Health inspection·March 18, 2022

F 0550 resident was severely cognitively impaired and Resident #25 required supervision with eating. Level of Harm - Minimal harm or potential for actual harm Observation of the facility on 03/07/22 at 8:29 A.M. revealed staff were passing trays on the first floor. Further observation of dining revealed a room tray was provided to Resident #65 but was not provided to Resident #35. Resident #35 and Resident #65 were roommates and were both eating in the same room. Resident #35 was observed asking State Tested Nurse Aide (STNA) #329 where her food was and STNA #329 stated her food was on the next cart. Residents Affected - Some Observation of the facility on 03/07/22 at 8:42 A.M. revealed Resident #35 was walking in the hallway asking for her breakfast tray. STNA #329 was observed to tell Resident #35 that her food was on the next cart. Interview with STNA #329 on 03/07/22 at 8:44 A.M. verified Resident #35 and Resident #65 were roommates and Resident #65 had received her tray, but Resident #35's food was on a different cart despite them both eating in their room. Observation of the facility on 03/07/22 at 8:49 A.M. revealed Resident #35's tray arrived in her room. Review of the facility's dignity policy, dated February 2020, revealed residents will be treated with dignity and respect at all times. 3. Review of the medical record for Resident #8 revealed an admission date of 11/05/19. Diagnoses included urinary retention, cerebral vascular accident (CVA/stroke), acute kidney failure, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, dementia, hematuria, and muscle wasting. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severely impaired cognition, had no behaviors, did not reject care, and the resident was noted with an indwelling catheter. Review of the plan of care, dated 07/11/19, revealed Resident #8 had alteration in bladder control related to dementia, CVA, BPH and urinary retention, and the resident was at risk for complications related to indwelling suprapubic catheter. Interventions included to position catheter bag and tubing below the level of the bladder and away from entrance room door. The plan of care was silent for any notes about the catheter bag being covered. Review of the physician's orders dated 02/11/19 revealed Resident #8 was ordered to have supra pubic catheter site cleansed with normal saline and split gauze every shift. Observations of the common dining room during breakfast service on 03/07/22 at 8:52 A.M. revealed Resident #8 was situated at the dining room table in a wheelchair and alongside numerous other residents. Resident #8 resident had an indwelling catheter bag hanging from the rear of wheelchair and without being covered. Interview with State Tested Nurses Aide (STNA) #361 on 03/07/22 at 8:54 A.M. verified Resident #8 was seated in the common dining room with his catheter bag uncovered and attached to his wheelchair. STNA #361 stated Resident #8 should have had his catheter bag covered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 2 of 39 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 03/18/2022 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 0550 Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled Quality of Life - Dignity, dated 12/01/20, revealed the resident shall be cared for in a manner that promotes and enhances well-being, level of satisfaction with life, feeling of self-worth and self esteem and residents are treated with dignity at all times. Notes also indicated demeaning practices and standards of care that compromise dignity was prohibited and staff are expected to promote dignity and assist residents with keeping urinary catheter bags covered. Residents Affected - Some This deficiency substantiates Complaint Number OH00114269. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 3 of 39 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 03/18/2022 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of the facility's policy, the failed to ensure when a resident formulated an advanced directive, the resident's advanced directive was accurately recorded in all locations of the medical record to ensure the resident's wishes would be followed as directed in the event of an emergency. This affected three (Residents #26, #40 and #489) of 18 residents reviewed for advance directives. The facility census was 94. Findings include: 1. Review of the medical record for the Resident #26 revealed an admission date of 12/08/20. Diagnoses included Parkinson's disease, bradycardia, congestive heart failure, cardiomyopathy, atherosclerotic heart disease (ASHD), acute kidney disease, dementia, psychosis, hemiplegia, cardiomyopathy, contracture of left hand, cardiac implants, mental disorder, and moderate protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact. Review of the plan of care revealed Resident #26's code status was listed as a do not resuscitate comfort care (DNR-CC) and advanced directive care planning was reviewed with resident/responsible party. Review of the medical record review of Resident #26's hard/paper chart at second floor nurse's station on 03/08/22 at 10:19 A.M. revealed an undated advanced directives form which indicated Resident #26 was a Full Code. Further review of the electronic medical record (EMR) for Resident #26 revealed a DNR-CC dated 04/20/21. Interview with Licensed Practical Nurse (LPN) #310 on 03/08/22 at 10:22 A.M. verified Resident #26's advanced directives in the EMR, and hard/paper chart at nurse's station did not match. LPN #310 stated she was not sure why the paper chart listed resident as a full code and the EMR showed resident a DNR-CC and her expectations would be the advanced directives were to match in both places in the event of an emergency. 