Health inspection·April 5, 2023

F 0567 Level of Harm - Potential for minimal harm facility did not maintain a petty cash account and residents could only get money from their resident funds accounts on Monday to Friday from 9:00 A.M. to 5:00 P.M. Interview on 04/05/23 at 1:12 P.M. with Resident #68 revealed there was no way to get any money from resident funds accounts on the weekends. Residents Affected - Some Review of the facility's resident trust fund policy dated 09/15/21 revealed resident trust fund petty cash was maintained in a safe or other secure cabinet in a secured location. Banking hours at the facility were 9:00 A.M. to 5:00 P.M. Monday to Friday. This deficiency represents non-compliance investigated under Complaint Number OH00140915. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 2 of 9 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 365196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Healthcare Center 5501 Verulam Cincinnati, OH 45213 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, observation, review of the facility's Self-Reported Incidents (SRIs), and review of the facility's abuse policy, the facility failed ensure residents were free from resident-to-resident physical abuse. This affected two (#59 and #74) of three residents reviewed for abuse. The facility census was 83. Findings include: 1. Review of the Resident #74's medical record revealed Resident #74 was admitted to the facility on [DATE]. Diagnoses included type two diabetes mellitus without complications, and generalized anxiety disorder. Review of Resident #74's admission Minimum Set (MDS) assessment dated [DATE] revealed Resident #74 was cognitively intact, and Resident #74 required supervision with bed mobility and transfers. Review of Resident #74's progress note dated 03/13/23 revealed another resident (Resident #68) was attempting to get to his room while Resident #74 and others were in the hallway. The other resident became impatient and tried to rush past others in the hallway. In the process, the other resident's electric wheelchair bumped this resident's wheelchair. Review of Resident #68's medical record revealed Resident #68 was admitted to the facility on [DATE]. Diagnoses included complete traumatic amputation at level between right hip and knee, and complete traumatic amputation at level between left hip and knee. Review of Resident #68's discharge MDS assessment dated [DATE] revealed Resident #68 was cognitively intact, and Resident #68 required supervision with assistance with bed mobility and transfers. Review of Resident #68's progress note dated 03/13/23 revealed Resident #68 had a verbal altercation using profane language. The residents were threatening each other, and Resident #68 became impatient while the other resident (Resident #74) was ambulating with a wheelchair. The witness stated Resident #68 attempted to run over the other resident (#74) with his electric wheelchair. Review of the self-reported incident (SRI) dated 03/14/23 revealed Resident #74 alleged Resident #68 hit him with his wheelchair. Resident #68 was coming down the hallway in his electric wheelchair and Resident #74 was going down the hallway in his wheelchair. Resident #68 became agitated because he could not get around Resident #74 and the residents had a verbal altercation. Resident #68 then 'rammed' his wheelchair into Resident #74's wheelchair. The residents were immediately separated by staff and Resident #68 was put on a one-on-one supervision. The residents were immediately assessed, and no injuries were noted. On 03/14/23, Resident #74 went to the Administrator and reported he wanted to call the police regarding the incident because he felt that it was abuse and wanted Resident #68's wheelchair taken away. Review of State Tested Nursing Assistant (STNA) #19's witness statement dated 03/12/23 revealed Resident #74 and Resident #68 were arguing at the nurse's station and Resident #68 kept riding up on Resident #74 real fast as if he was trying to hit him with his electric wheelchair. Every time Resident #74 said something, Resident #68 would roll up on him very fast and it looked as if he was trying to purposely hit him with the chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 3 of 9 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 365196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Healthcare Center 5501 Verulam Cincinnati, OH 45213 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 0600 Level of Harm - Minimal harm or potential for actual harm Review of STNA #803's written statement dated 03/12/23 revealed Resident #68 became irritated at Resident #74 for taking too long to move out of the way so he could get to his room. Resident #68 started cursing and Resident #74 started cursing back. They started threatening each other and Resident #68 was trying to run Resident #74 over with his wheelchair and Resident #74 was blocking him with the treatment cart after a few minutes another State Tested Nurse Aide (STNA) came to help and settled them both down. Residents Affected - Few Review of Resident #74's occurrence report dated 03/12/23 revealed Resident #74 had no injuries and Resident #74's physician was notified. The incident