Inspection·December 18, 2023

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 medical record review, observations, staff and resident interviews, and policy review, the facility failed to ensure bathing and personal hygiene were provided to residents who dependent on staff for assistance with activities of daily living (ADL). This affected two (Residents #6 and #77) of three residents reviewed for ADL care. The facility census was 76. Residents Affected - Few Findings include: 1. Medical record review for Resident #6 revealed an admission date of 07/28/23. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. His functional status was impairment on upper and lower extremities. He was dependent on staff for bathing. Review of the bathing records for Resident #6 from 10/01/23 through 12/12/23 revealed out of 20 opportunities for bathing, he received 12 bed baths. Review of the care plan dated 12/01/23 revealed Resident #6 had an activities of daily living deficit and required assistance for bathing with up to two-person assistance. Interview and observation with Resident #6 on 12/11/23 at 11:05 A.M. revealed he received bed baths, but not on a regular basis. He said they don't wash under his bandage on his left hand, don't wash his feet, and staff hasn't trimmed or cleaned his nails. In between his fingers on both hands were dry, scaly, and dirty. His nails were long and had a dark substance under them. His toes were dry, scaly and dirty. Interview with Licensed Practical Nurse (LPN) #160 on 12/12/23 at 1:03 P.M. confirmed the nails, fingers and toes were dirty and needed some attention. LPN #160 stated the staff were supposed to be doing this during his bathing. 2. Closed medical record review for Resident #77 revealed an admission on [DATE]. Diagnoses included obstructive uropathy, bipolar disorder, and Schizophrenia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #77 was cognitively intact. His functional status was impairment on upper and lower extremities. Resident #77 was dependent on staff bathing. Review of the care plan dated 11/08/23 revealed Resident #77 was dependent for bathing. Review of the bathing records for Resident #77 revealed from 11/08/23 through 11/22/23, the resident received four bed baths. Resident #77 missed three baths on on 11/10/23, 11/17/23, and 11/20/23. The documentation was marked non-applicable (NA) on 11/10/23, 11/17/23, and 11/20/23. Interview with the Regional Director of Clinical Services (RDCS) #200 on 12/12/23 at 2:00 P.M. revealed she tried to call some of the staff who either didn't documented the bathing or placed a NA for (continued on next page) 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 12/18/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm non-applicable in the box for Resident #6 and #77, but was unsuccessful in reaching the staff. RDCS #200 verified if it wasn't documented, it wasn't completed for the bathing. Review of the facility's undated policy titled Routine Resident Care revealed their policy was to provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse bathing. Residents Affected - Few Review of the facility's undated policy titled Nail and Hair Hygiene Services revealed it is the policy of this facility to promote resident centered care by attending to the physical emotional, social, and spiritual needs and honor resident lifestyle preferences while in the care of this facility. This facility will provide routine care for the resident for hygienic purposes and for the routine care also includes nail hygiene services including routine trimming, cleaning and filing. Routine nail hygiene may be performed in conjunction with bathing or performed separately. This deficiency represents non-compliance investigated under Complaint Number OH00148560. 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 12/18/2023 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 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 observation, medical record review, staff and resident interview, and policy review, the facility failed to follow the physician's orders for treatment of a resident's pressure ulcers. This affected one (#6) of three residents reviewed for pressure ulcers. The facility identified there were three residents with pressure ulcers residing in the facility. The facility census was 76. Residents Affected - Few Findings include: Medical record review for Resident #6 revealed an admission date of 07/28/23. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was dependent on staff for bed mobility and transfers. Resident #6 had four stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed), and three of them were present upon admission. Resident #6 also had one stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon, or muscle.) that was present upon admission and one unstageable pressure ulcer (Slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) that wasn't present upon admission. Review of the care plan dated 12/01/23 revealed Resident #6 has impaired skin integrity with five pressure wounds and three skin tears due to incontinence, poor mobility, with diagnoses of quadriplegia and poor nutritional intake. Interventions included to encourage and assist the resident to turn and reposition every two hours and to provide appropriate off-loading cushion. Review of the physician orders for Resident #6 dated 12/02/23 revealed an order to turn and reposition Resident #6 every two hours as tolerated. There was also a physician order to place moon boots on Resident #6 when in and out of bed as tolerated. Interview and observation with Resident #6 on 12/11/23 at 11:05 A.M. revealed the staff don't turn him like they were supposed to, and they don't place his moon boots on him either. He stated his moon boots had not been on him since he came back from the hospital. Resident #6 was observed in bed without his moon boots on. The boots were observed up on the top shelf of the closet. Observations on 12/11/23 from 11:10 A.M. to 1:30 P.M. revealed there was staff who went into Resident #6's room, but there was no staff who turned and repositioned Resident #6 and staff did not place his moon boots on Resident #6's feet. Interview with State Tested Nursing Aide (STNA) #145 on 12/11/23 at 1:36 P.M. revealed she came