2. Review of the medical record for the Resident #40 revealed an admission date of 04/30/21. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), diabetes mellitus and dementia. Review of the MDS assessment dated [DATE] revealed Resident #40 was cognitively intact. Review of the plan of care revealed Resident #40's code status was listed as a DNR-CC. Advanced Directive care planning was reviewed with resident/responsible party. Review of the medical record review of Resident #40's hard/paper chart at the second-floor nurse's station on 03/07/22 at 12:05 P.M. revealed an undated advanced directives form which indicated Resident #40 was a Full Code. Further review of the EMR for Resident #40 revealed a DNR-CC unsigned by the resident and unable to verify the date due to being written as 06/11/2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 4 of 39 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 03/18/2022 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with LPN #353 on 03/07/22 at 12:06 P.M. verified Resident #40's advanced directives in the EMR and hard/paper chart did not match. LPN #310 stated she was not sure why the paper chart and EMR did not match and her expectations would be the advanced directives were to match in both places in the event of an emergency. 3. Review of the medical record for Resident #489 revealed an admission date of 02/22/22. Diagnoses included central dislocation of right hip, chronic kidney disease, stage III, gout, alcohol dependence with alcohol-induced mood disorder, venous insufficiency, obesity, repeated falls, chronic diastolic, heart failure, mood disorder due to known physiological condition, sleep apnea, and delirium due to known Review of Resident #489's physician orders revealed an order dated 02/22/22 for a DNR (do not resuscitate) code status. Review of Resident #489's medical record revealed there was a blank DNR form, that was not signed by the resident or physician. Interview on 03/08/22 at 10:05 A.M. with LPN #302 verified Resident #489's chart did not contain a signed DNR form. Review of the undated facility policy titled Advance Directive revealed the advanced directives would be respected in accordance with the state law and facility policy. Policy indicated the facility would accurately and prominently display the advanced directives in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 5 of 39 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 03/18/2022 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's policy, the facility failed to ensure staff notified the resident's representative of seizure activity and the resident's transfer to the hospital. This affected one (Resident #49) of three residents reviewed for notification of change in condition. The facility census was 94. Findings include: Review of the medical record for Resident #49 revealed an admission date of 07/20/21 with a diagnosis of seizure disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively impaired and required extensive assistance of one staff with activities of daily living (ADLs). Review of the face sheet for Resident #49 revealed Resident #49 had a family representative who was designated as her emergency contact. Review of the nursing progress note for Resident #49 dated 01/22/22 revealed Resident #49 had a seizure starting at 5:28 P.M. Resident #49 was sitting in her wheelchair and the nurse called 911 and Resident #49 was transferred to the hospital. The record was silent regarding notification of resident's representative of the seizure and transport to the hospital. Review of the nursing progress notes for Resident #49 dated 01/25/22 revealed the resident returned to the facility from the hospital. On 01/26/22, Resident #49 was sent to the hospital due to having multiple seizures within an hour. The record was silent regarding notification of resident's representative of seizures and transport to the hospital. Interview on 03/07/22 at 11:30 A.M. with Licensed Practical Nurse (LPN) #310 confirmed Resident #49's record was silent regarding resident representative notification of resident's seizures and transfers to the hospital. Review of the facility's policy titled Change in a Resident's Condition or Status, dated December 2018, revealed the facility would notify the resident representative of change in resident status including the decision to transfer the resident to the hospital. This deficiency substantiates Complaint Numbers OH00130906, OH00115048, OH00114269, OH00114137, and OH00111296. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 6 of 39 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 03/18/2022 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, staff interview, resident interview, and review of facility policy and documents, the facility failed to ensure resident rooms and common areas on the second floor of the facility were clean and sanitary. This affected Residents #10, #23, #26, #55, #62, and #77. This had potential to affect all 44 residents who resided on the second floor. The facility census was 94. Findings include: Observation on 03/07/22 at 8:02 A.M. revealed the floors in the hallways and common areas on the second floor has visible debris, stains, and were sticky throughout. The trash receptacles in the dining area where residents were seated and awaiting breakfast were overflowing with waste which was spilling onto the floor. Interview on 03/07/22 at 8:02 A.M. with Licensed Practical Nurse (LPN) #353 confirmed the floors in the hallways and the dining area were dirty and needed to be cleaned and the trash was overflowing. LPN #353 confirmed she didn't think they had housekeeping staff over the weekend. Interview on 03/07/22 at 8:07 A.M. with Floor Technician (FT) #334 confirmed he worked Monday through Friday and there was not currently a floor tech available on the weekends. FT #334 confirmed the floors on the second floor including the hallways and dining area were dirty and had not been swept and mopped since he did them on Friday. FT #334 confirmed the trash cans in the dining room were overflowing and needed to be emptied. Interview on 03/07/22 at 8:10 A.M. with Resident #62 stated the floors in the hallway and the dining room were dirty and no one had been in over the weekend to clean them. Interview on 03/07/22 at 8:17 A.M. with Housekeeper #356 confirmed the floor technicians swept and mopped the hallways and common areas and emptied trash in the common areas and the housekeepers cleaned individual resident rooms. Housekeeper #356 confirmed the floor on the second floor in the hallways and dining area was dirty and needed to be swept and mopped as soon as possible. Housekeeper #356 confirmed the trash receptacles in the second-floor dining room were overflowing and needed to be emptied. Review of the facility housekeeping scheduled for 02/28/22 through 03/06/22 revealed there was no floor technician scheduled for the weekend dates of 03/04/22 and 03/05/22. During observations of the second floor resident rooms on 03/07/22 beginning at 8:28 A.M. revealed the following: a. Resident #10's room and bathroom had unknown sticky substance throughout the floor. The bathroom had dried stool throughout the inside of the toilet, toilet seat appeared to have stool on it, unknown dark substance in the floor around the toilet and floor was littered with paper and what appeared to be food particles. Interview with Resident #10 at same time, indicated the room had not been cleaned for a few days. b. Residents #26 and #77's room had sticky substance throughout the floor, alcohol pads, trash, and food particles/crumbs throughout the floor. Interview with State Tested Nursing Aide (STNA) #361 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 7 of 39 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 03/18/2022 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 0584 verified the room's condition. STNA #361 stated she did not know when resident's rooms were last cleaned. Level of Harm - Minimal harm or potential for actual harm c. Resident #55's room had sticky substance throughout the floor and trash on the floor. Resident #55 indicated the room had not been cleaned in a while. Residents Affected - Some d. Resident #23's bed frame had dark dried substance which appeared to be dried crusted food throughout the side of the bed frame which was closest to the door. Observation at same time revealed STNA #361 donned gloves, sprayed, scraped, and cleaned the substance off of the bed. Interview with STNA #361 at same time verified the bed frame had dried food throughout the bed frame. Interview with Housekeeping Aide #356 on 03/07/22 at 9:15 A.M. indicated she was the housekeeper on duty over the weekend and was not able to clean the second floor. Housekeeping Aide #356 verified the Resident #10, #26, #77, #55, and #23's room conditions. Housekeeping Aide #356 indicated she was tasked with cleaning resident rooms and stated her expectations would be for each resident to have their rooms cleaned daily. Review of the undated facility document titled Housekeeper's Checklist revealed staff should make sure the dining room is swept and mopped. This deficiency substantiates Complaint Numbers OH00113672 and OH00130906. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 8 of 39 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 03/18/2022 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Based on medical record review, staff interview, and policy review, the facility failed to ensure an admission Minimum Data Set (MDS) assessment was completed within 14 days of admission. This affected three (#486, #487, and #489) of four residents reviewed for new admission to the facility. Findings include: 1. Review of the medical record for Resident #486 revealed an admission date of 02/24/22. Diagnoses included hemiplegia affecting right dominant side, gastro-esophageal reflux disease without esophagitis, essential hypertension, hypothyroidism, and hyperlipidemia. Review of the medical record revealed an admission MDS assessment had not yet been completed. Interview on 03/10/22 at 11:48 A.M. with Assistant Regional Director of Clinical Operations (ARDCO) #400 verified Resident #486's MDS assessment was not completed by the fourteenth day following her admission. 2. Review of the medical record of Resident #487 revealed an admission date of 02/17/22. Diagnoses included partial traumatic amputation of right great toe, essential hypertension, anxiety, disorder, post-traumatic stress disorder, diabetes mellitus, acquired absence of left toes, and major depressive disorder. Review of the MDS assessments revealed a comprehensive assessment was not yet completed. Interview on 03/09/22 at 11:44 A.M. with ARDCO #400 verified Resident #487's comprehensive MDS assessment was not completed by the fourteenth day following admission. 