report stated two residents were arguing around the nurse's station and one resident with an electric wheelchair was observed hitting Resident #74's wheelchair. Staff separated the two residents to prevent any physical abuse. Review of Resident #68's occurrence report dated 03/12/23 at 2:15 P.M. revealed Resident #68 had no injuries and Resident #68's physician was notified. The incident report stated two residents were in a verbal altercation that led to Resident #68 attempting to run into the other resident's wheelchair with his electric wheelchair. The physician was made aware, and the DON was notified. Resident #68 lost patience and became irate with the other resident when he could not get to his room. Resident #68 denied trying to run over Resident #74 with this electric wheelchair. Telephone interview on 04/05/23 at 1:18 P.M. with STNA #803 revealed Resident #74 was going down the hallway backwards on 03/12/23 and Resident #68 made a comment that it would take an hour to get around him in the hallway. STNA #803 stated Resident #74 and Resident #68 started to argue and Resident #68 hit Resident #74's wheelchair with his electric wheelchair multiple times and Resident #74 attempted to hide behind a treatment cart in order to keep Resident #68 from hitting him with his electric wheelchair but Resident #68 continued to ram the treatment cart with his electric wheelchair until another staff member showed up to assist STNA #803. Interview with Resident #74 on 04/03/23 at 10:02 P.M. revealed Resident #68 got mad at him in the hallway on 03/12/23 and he ran into the side of his wheelchair with his electric wheelchair. Resident #74 stated he had to put a medication cart between him and Resident #68 due to Resident #68 attempting to ram him with his electric wheelchair eight times on purpose. Resident #74 reported that he also used a wooden chair to block Resident #74 on the date of that incident. Interview on 04/04/23 at 11:45 A.M. with Therapy Director #807 revealed she evaluated Resident #68's electric wheelchair use after the incident with his wheelchair on 03/12/23 and Resident #68 passed his evaluation. Therapy Director #807 stated she felt Resident #68's history of hitting other residents with his electric wheelchair was behavioral. 2. Review of Resident #59's medical record revealed Resident #59 was admitted to the facility on [DATE]. Diagnoses included paraplegia, major depressive disorder, schizoaffective disorder, and post-traumatic stress disorder. Review of the MDS assessment dated [DATE] revealed Resident #59 was cognitively intact, and Resident #59 required supervision with bed mobility and transfers. Further review of Resident #68's progress note dated 03/30/23 revealed Resident #68 was witnessed in the back of the smoking area saying racial slurs to another resident. Resident #68 then became angry and aggressively rammed his electric wheelchair into Resident #59's legs multiple times. Resident #74 then tried to stop Resident #68 and Resident #68 began ramming his electric wheelchair into Resident #74's legs. Staff members intervened and Resident #68 rolled away. Shortly after, Resident #68 confronted Resident #59 again and began smacking him in the face multiple times. The Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 4 of 9 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 365196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Healthcare Center 5501 Verulam Cincinnati, OH 45213 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intervened. Resident #68 rolled down the street to the store. One-on-one supervision was immediately assigned for when the resident returned. The progress note dated 03/30/23 revealed Resident #68 was escorted to the psychiatric facility per physician orders. Review of the SRI dated 03/30/23 revealed staff witnessed Resident #68 stating racial slurs to Resident #74 and #59. Residents #74 and #59 became upset and yelled at Resident #68. Resident #74 then began hitting Resident #74 and #59's legs with his wheelchair. Review of STNA #19's witness statement dated 03/30/23 revealed STNA #19 witnessed Resident #68 roll up on Resident #59 with his power chair. They began to argue, and Resident #68 ran over Resident #59's left leg with his power chair. Resident #59 said to stop hitting his leg with the chair and Resident #68 then hit him with it again. Resident #68 then rolled up on Resident #74 and was trying to push his chair with his power wheelchair. Resident #74 got up and they had words. Interview with Resident #74 on 04/03/23 at 10:02 P.M. revealed Resident #68 attempted to run over him with the wheelchair again on 03/30/23 due to the facility not taking away Resident #68's wheelchair. Interview with Resident #59 on 04/03/23 at 3:50 P.M. revealed Resident #59 did not want to talk about the incident with Resident #68 but stated Resident #68 rammed him and other people purposely with his electric wheelchair. Interview on 04/04/23 at 11:05 A.M. with STNA #19 revealed she witnessed Resident #68 purposely try to run over other residents with his electric wheelchair on two occasions. STNA #19 stated she heard arguing on 03/12/23 and walked over to the 200 nurse's station and saw Resident #68 hitting Resident #74 