into work at 7:00 A.M. and didn't have time to turn Resident #6. STNA #145 stated she didn't know Resident #6 was supposed to be turned every two hours and verified Resident #6 was dependent on staff for turning and repositioning. Observation and interview with Resident #6 on 12/12/23 at 1:02 P.M. revealed the resident didn't have his moon boots on. Licensed Practical Nurse (LPN) #160 on 12/12/23 at 1:03 P.M. confirmed Resident #6 didn't have his moon boots on. (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 12/18/2023 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of dressing changes to Resident #6's pressure ulcers on 12/12/23 at 1:08 P.M. with Licensed Practical Nurse (LPN) #160 revealed she double gloved her hands, sprayed wound cleanser on the bandages of the one area of the left buttock and lower back region and removed the bandages and didn't clean with a clean gauze. LPN #160 removed her gloves and placed a set of new gloves on her hands and continued to place moistened Dakin's gauze to the left buttock and upper back region. LPN #160 changed her gloves and applied abdominal pad over the wounds. LPN #160 continued with the left hip ulcer and removed the bandage and sprayed wound cleanser on the wound and didn't clean the wound. LPN #160 applied Dakin's moistened gauze to this wound and removed her gloves and went to the bathroom to wash her hands. Interview with the LPN #160 on 12/12/23 at 2:24 P.M. stated she was told she could wash her hands at the beginning of a dressing change and at the end of it. LPN #160 verified she didn't wash her hands after hands were contaminated. LPN #160 verified she did not follow the physician orders to clean the wounds with normal saline. LPN #160 verified she should not have double gloved her hands. Interview with the Director of Nursing (DON) on 12/12/23 at 2:33 P.M. revealed the expectation of the nurse would be to cleanse the wound with the normal saline per physician order and to wash her hands from dirty to clean no matter how many times it would take. The DON verified the nurse should have not double gloved her hands. Review of the facility's undated policy titled Skin Care and Wound Management revealed to communicate risk factors and interventions to the care giving team. Review of the facility's policy titled Standard Precautions, dated 04/01/17, revealed practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the chain of infection. Proper cleaning of hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming resistant to antibiotics. This facility will adhere to Centers for Diseace Control and Prevention (CDC) guidelines and recommendations for hand hygiene unless otherwise explicitly stated. When hands are not visibly soiled, alcohol-based hand sanitizers are the preferred method for cleaning hands in this healthcare setting. Use soap and water method for cleaning hands when hands are visibly dirty or soiled or known or suspected exposure to Clostridium difficile (C.difl) or norovirus, if the facility is experiencing an outbreak, before eating and after using a restroom (CDC, 2016). For all other times, alcohol based hand sanitizers are recommended by the Centers for Disease Control and Prevention in the healthcare setting. When hands move from a contaminated body site to a clean body site during patient care including dressing changes. This deficiency represents non-compliance investigated under Complaint Number OH00148905. 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 12/18/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure catheter care and incontinence care was provided correctly to a resident. This affected one (#6) of three residents reviewed for catheter care and one (#6) of one resident reviewed for incontinence care. The facility identified there were four residents who required catheter care. The facility census was 76. Findings include: Medical record review for Resident #6 revealed an admission date of 07/28/23. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction, pressure ulcer to sacral region on admission, and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Resident #6 was dependent on staff for toileting and had an indwelling catheter. Observation on 12/13/23 at 10:04 A.M. revealed State Tested Nursing Aide (STNA) #79 was providing incontinence care to Resident #6. STNA #79 took a wet washcloth and wiped from under the scrotum up across the top of the scrotum. As STNA #79 was wiping upwards, there was stool on the washcloth. STNA #79 continued to fold the washcloth and wipe upwards and continued to find stool on the cloth. STNA #79 didn't wash the penis or the scrotum. She didn't rinse or dry the area. Further observation of catheter care revealed STNA #79 removed a bloody four by four bandage from around of the insertion site of the suprapubic catheter. STNA #79 didn't wipe the tubing from the insertion site pulling upward and she didn't clean around the insertion site. Interview with STNA #79 on 12/13/23 at 10:20 A.M. confirmed she didn't perform the incontinence care properly and it wasn't her practice to perform the care in this manner. STNA #79 stated she didn't know how to clean the supra/pubic catheter because it wasn't done for the residents. Review of the facility's undated policy titled Catheter Care revealed catheter care is to be performed at least twice daily on residents that have indwelling catheters, for as long as the catheter is in place. The policy revealed to don gloves, expose the area only, observing for dignity and warmth. Obtain clean, wet washcloth with warm soap and water, securely grasp the catheter tubing nearest the opening to prevent movement or accidental dislodgement. Clean around catheter just above entrance and wipe in an upward motion to clean the tubing. This deficiency represents non-compliance investigated under Complaint Number OH00148560. 