATE]. SSD #84 was unable to provide information regarding the PASARR for Resident #70. Event ID: Facility ID: 365065 If continuation sheet Page 7 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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. Based on record review, resident interview, staff interview, and policy review, the facility failed to complete a thorough investigation to identify the root cause of the fall during a Hoyer lift transfer. This affected one (#47) of three residents reviewed for falls. The facility census is 83. Findings include: Review of Resident #47's medical record revealed an admission date of 05/09/23, with diagnoses including: heart failure, hypertension, Diabetes Mellitus 2, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/15/23, for Resident #47 revealed she was cognitively intact. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, dressing, and personal hygiene. Resident #47 was totally dependent on staff for assistance with transfers and toilet use. Resident # 47 was independent with eating. Review of nursing progress notes for Resident #47 revealed a nursing note created on 06/21/23 at 7:09 P.M. and effective for 06/21/23 at 11:15 A.M. revealed, the resident stated the Hoyer lift tipped while the aide/s was transferring her to the wheelchair. Interview on 09/25/23 with Resident #47 revealed she was dropped from a Hoyer lift during a Hoyer lift transfer from her bed to the wheelchair. Review of the facility form titled, IDT Post Fall/Incident Investigation/Summary, dated 06/21/23 at 11:15 A.M., revealed the Hoyer lift became unbalanced, tipped over and resulted in Resident #47 falling to the floor. The IDT team identified the need for more staff assisting with transfers. Review of the facility statements obtained from staff revealed the facility failed to obtain a statement from STNA #200 or #201 who were present and attempted to transfer Resident #47 from the wheelchair to the bed on 06/21/23. Review of the statement from Registered Nurse (RN) #49 revealed she was the nurse working on the floor on the day of the incident. RN #49 stated, STNA #200 and #201 informed her the Hoyer lift tilted while they were transferring the resident from the bed to the wheelchair and caused the Resident (#47) to fall on the floor. Interview on 09/28/23 at 4:24 P.M., with the Director of Nursing (DON) confirmed Resident #47 was dropped from a Hoyer during a transfer on 06/21/23. The DON stated a new Hoyer lift was ordered following the fall. The DON stated she interviewed the two aides involved in the transfer and the previous Hoyer lift was not sturdy enough for Resident #47's weight. The DON stated she thought the previous Hoyer lift held 600 pounds (lbs.) to 800 lbs. However, the DON felt the tip of the Hoyer was related to the distribution of Resident # 47's weight. The DON confirmed she did not feel the issue was related to the need for more staff present, however, she felt the required a Hoyer lift that accommodated a higher weight limit. The DON confirmed the current Hoyer lift has a weight limit of 1000 lbs. Subsequent interview on 10/02/23 at 3:55 P.M., with Resident #47 confirmed two aides were present during the transfer on 06/21/23. Resident #47 stated the Hoyer left leg was caught on the leg of the bed. Resident #47 confirmed the Hoyer lift tipped and she (Resident #47) fell to the ground. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 8 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 Resident #47 stated she cannot say if it is true or not but one of the aides involved in the Hoyer lift transfer, told her the Hoyer lift used was not sturdy prior to her (Resident #47) incident. Subsequent interview on 10/02/23 at 11:08 A.M., with the Director of Nursing (DON) confirmed she failed to obtain the statements of the two former STNA (#200, #201) who no longer worked at the facility. The DON stated she had the statements, however, she is no longer able to locate the statements. Review of the policy titled, Fall and Fall Risk, managing, dated December 2007, revealed the facility will 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. This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146509 and OH00146416. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 9 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and observations, revealed the facility failed to ensure pain medications were available and provided timely to a resident to maintain pain management. This affected one (#1) of one resident reviewed for pain management. The facility census was 83. Residents Affected - Few Findings include: Review of Resident #1's medical record revealed an admission date of 04/23/07, with diagnoses including age-related osteoporosis and osteoarthritis. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. Review of physician's orders dated 09/18/23 for Voltaren (diclofenac sodium) gel 1%, apply two grams (g) topically to wrist and arm every day and night shift. Observation and interview on 09/25/23 at 11:08 A.M., revealed Resident #1 was noted to be shaking her left forearm, wrist, and hand. Resident #1 stated that she had arthritis and it hurt. Resident #1 reported that she told the nurse, and she was given pain medication, but it still hurt. Interview and observation on 09/25/23 at 3:50 P.M., revealed Resident #1 were shaking her left arm, wrist, and hand. She reported she was still having pain and that her topical analgesic was not available. Interview on 09/25/23 at 4:06 P.M., with Licensed Practical Nurse (LPN) #23 verified she gave Resident #1 her oral pain medication, but her topical pain medication, Voltaren, was not at the facility and she had to reorder it from the facility. Interview on 09/27/23 at 8:25 A.M., with LPN #23 stated that Resident #1's Voltaren arrived on 09/26/23. This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146509, OH00146416, and OH00146234. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 10 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observations, grievance report review, spread sheet review, email communication review, policy review, resident interviews, staff interviews, Registered Dietician interview, the facility failed to ensure residents were provided with adequate portion sizes and substitutes according to the approved menus/spreadsheets. This had the potential to affect 82 of 82 residents who were served food from the kitchen. The facility identified one resident (#19) did not receive food from the facility kitchen. The facility census was 83. Findings include: Review of the facility form titled, Grievance/Complaint Report, dated 07/03/23 revealed Resident #40 stated he was, getting small portions, and would like more protein. Interview on 09/25/23 at 1:53 P.M., with Resident #7stated the facility only provides small portions of food. Resident #7 stated he will ask for more food and staff will tell them they are out of food. A follow up interview with Resident #07 on 10/02/23 at 3:44 P.M., revealed the facility had an issue in the kitchen over the weekend and was unable to utilize the facility stove. Resident #07 stated he was given three or four bites of oatmeal for breakfast and nothing else on 09/30/23. Resident # 07 stated he was given a hot dog at lunch time on 09/30/23 and nothing else for lunch. Resident #07 stated he was given grilled cheese for dinner with sliced tomatoes on 09/30/23. Interview on 09/26/23 at 10:45 A.M., with Resident #132 stated the facility served small portions, and they were not served more food if they asked for it. Observation on 09/27/23 at 11:39 A.M., of the lunch time tray line revealed the facility was serving pulled pork on a burrito shell, topped with shredded cheese, a side of rice, orange slices, and orange drink. Observation of the tray line revealed Dietary [NAME] (DC) #97 used a set of metal tongs to dip the pulled pork onto the burrito shell, he utilized his gloved hand to dip the shredded cheese garnish and utilized a four-ounce (oz) spoon for the rice. Review of the facility spread sheet for the lunch meal on 09/27/23 revealed the facility would provide three oz of pork, 1 burrito shell, 1/8 cup of shredded cheese, ½ cup of spanish rice, and ½ cup of oranges. Interview on 09/27/23 at 11:55 A.M., after the lunch cart had left the kitchen for delivery Dietary Manger (DM) #82 confirmed DC #97 utilized tongs to serve the pulled pork and he should have used a three oz dip. DM #82 confirmed the cook was using a three and half oz spoon, however, he was utilizing a four oz spoon for rice. DM #82 verified the facility ran out of food and was unable to serve the last five residents without cooking more rice. Observation on 09/27/23 at 4:45 P.M., of the evening tray line revealed the facility served chicken nuggets, green beans, french fries, and cookies for dinner, with orange drink. Observation of the tray line revealed DC #40 used tongs to dip the chicken nuggets onto the resident's plates and utilized his gloved hand to dip the french fries. Interview at the time of the observation, with DC #40, verified he was utilizing tongs and was using a gloved hand to serve french fries. DC #40 stated he was using a four oz spoon for green beans, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 11 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0803 and 3 oz spoon for mashed potatoes. Level of Harm - Minimal harm or potential for actual harm Review of the facility spread sheet for dinner on 09/27/23 revealed the facility would provide the following meal for dinner, chicken nuggets two oz of protein, ½ cup of tater tots, ½ cup of green beans, and frosted white cake (one piece), and a biscuit, and 8 oz of milk. Residents Affected - Some Review of an email written from the Director of Nursing (DON) to the facility Registered Dietician (RD) #102, dated 09/30/23 at 1:14 P.M., revealed the email stated the facility was unable to utilize the stove related to a gas leak. The email stated, Breakfast today was cereal, served late and didn't match the menu. Lunch today was lunch meat on time and didn't match the menu. Dinner is going to be what was on the menu but cooked on the grill. Interview on 10/03/23 at 9:20 A.M., with the Registered Dietician (RD) #102 confirmed she was only made aware of the food substitutions listed on the email to the Administrator for Saturday 09/30/23. RD #102 could not confirm if any other items were provided for the meal on 09/30/23. RD #102 stated the facility had already provided breakfast and lunch before an approval of the menu could be given. RD #102 confirmed the facility is supposed to utilize the spreadsheets to determine the amount of food to be given to each resident. Review of the policy titled, Substitutions, dated April 2007 stated, the Food Service Manager, in conjunction with the Clinical Dietitian, may make food substitutions as appropriate or necessary. Further review of the policy revealed, the Food Service Manager will maintain an exchange list identifying the seven exchanges of food groups. Review of the policy titled, Kitchen Weights and Measures, dated April 2007, stated, food service staff will be trained in proper use of cooking and serving measurements to maintain portion control. Further review of the policy stated, staff will be trained in the appropriate measurement and type of serving utensil for each food. The Food Service Supervisor will, ensure cooks prepare the appropriate amount of food for the number of servings required. This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146416, OH00146414 and OH00146969. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 12 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and policy review, the facility failed to store and prepare food in a safe manner. This had the potential to affect 82 residents who received food from the kitchen. The facility census was 83. Findings include: During observation of the kitchen refrigerator on 09/25/23 at 9:21 A.M., there was a plastic container in the refrigerator with sliced cucumbers with no label of the contents, only a date; a block of cheese, opened, with no label or date; a large plastic container of what appeared to be mushrooms with a date, however, no label to confirm what it was; a large bag of peppers with no label or date; a large plastic container of what appeared to be juice located on a shelf in the refrigerator with no label or date. Next to the large container of juice was another large plastic container with a large clump of unknown food inside it. Dietary Manager (DM) #82 stated at the time of the observation it was juice with fruit and that was what was left of the fruit. It did not contain a label or date. There were two large plastic containers containing flour and sugar in the main kitchen under the counter. The containers did not have a label or a date. The top of the three compartment sink was soiled with dirt and food crumbs. There was a large cookie sheet pan sitting by the dishwasher with drain flies flying around it. Underneath the dishwasher was black sludge dirt, two plastic lids, food crumbs, and dirt. There were broken tiles behind the stove. Observation of the dry storage area revealed a bag of moldy hot dog buns. During interview on 09/27/23 at 11:35 A.M. DM #82 confirmed the above observations. During observation on 09/27/23 at 11:39 A.M., a yellow substance was rolling around underneath several clean trays as they were loaded onto the lunch cart. The tray line was stopped and Dietary [NAME] (DC) #97 stated the yellow substance was eggs from breakfast all along the tray prep top area. DC #97 utilized his gloved hands to garnish burritos with cheese instead of using a utensil. The tray line rand out of plates and silverware during lunch service. DM #82 took dirty dishes and silverware from the first tray cart and washed them to have enough dishware to complete lunch service. DM #82 confirmed the facility did not have enough silverware and dishes to serve all the residents. During observation on 09/27/23 at 4:45 P.M. (DC) #40 utilized his gloved hand to serve french fries. DC #40 took dirty dishes from the dirty food cart returned to the kitchen and washed them to have enough dishware to serve all residents dinner. DC #40 confirmed the facility did not have enough silverware and dishes to complete the tray line. During observation on 09/28/23 at 3:40 P.M., the sludge, dirt, and debris all over the floor and trash under dish machine, sink, and stove remained. This was confirmed by DM #82. Review of the document from the pest control company visit, dated 07/10/23, stated, roaches in the broken tile behind the ovens in the kitchen, this still needs repaired. The document dated 08/14/23 revealed Kitchen has very poor sanitation. Please focus on keeping the dishwasher area clean please. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 13 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0812 Notes-Please focus on keeping the dishwasher area clean. Level of Harm - Minimal harm or potential for actual harm Review of the State of Ohio county health department, Food Inspection Report, dated 08/15/23, revealed, observed the presence of roaches under the stove of the facility, and it is not being adequately controlled. Observed the top of the dish washing machine soiled in debris. The reporter stated the floors in the kitchen are not cleaned as often as necessary. Observed fruit flies and vegetables in the walk-in refrigerator. Residents Affected - Many Review of the facility policy titled, Food Receiving and Storage, dated October 2017, stated, Foods shall be received and stored in a manner that complies with safe food handling practices. All food stored in the refrigerator or freezer will be covered, labeled, and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 14 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observation, resident interview, staff interview and policy review, the facility failed to ensure residents were provided a dining room to eat their meals. This had the potential to affect 82 of 82 residents that receive meals from the dining room. The facility identified one (Resident #19) who did not receive his meals from the kitchen. The facility census was 83. Findings include: Observation of the dining meals throughout the week of the annual survey revealed the residents did not utilize the facility dining room. Review of Resident #07's medical record revealed an admission date of 06/13/23, with diagnoses including: diabetes mellitus 2, essential primary hypertension, hyperlipidemia, osteoarthritis, insomnia, anxiety disorder, schizophrenia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obesity, and osteoarthritis. Review of quarterly MDS assessment for Resident #07 revealed he was cognitively intact. Further review of the MDS assessment revealed he was independent from the need of assistance with his meals. Interview on 10/02/23 at 3:45 P.M., with Resident #07 stated he would enjoy eating in the dining room. Resident #07 stated he has never been given the opportunity to eat anywhere other than his room. Interview on 09/27/23 at 5:29 P.M., with Dietary Manager (DM) #82 revealed the reason why the facility does not utilize the dining room is because the ceiling tiles need to be replaced. Interview on 09/28/23 at 1:32 P.M., with the Administrator, revealed the facility dining room has not been open for the residents in over six months. The Administrator stated the facility has kept the dining room closed for various reasons including waiting on the new Director of Nursing (DON) to take over her position and waiting on the new Dietary Manager (DM) to start his position. The Administrator stated the dining room was located in the basement. The Administrator stated the care team has to figure out the logistics of the Residents getting to and from the dining room. Review of the policy titled, Quality of Life-Homelike Environment, dated May 2017 stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy revealed the facility and staff shall maximize the characteristics of the facility to reflect a homelike setting including a clean, sanitary, and orderly environment. The policy stated, staff shall provide person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. This deficiency represents the noncompliance investigated during the complaint investigation of Complaint Number OH00146416. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 15 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and policy review, the facility failed to provide a home like environment by maintaining shower rooms and ensuring there was enough plates and silverware to serve meals. This had the potential to affect up to 50 of 83 residents who reside in the faciltiy. Excluding Resident #19, who does not receive food and a total of 59 residents who do not utilize the shower rooms. The facility census was 83. Findings include: 1. Observation on 09/26/23 at 9:24 A.M., of the shower room located by the central services room revealed the air vents contained large amounts of fuzzy dust and dirt hanging off them in a fringe- like manner. The shower room contained black sludge like substances around the bottom of the shower room walls and on the floor of the shower room. The shower room had busted tile with exposed wall. Interview on 09/26/23 at 9:24 A.M., with State Tested Nurse Aide (STNA) #83 confirmed the air vents in the shower room located near the central supply room had fuzzy, dust and dirt hanging off the vents. STNA #83 confirmed the shower contained a black sludge like substance around the bottom of the shower room and on the floor of the shower room. STNA #83 confirmed the shower room had busted tiles and exposed wall. Observation 09/28/23 at 11:13 A.M., revealed the East Shower room contained a fuzzy dirt substance hanging from the shower vents. The around the bottom of the walls and flooring in the shower contained a black sludge and a black substance with fuzz around it. The shower tile was chipped, and caulking was exposed. Interview on 09/28/23 at 11:13 A.M., with Licensed Practical Nurse (LPN) #24 confirmed the East Shower room contained dirt and long fuzzy dust hanging from the shower vent. LPN #24 stated, that black fuzzy stuff around the bottom of the walls and flooring of the shower is mold. LPN #24 confirmed the tiles were chipped and caulking exposed. 2. Observation on 09/27/23 at 11:35 A.M., of the tray line for lunch revealed the facility did not have enough plates and silverware to complete the tray line. Observations revealed the Dietary Manager (DM) #82 pulled plates from the first hall soiled cart, that had just returned from being delivered and returned to the kitchen. DM #82 then proceeded to run the plates and silverware through the dishwasher and then utilize the dishes and silverware, for the last hall cart to go out for lunch, to ensure enough dishes and silverware were available for all residents. Interview on 09/27/23 at 12:40 P.M., with DM#82 confirmed the facility does not have enough plates or silverware to serve each resident at every meal without washing items from the first soiled returned dining cart. Observation on 09/27/23 at 5:25 P.M., of the dinner meal revealed the facility was unable to complete the tray line without washing ten trays from the first soiled hall cart returned. Interview on 09/27/23 at 5:29 P.M., with the DM #82 confirmed the facility does not have enough plates or silverware to complete the trays for dinner without washing the soiled items from first hall cart that goes out. DM #82 stated the facility should complete a facility sweep of resident rooms to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 16 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 - Some see if there are trays and silverware that have not been returned because the residents will eat meals in their room. Review of the policy titled, Quality of Life-Homelike Environment, dated May 2017 stated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Further review of the policy revealed the facility and staff shall maximize the characteristics of the facility to reflect a homelike setting including a clean, sanitary, and orderly environment. The policy stated, staff shall provide person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. This deficiency represents noncompliance discovered during complaint investigation of Complaint Numbers OH00146517, OH00146416, OH00146414, and OH00146234. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 17 of 18 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 365065 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harrison Pavilion Care Center 2171 Harrison Avenue Cincinnati, OH 45211 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and policy review, the facility failed to ensure the facility was free of gnats. This affected the kitchen area. The facility census was 83. Residents Affected - Few Findings include: During observation during the initial tour of the facility kitchen on 09/25/23 at 9:21 A.M., a large, soiled cookie sheet pan had drain flies flying around the pan. During interview at the time of the observation, Dietary Manager (DM) #82 confirmed the facility has an issue with gnats in the drain. Review of the pest control billing statements revealed the facility had been treated for gnats on 08/14/23. The statement stated the Kitchen has very poor sanitation. Please focus on keeping the dishwasher area clean please. Review of the policy titled Pest Control, dated May 2008, stated, the facility shall maintain an effective pest control program and the building is kept free of insects and rodents. This deficiency represents noncompliance discovered during complaint investigation of Complaint Number OH00146416. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365065 If continuation sheet Page 18 of 18