with his electric wheelchair multiple times. STNA #19 stated she then got between the residents. STNA #19 stated she was outside in the smoking area on 03/30/23 and heard residents arguing. Resident #68 then started to run over Resident #59's left leg with his electric wheelchair. Resident #59 told him to stop, and Resident #68 responded by saying what if I do not. STNA #19 stated Resident #68 then started to run over Resident #74's legs with his wheelchair and reported Resident #68 used his wheelchair as a weapon. Interview and observation with Resident #68 on 04/04/23 at 1:12 P.M. revealed Resident #68 denied hitting any residents with his electric wheelchair. Resident #68 was riding his electric wheelchair throughout the facility. Review of the facility's undated abuse, neglect and misappropriation policy revealed the facility will prevent the abuse, mistreatment, or neglect of residents. This deficiency represents non-compliance investigated under Complaint Number OH00141361. This is an example of continued non-compliance from the survey dated 03/06/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 5 of 9 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 365196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Healthcare Center 5501 Verulam Cincinnati, OH 45213 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, review of the facility policy, and record review, the facility failed to ensure the kitchen, and kitchen equipment were maintained in a sanitary manner. This had the potential to affect all residents in the facility except Resident #29 that was listed as no food by mouth. The facility census was 83. Findings include: Observation of the facility's kitchen on 04/04/23 at 8:23 A.M. revealed there were two juice nozzles with a brown substance observed inside the juice machine cap and nozzle. There were also five dirty dinner trays from 04/03/23 in the dish room and a dirty mop head next to the stove. There was brown build up on the side of the dishwasher that Dietary Manager #801 was observed to be able to scrub off. There was also a yellow and green substance on the floor below the dishwasher, pipes of the dishwasher and on the floor next to the dishwasher. Observation of the walk in refrigerator revealed an expired gallon of whole milk dated 03/30/23. Observation of the dishwasher revealed the dishwasher was 120 degrees Fahrenheit on the wash and rinse with the sanitizer solution read zero parts per million. Observation of inside the ice machine in the kitchen revealed a pink and brown substance on the ledge of the ice machine where the ice falls. Observation of the floor in the kitchen revealed the floor to have a visible brown substance on the floor throughout the kitchen. Interview with Dietary Manager #801 on 04/04/23 at 8:23 A.M. verified there was a brown substance inside the juice machine cap and nozzle that she identified as mold and there was five dirty trays from dinner on 04/03/23 in the dish room. Dietary Manager #801 also confirmed there was a dirty mop head next to the stove and there was a brown stance built up on the side of the dishwasher that she was able to scrub off. Dietary Manager #801 verified there was a yellow and green substance on the dishwasher pipes, floor below the dishwasher and the floor next to the dishwasher. Dietary Manager #801 also verified there was an expired gallon of milk dated 03/30/23 in the walk in refrigerator. Dietary Manager #801 confirmed the dishwasher was running with no sanitizer or sanitizer at zero parts per million and that there was a pink and brown substance on the ledge of the ice machine. Dietary Manager #801 verified the brown substance throughout the kitchen floor and stated the floor was approximately [AGE] years old and had not been stripped and cleaned in over one year. Review of the facility's food equipment policy dated September 2017 revealed all food service equipment will be clean, sanitary and in proper working order. Review of the facility's dishwasher service call dated 04/05/23 revealed the facility had a cracked sanitizer dishwasher line and the line was replaced. Review of a list of residents who had physician orders to not receive food by mouth dated 04/05/23 revealed Resident #29 was listed as being no food by mouth. This was an incidental finding during the course of the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 6 of 9 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 365196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Healthcare Center 5501 Verulam Cincinnati, OH 45213 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 observations, staff interview, and record review, the facility failed to maintain an effective pest control program for flies in the kitchen. This had the potential to affect all residents in the facility except Resident #29 that was listed as no food by mouth. The facility census was 83. Residents Affected - Many Findings include: Observation of the facility's kitchen on 04/04/23 at 8:23 A.M. revealed there were two juice nozzles that were still connected to the juice machine in a pitcher of water with two fruit flies floating on top. Observation of the kitchen revealed fruit flies to be flying in the dish room, in the