Health inspection·April 25, 2019

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Telephone interview with Physician #500 on 04/25/19 at 9:44 A.M. revealed Physician #500 could not be sure where Resident #68 obtained his subdural hematoma that was identified at the hospital on [DATE]. Physician #500 reported Resident #68 could have sustained the injury from his fall on 02/23/19, from hypertension or from another unknown cause. Review of the facility's self-reported incidents (SRIs) revealed there were no SRI completed for Resident #68's injury of unknown origin or subdural hematoma that was identified by the hospital on [DATE]. Interview with Corporate Registered Nurse (Corporate RN) #400 on 04/24/19 at 2:40 P.M., verified an SRI was not completed for the resident's subdural hematoma that was an injury of unknown origin identified by the hospital on [DATE]. Review of the facility's Abuse and Neglect policy dated March 2019 revealed all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source will be reported to the state licensing and certification agency within two hours if the alleged violation involves abuse or has resulted in serious bodily injury or within twenty four hours if the alleged violation does not involve abuse and has not resulted in serious bodily harm. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 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 366145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeridge Villa Health Care Center 7220 Pippin Rd Cincinnati, OH 45239 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a resident's injury of unknown origin was reported to the state survey agency. This affected one (Resident #68) of three residents reviewed for abuse. The facility census was 98. Findings include: Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including altered mental status, dementia in other diseases classified elsewhere without behavioral disturbance, peripheral vascular disease, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive chronic kidney disease, other abnormalities of gait and mobility, unsteadiness on feet, and other lack of coordination. Review of Resident #68's medical record indicated the resident had a fall on 02/23/19. The resident hit his left eye on the bottom of the bed and had left eye swelling and a small scratch. Resident #68 was started on neurological checks with no issues noted. Review of Resident #68's medical record revealed the resident was discharged to the hospital on [DATE] with a subdural hematoma. Resident #68's returned to the facility on [DATE]. Resident #68's medical record did not contain any additional information regarding the cause of the subdural hematoma. Review of Resident #68's hospital history and physical dated 03/14/19 revealed the resident had a subdural hematoma with a change in mental status. The record also stated there were no other gross neurological deficits and the subdural hematoma could be related to trauma due to it being less likely related to hypertension because Resident #68's vitals were normal in the emergency department. Review of Resident #68's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have severe cognitive impairment and require extensive assistance with bed mobility, dressing and personal hygiene. Resident #68 also required limited assistance with transfers, eating and toileting. Interview with Assistant Director of Nursing (ADON) #85 on 04/24/19 at 1:46 P.M., verified Resident #68 had not had any falls at the facility since 02/23/19. ADON #85 stated the resident had a change in condition and was lethargic on 03/13/19. As a result, Resident #68 was sent out to the hospital and was later diagnosed with a subdural hematoma while at the hospital. ADON #85 verified she was not aware of the cause of Resident #68's subdural hematoma that was identified at the hospital on [DATE]. Telephone interview with Physician #500 on 04/25/19 at 9:44 A.M. revealed Physician #500 could not be sure where Resident #68 obtained his subdural hematoma that was identified at the hospital on [DATE]. Physician #500 reported Resident #68 could have sustained the injury from his fall on 02/23/19, from hypertension or from another unknown cause. Review of the facility's self-reported incidents (SRIs) revealed there were no SRI completed for Resident #68's injury of unknown origin or subdural hematoma that was identified by the hospital on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 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 366145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeridge Villa Health Care Center 7220 Pippin Rd Cincinnati, OH 45239 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with Corporate Registered Nurse (Corporate RN) #400 on 04/24/19 at 2:40 P.M., verified an SRI was not completed for the resident's subdural hematoma that was an injury of unknown origin identified by the hospital on [DATE]. Review of the facility's Abuse and Neglect policy dated March 2019 revealed all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source will be reported to the state licensing and certification agency within two hours if the alleged violation involves abuse or has resulted in serious bodily injury or within twenty four hours if the alleged violation does not involve abuse and has not resulted in serious bodily harm. Event ID: Facility ID: 366145 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 366145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeridge Villa Health Care Center 7220 Pippin Rd Cincinnati, OH 45239 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included hypertension, anemia, heart failure, peripheral vascular disease, diabetes mellitus, seizure disorder, respiratory failure, dependence on renal dialysis and end stage renal disease. A review of Resident #55 quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a moderate cognitive impairment and required limited assistance to extensive assistance of staff with activities of daily living. Review of Resident #55's medical record revealed the resident was sent out to the hospital on [DATE] at 7:30 A.M., after a change in condition following a fall. The resident returned from the hospital on [DATE] at 6:32 P.M. Interview