3. Review of the medical record of Resident #489 revealed an admission date of 02/22/22. Diagnoses included central dislocation of right hip, chronic kidney disease, stage III, alcohol dependence with alcohol-induced mood disorder, venous insufficiency, obesity, repeated falls, chronic diastolic, heart failure, mood disorder due to known physiological condition, sleep apnea, and delirium due to known physiological condition. Review of the MDS assessments revealed a comprehensive MDS assessment was not yet completed. Interview on 03/09/22 at 11:44 A.M., ARDCO #400 verified Resident #489's comprehensive MDS assessment was not completed by the fourteenth day following admission. Review of the facility's policy titled Comprehensive Assessments and the Care Delivery Process, dated 12/2016, revealed the MDS should be completed by the fourteenth day after admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 9 of 39 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 03/18/2022 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 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 observations, medical record review, review of facility policy, resident interview, and staff interview, the facility failed to ensure the resident's who required assistance from staff received assistance with personal hygiene. The facility failed to ensure the resident's fingernails were trimmed and clean and ensure female residents did not have facial hair. This affected three (#23, #71, and #72) of three residents reviewed for activities of daily living (ADL). The facility identified 91 residents who require assistance with one or more ADL tasks. The facility census was 94. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #72 revealed an admission date of 06/14/19. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery, morbid obesity, left hand contracture, and chronic obstructive pulmonary disease (COPD). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had intact cognition. The resident did not exhibit any behaviors during the assessment period. Resident #72 was dependent on one person for personal hygiene. Observation and interview on 03/07/22 at 10:17 A.M. revealed there was hair on Resident #72's chin, approximately one-fourth inch. Resident #72 stated she does not like when she has chin hair and asks staff to shave it for her, however some staff will not help her with it. Subsequent observation on 03/08/22 at 4:16 P.M. revealed Resident #72 still had hair on her chin. Interview on 03/08/22 at 4:18 P.M. with Licensed Practical Nurse (LPN) #310 verified Resident #72 had hair on her chin, approximately one-fourth inch long, and needed to be shaved. LPN #310 stated the residents were supposed to be shaved on shower days. Observation and interview on 03/08/22 at 4:25 P.M. revealed Resident #72's finger nails were long, approximately one-fourth inch beyond the finger tip and dirty. Resident #72 stated she preferred to have her fingernails trimmed and clean. Interview on 03/08/22 at 4:27 P.M. with State Tested Nursing Assistant (STNA) #362 verified Resident #72's finger nails were long and dirty. Observation and interview on 03/09/22 at 8:43 A.M. revealed Resident #72 still had hair on her chin and fingernails had not been cut and remained dirty. Observation on 03/10/22 at 9:39 A.M. revealed Resident #72's chin had been shaved, however her fingernails were still long and dirty. 2. Review of the medical record for Resident #23 revealed an admission date of 04/15/99 with diagnoses including multiple sclerosis (MS) and diabetes mellitus (DM). Review of the care plan dated 06/01/18 revealed Resident #23 resident had DM and received insulin. Interventions included refer to podiatrist and/or nurse for nail care and to cut long nails. Review of the MDS assessment dated [DATE] revealed Resident #23 was cognitively impaired and was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 10 of 39 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 03/18/2022 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 0677 required extensive assistance of one to two staff with personal hygiene. Level of Harm - Minimal harm or potential for actual harm Observation on 03/07/22 at 7:52 A.M. revealed Resident #23 had long (approximately one-fourth of an inch past the end of the fingers) fingernails with debris under them. Residents Affected - Few Interview on 03/07/22 at 7:53 A.M. with State Tested Nursing Assistant (STNA) #327 confirmed Resident #23's fingernails were long and had debris under them. STNA #327 stated Resident #23 was diabetic so the STNAs were not permitted to trim the resident's nails. Interview on 03/07/22 at 8:00 A.M. with Licensed Practical Nurse (LPN) #425 confirmed Resident #23's nails were long and dirty. LPN #425 further confirmed she was agency, and she wasn't sure who was supposed to trim and clean resident's nails. Observation on 03/07/22 at 9:08 A.M. revealed Resident #23's fingernails remained long with debris under them. Interview on 03/07/22 at 9:08 A.M. with LPN #352 confirmed Resident #23's fingernails were long and needed to be trimmed and cleaned. LPN #352 stated Resident #23 was diabetic and nurses were supposed to clean and trim resident's fingernails as needed. Review of the facility policy titled Care of Fingernails and Toenails, dated February 2018, revealed the facility would keep resident nail beds cleaned and would keep nails trimmed to prevent infections. 