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 12/18/2023 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 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 observation, medical record review, staff and resident interview, the facility failed to ensure a resident's pain was managed. This affected one (#26) of one resident reviewed for pain. The facility census was 76. Residents Affected - Few Findings include: Medical record review for Resident #26 revealed an admission date of 11/07/22. Diagnoses included cerebrovascular attack with paralysis, diabetes mellitus, and arthritis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the physician's order dated 12/22/22 revealed Buralbital-APAP-Caffeine (also known as Fioricet) oral tablet 50-325-40 milligram (mg) to give one tablet every six hours as needed for migraine headache. Review of the care plan dated 05/03/23 revealed Resident #26 has complaints of acute and chronic pain. Interventions were to observe for pain every shift, provided medication per orders, and monitor for side effects. Review of the progress notes dated 12/03/23 through 12/11/23, revealed the Fioricet had not been administered to Resident #26 and there wasn't any evidence the Fioricet was reordered either. Review of a note written on 12/12/23 at 8:22 A.M. revealed Resident #26 complained about a headache and was given 650 mg of Tylenol. A follow up note written on 12/12/23 at 9:43 A.M. revealed Resident #26 rated his pain level score at a ten, 10/10 (zero was no pain and 10 was the most severe pain) and Tylenol was ineffective. At 11:30 A.M., the physician discontinued the Fioricet and ordered Excedrin 250-250-65 mg to take two tablets every 24-hours for migraine headache. This was administered to the resident at 1:03 P.M. and at 2:29 P.M., Resident #26 said he felt like the Excedrin was working and rated his pain at a eight out of a ten. At 5:27 P.M., the physician reordered the Fioricet 50-325-40 mg to administer one tablet every six hours as needed for migraine headache to start on 12/13/23. Observation on 12/12/23 at 8:00 A.M. revealed Resident #26 was asking for his Fioricet for his migraine headache. The nurse said she put in the order on 12/11/23 for the medication and she would check to see if it was in the facility yet. She administered a 500 milligram (mg) Tylenol for his headache. Interview with Resident #26 on 12/11/23 at 8:23 A.M. revealed he has asked for his migraine medication for one to two weeks now and the facility hasn't received it yet. Resident #26 stated he has a headache when he wakes up in the morning and when he goes to bed in the evening. He rated his pain at a seven out of a 10 pain scale. Interview with Licensed Practical Nurse (LPN) #152 on 12/12/23 at 8:25 A.M. revealed she sent in a script on 12/11/23, but had not received the medication from the pharmacy yet and hopefully the medication would come in on the next delivery today. She confirmed there wasn't any evidence she re-ordered the medication on 12/11/23. This deficiency represents non-compliance investigated under Complaint Number OH00148560. 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 12/18/2023 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Potential for minimal harm Based on observation and review of a test tray, staff and resident interview, and policy review, the facility failed to ensure the coffee was served hot and was at the proper temperature. This affected two (#6 and #15) of two residents reviewed for meals and had the potential to affect other residents who drink coffee. The facility census was 76. Residents Affected - Some Findings include: Interviews with Resident #6 and #15 on 12/11/23 at 11:05 A.M. revealed the coffee was cold when it was served to them. Review of the last tray from the kitchen on 12/13/23 at 9:00 A.M. after all of the trays were delivered revealed the coffee temperature was 114 degree Fahrenheit (F) and it tasted lukewarm. Interview with Dietary Manager #74 on 12/13/23 at 9:10 A.M. confirmed the coffee was at 114 degrees F. Review of the facility policy titled Food Preparation, dated 09/01/17, revealed all foods will be held at appropriate temperatures, greater than 135° F for hot holding, and less than 41°F for cold food holding. This deficiency represents non-compliance investigated under Complaint Number OH00148560. 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 12/18/2023 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and resident and staff interview, the facility failed to ensure drinks were available on the meal trays for the residents. This affected two (#6 and #15) of two residents reviewed for meals. The facility census was 76. Findings include: 1. Medical record review for Resident #6 revealed an admission date of 07/28/23. Diagnoses included quadriplegic from a traumatic spinal cord dysfunction and neurogenic bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and he was dependent on staff for eating. Interview with Resident #6 on 12/11/23 at 11:05 A.M. revealed the kitchen runs out of juices and coffee at the end of his hall due to it being the last hall in the facility to get served for meals. Observation of the lunch meal service on 12/11/23 at 1:15 P.M. revealed Resident #6's hall was the last to be served. The lunch was delivered to the resident's room at 1:25 P.M. and there wasn't coffee or juice on Resident #6's meal tray. Interview with State Tested Nursing Aide (STNA) #145 on 12/11/23 at 1:36 P.M. confirmed there wasn't anymore coffee or juice to give to Resident #6 so she gave Resident #6 water. STNA #145 confirmed she didn't check with the kitchen to see if there was more coffee or juice available. 2. Medical record review for Resident #15 revealed an admission date of 05/25/23. Diagnoses included neurological condition. Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was cognitively intact and he was able to feed himself. Interview with Resident #15 on 12/11/23 at 11:05 A.M. revealed his room was at the end of the hall and the last hall served for meals. He stated there were times when the staff run out of coffee and juice to serve to them. Observation of the lunch meal service on 12/11/23 at 1:25 P.M. revealed Resident #15's hall was the last to be served. The lunch was delivered to the resident's room at 1:25 P.M. and there wasn't coffee or juice on Resident #15's meal tray. Interview with STNA #145 on 12/11/23 at 1:36 P.M. confirmed there wasn't anymore coffee or juice to give to Resident #15 so she gave Resident #15 water. STNA #145 confirmed she didn't check with the kitchen to see if there was more coffee or juice available. 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