room with the juice machine and in the kitchen next to the steam table. Interview with Dietary Manager #801 on 04/04/23 at 8:23 A.M. verified the facility had fruit flies in the facility for a long time and stated they attempted to get rid of the flies, but they would routinely come back due to the facility being unable to find the nest. Review of the facility's pest control records from 12/21/22 to 03/30/23 revealed general pest control services were provided on 01/09/23, 02/13/23, 02/27/23, 03/27/23 and 03/30/23. Further review of the pest control services from 03/27/23 revealed the kitchen was very dirty and the baseboards needed replaced around the dish tank. There were dirty dishes all over under the tank. The pest control records did not report any services specific to fruit flies. Review of the pest control policy dated 09/15/21 revealed the facility will sprayed by pest control services. Review of a list of no food by mouth residents dated 04/05/23 revealed Resident #29 was listed as being no food by mouth. This deficiency represents non-compliance investigated under Complaint Number OH00140915 and OH00141361. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 7 of 9 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 365196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Healthcare Center 5501 Verulam Cincinnati, OH 45213 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility policy, and record review, the facility failed to ensure residents kept their smoking materials stored by staff when the residents were not smoking according to the facility's smoking policy. This affected three (#37, #55 and #59) of three residents reviewed for smoking. The facility identified 31 residents who smoked at the facility. The facility census was 83. Residents Affected - Few Findings include: 1. Review of Resident #59's medical record revealed Resident #59 was admitted to the facility on [DATE]. Diagnoses included paraplegia, major depressive disorder, schizoaffective disorder, and post-traumatic stress disorder. Review of the discharge Minimum Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact, and Resident #59 required supervision with bed mobility and personal hygiene. Review of Resident #59's smoking assessment dated [DATE] revealed Resident #59 was an independent smoker. Observation of Resident #59 on 04/05/23 at 2:17 P.M. revealed Resident #59 was sitting in his wheelchair in the lobby with a cigarette behind his ear. Interview with the Director of Nursing (DON) on 04/05/23 at 2:17 P.M. verified Resident #59 had a cigarette behind his ear and nursing staff were to keep all resident smoking materials secured when residents were not smoking. 2. Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, cannabis abuse and schizoaffective disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #55 was cognitively intact, and Resident #55 required supervision with bed mobility and personal hygiene. Review of Resident #55's smoking assessment dated [DATE] revealed Resident #55 was an independent smoker. Observation of Resident #55 on 04/05/23 at 2:25 P.M. revealed Resident #55 was in the dining room with a cigarette in her mouth. Resident #55 also had a lighter that she got out of her bag. Interview with the DON on 04/05/23 at 2:17 P.M. verified Resident #55 had a cigarette, and a lighter and nursing staff were to keep all resident smoking materials secured when residents were not smoking. 3. Review of Resident #37's medical record revealed Resident #37 was admitted to the facility on [DATE]. Diagnoses included cocaine abuse, delusional disorder, schizoaffective disorder, alcohol abuse, bipolar disorder, and major depressive disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #37 was cognitively intact, and Resident #37 required extensive assistance from staff with bed mobility and personal hygiene. Review of Resident #37's smoking assessment dated [DATE] revealed Resident #37 required one-on-one assistance with smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 8 of 9 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 365196 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Healthcare Center 5501 Verulam Cincinnati, OH 45213 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 0926 Level of Harm - Minimal harm or potential for actual harm Observation of Resident #37 on 04/05/23 at 2:30 P.M. revealed Resident #37 was in the hallway next to the 100 nurses station with a cigarette behind his ear. Interview with the DON on 04/05/23 at 2:17 P.M. verified Resident #37 had a cigarette and nursing staff were to keep all resident smoking materials secured when residents were not smoking. Residents Affected - Few Review of the facility's resident smoking policy dated 09/20/22 revealed residents will be assessed by the interdisciplinary team and designated as independent or supervised. The facility will secure smoking materials in a locked area when not in use by the resident for both independent and supervised smokers. Smoking materials will be returned to facility staff upon the completion of smoking. This was an incidental finding during the course of the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365196 If continuation sheet Page 9 of 9