with Corporate Registered Nurse (Corporate RN) #400 on 04/24/19 at 8:41 A.M. verified a written notice which specified the duration of the bed-hold policy was not given to Resident #55 within 24 hours of her hospitalization on 04/18/19. Review of the facility's undated Return to facility and Bed Hold policy (undated) was conducted. This policy instructed that in the event of transfer or discharge due to exhaustion of Medicaid bed hold days: the facility will notify the resident and residents' representative of the transfer and the the reason for the move in writing and in a language they understood. Based on record review and staff interview, the facility failed to ensure residents received written notice which specified the duration of the bed-hold policy upon hospitalization. This affected six (Resident #10, Resident #49, Resident #55, Resident #68, Resident #83 and Resident #87) of seven residents reviewed for discharge notification. The facility census was 98. Findings include: 1. Record review revealed Resident #68 was admitted to the facility on [DATE] with the following diagnoses; altered mental status, dementia in other diseases classified elsewhere without behavioral disturbance, peripheral vascular disease, essential hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive chronic kidney disease, gastro esophageal reflux disease without esophagitis, dysphagia, primary osteoarthritis, hyperlipidemia polyneuropathy chronic angle closure glaucoma, non traumatic acute subdural hemorrhage, other abnormalities of gait and mobility, unsteadiness on feet, other lack of coordination, dysphagia, and sepsis. Review of Resident #68's medical record revealed the resident was discharged to the hospital on [DATE] with a subdural hematoma and returned to the facility on [DATE]. Resident #68 was also discharged to the hospital on [DATE] with sepsis and returned to the facility on [DATE]. Further review of Resident #68's chart revealed resident was given a bed hold notice for his 03/13/19 hospitalization on 03/19/19. Resident #68's was also given a bed hold notice for his 03/21/19 hospitalization on 03/25/19. Review of Resident #68's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have severe cognitive impairment and require extensive assistance with bed mobility, dressing and personal hygiene. Resident #68 also required limited assistance with transfers, eating and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 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 366145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeridge Villa Health Care Center 7220 Pippin Rd Cincinnati, OH 45239 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 0625 toileting on the 03/30/19 MDS. Level of Harm - Minimal harm or potential for actual harm Interview with Corporate Registered Nurse (Corporate RN) #400 on 4/24/19 at 8:41 A.M. verified a written notice which specified the duration of the bed-hold policy was not given to Resident #68 within 24 hours of his hospitalizations on 03/13/19 and 03/25/19. Residents Affected - Some Review of the facility's undated Return to facility and Bed Hold policy revealed the facility would provide the resident with the form necessary to hold the bed. 2. Record review revealed Resident #87 was admitted to the facility on [DATE] with the following diagnoses; delirium due to known physiological condition, unspecified psychosis not due to a substance or known physiological condition, lymphangioma, hyperglycemia, major depressive disorder, multiple sclerosis, neoplasm of unspecified behavior of respiratory system, dissociative identify disorder, hyperlipidemia, other osteoporosis without current pathological fracture, other symbolic dysfunctions, dementia in other diseases classified elsewhere with behavioral disturbance and other lack of coordination. Review of Resident #87's medical record revealed the resident was discharged to the hospital on [DATE] with psychosis. Resident #87 returned to the facility on [DATE]. Further review of Resident #87's chart revealed resident was given a bed hold notice for her 01/26/19 hospitalization on 02/05/19. Review of Resident #87's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have moderate cognitive impairment and require limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Interview with Corporate Registered Nurse (Corporate RN) #400 on 4/24/19 at 8:41 A.M. verified a written notice which specified the duration of the bed-hold policy was not given to Resident #87 within 24 hours of her hospitalization on 01/26/19. Review of the facility's undated Return to facility and Bed Hold policy revealed the facility will provide the resident with the form necessary to hold the bed. 3. Review of Resident #10's medical record revealed the resident was admitted on [DATE] with diagnoses including symbolic dysfunctions; cerebral infarction due to thrombosis of right cerebellar artery; recurrent depressive disorders; dementia with behavioral disturbance; and hemiplegia on left side. Review of progress notes dated 02/06/19 revealed Resident #10 was sent to a local emergency room and admitted with diagnoses including aggressive behaviors. Resident was admitted to hospital from [DATE] until 02/11/19. Review of untitled letter dated 02/11/19 revealed the resident received written notice of his remaining Medicaid days upon return to the facility with no evidence of bed hold letter being sent within 24 hours of resident's transfer to the hospital. Interview on 04/24/19 at 8:41 A.M. Corporate Registered Nurse (Corporate RN) #400 verified a written notice which specified the duration of the bed-hold policy was not given to Resident #10 within 24 hours of his hospitalization on 02/07/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 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 366145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeridge Villa Health Care Center 7220 Pippin Rd Cincinnati, OH 45239 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of Resident #49's medical record revealed Resident # 49 was admitted on [DATE] with diagnoses including lack of coordination, muscle weakness, unspecified psychosis, bipolar disorder, dementia, personality disorder, and schizoaffective disorder, bipolar type. Review of progress notes dated 03/14/19 at 12:31 P.M., revealed Resident #49 was sent to a local hospital after reported instances of refusal of care, medications, and food and admitted for a urinary tract infection, sepsis, change in mental status and poor appetite. Resident #49 returned to the facility on [DATE]. The record was silent in regards to the bed hold policy being shared with resident or resident's representative. Review of untitled letter dated 04/03/19 revealed Resident #49 received notice of her remaining Medicaid days upon returning to the facility with no evidence of bed hold letter being sent within 24 hours of resident's transfer to the hospital on [DATE]. Interview on 04/24/19 at 8:41 A.M. Corporate Registered Nurse (Corporate RN) #400 verified a written notice which specified the duration of the bed-hold policy was not given to Resident #49 within 24 hours of her hospitalization on 03/14/19. 5. Review of Resident #83's medical record revealed the resident was admitted on [DATE] with diagnoses of epilepsy, conversion disorder with seizures of convulsions, psychosis, dementia, epilepsy, and non-traumatic acute subdural hemorrhage. Review of progress notes dated 02/01/19 revealed Resident #83 was sent to a local hospital after a five minute seizure on 02/01/19 and discharged back to the facility on 02/0 4/19. Review of untitled letter dated 02/04/19 revealed the resident received written notice of her remaining Medicaid days upon return to the facility with no evidence of bed hold letter being sent within 24 hours of resident's transfer to the hospital. Interview on 04/24/19 at 8:41 A.M. Corporate Registered Nurse (Corporate RN) #400 verified a written notice which specified the duration of the bed-hold policy was not given to Resident #83 within 24 hours of his hospitalization on 02/01/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 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 366145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeridge Villa Health Care Center 7220 Pippin Rd Cincinnati, OH 45239 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 pre-admission screening and resident review (PASARR) for a newly admitted resident. This affected one (Resident #17) of two residents reviewed for PASARR. The facility census was 98. Residents Affected - Few Findings include: Record review revealed Resident #17 was admitted to the facility on [DATE] with the following diagnoses; toxic effect of keystones, other symbolic dysfunctions, other abnormalities of gait and mobility, end stage renal disease, dementia in other disease classified elsewhere with behavioral disturbance, mood disorder due to known physiological condition, legal blindness, impulse disorder, personal history of traumatic brain injury, type two diabetes mellitus with diabetic neuropathy, other chronic pain, weakness, hyperlipidemia, dementia in other disease classified elsewhere without behavioral disturbance, schizoaffective and unspecified atrial fibrillation. Review of Resident #17's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have moderate cognitive impairment and require limited assistance with bed mobility, transfers and personal hygiene. Resident #87 also required supervision with eating and extensive assistance with dressing and toileting on the 01/16/19 MDS. Review of Resident #17's chart reviewed resident did not have a PASARR in his chart. Interview with Admissions Director (AD) #2 on 04/23/19 at 7:53 A.M., verified the facility did not have a PASARR for Resident #17. AD #2 stated the resident transferred from another facility and that facility did not provide a PASARR but was able to provide a level or care indicating a PASARR was completed in the past. AD #2 was unable to provide any information regarding Resident #17's PASARR and did not know if he required specialized services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 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 366145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeridge Villa Health Care Center 7220 Pippin Rd Cincinnati, OH 45239 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 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident that a had a psychiatric hospitalization. This affected one (Resident #87) of one resident reviewed for significant change PASARR. The facility census was 98. Findings include: Record review revealed Resident #87 was admitted to the facility on [DATE] with the following diagnoses; delirium due to known physiological condition, unspecified psychosis not due to a substance or known physiological condition, lymphangioma, hyperglycemia, major depressive disorder, multiple sclerosis, neoplasm of unspecified behavior of respiratory system, dissociative identify disorder, hyperlipidemia, other osteoporosis without current pathological fracture, other symbolic dysfunctions, dementia in other diseases classified elsewhere with behavioral disturbance and other lack of coordination. Review of Resident #87's PASARR dated 11/08/18 revealed the PASARR was obtained upon Resident #87's admission to the facility. Resident #87's PASARR dated 11/08/18 reported Resident #87 to have a serious mental illness but was appropriate for nursing home care without any specialized services. Review of Resident #87's progress notes revealed the resident had a psychiatric hospital admission for psychosis on 01/26/19. The resident was reported to return to the facility from the psychiatric hospital on [DATE]. Further review revealed Resident #87's medical record did not contain a significant change PASARR or notification to the state mental health authority upon Resident #87's psychiatric hospitalization on 01/26/19. Review of Resident #87's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have moderate cognitive impairment and require limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #87 also required supervision with eating. Interview with Registered Nurse (RN) #97 on 04/23/19 at 2:50 P.M. verified a notification to the state mental health authority or significant change PASARR was not completed upon Resident #87's psychiatric hospitalization on 01/26/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 9 of 9