3. Review of Resident #71's medical record revealed Resident #71 was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, vascular dementia without behavioral disturbance, chronic pain and generalize anxiety disorder. Review of Resident #71's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact and Resident #71 required extensive from staff with personal hygiene. Resident #71 also required one person physical assistance with bathing. Observation and interview with Resident #71 on 03/06/22 at 11:11 A.M. revealed Resident #71 was sitting in her wheelchair and was noted with approximately six hairs on her chin that were approximately one inch in length. Resident #71 stated she had never had her chin hairs shaved at the facility. Resident #71 reported she wanted her chin hairs shaved and she had her own razor. Subsequent observations of Resident #71 on 03/08/22 at 1:50 P.M. revealed Resident #71 to be sitting in her wheelchair and was noted with approximately six hairs on her chin that were approximately one inch in length. On 03/08/22 at 3:45 P.M., Resident #71 was laying in her bed. Resident #71 was noted with approximately six hairs on her chin that were approximately one inch in length. Interview with Licensed Practical Nurse (LPN) #310 on 03/08/22 at 3:45 P.M. verified Resident #71 had approximately six hairs on her chin that were approximately one inch in length. Observation of Resident #71 on 03/09/22 at 12:27 P.M. revealed Resident #71 was laying in her bed. Resident #71 was noted with approximately six hairs on her chin that were approximately one inch in length. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 11 of 39 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 03/18/2022 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's Shaving the Resident policy, dated February 2018, revealed the facility will shave residents to promote cleanliness and to provide skin care. The facility will document the date and time the procedure was performed and the reasons why and the interventions taken if the resident refused. Review of the facility's dignity policy dated February 2020 revealed residents will be groomed as they wish to be groomed including grooming of facial hair. This deficiency substantiates Complaint Number OH00130906 and OH00113149. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 12 of 39 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 03/18/2022 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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, staff interview, and review of the facility's policy, the facility failed to ensure the staff changed the resident's peripherally inserted central catheter (PICC) line dressings as ordered by the attending physician. This affected one (Resident #487) of one facility-identified residents with PICC lines. The facility census was 94. Residents Affected - Few Findings include: Review of the medical record for Resident #487 revealed an admission date of 02/17/22 with a diagnosis of osteomyelitis. Review of the admitting physician orders for Resident #487 revealed an order to change the dressing to resident's PICC line weekly and as needed. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 02/17/22 to 03/06/22 for Resident #487 revealed the dressing change to resident's PICC line was not documented as being completed. Observation on 03/07/22 at 11:24 A.M. of Resident #487 revealed resident had a PICC line to her right arm with a dressing dated 02/25/22. Interview on 03/07/22 at 11:24 A.M. with Resident #487 confirmed the facility had not changed the PICC line dressing to her right arm. Resident #487 confirmed she was admitted with a PICC line from the hospital on [DATE] and her friend who was a nurse came in and brought in a dressing from her home and applied it to the PICC line on 02/25/22. Interview on 03/07/22 at 11:30 A.M. with Licensed Practical Nurse (LPN) #310 confirmed Resident #487 had a PICC line dressing on her arm dated 02/25/22 and the facility had not placed the dressing. Review of the facility's policy titled PICC, and Midline Dressing Changes, dated April 2016, revealed a PICC line dressing should be changed every five to seven days or if it is wet, not intact, or compromised in any way. This deficiency substantiates Complaint Number OH00130906. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 13 of 39 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 03/18/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, staff interview, and review of the facility's policy, the facility failed to provide dressing changes to a pressure ulcer as ordered by the physician. This affected one (Resident #9) of four facility-identified residents with pressure ulcers. The facility census was 94. Residents Affected - Few Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/30/21 with a diagnosis of cerebral infarction. Review of the Minimum Data Set (MDS) assessment, dated 02/18/22, revealed Resident #9 was cognitively impaired and was totally dependent on staff for activities of daily living (ADLs). Review of the wound physician note for Resident #9 dated 03/02/22 revealed the resident had an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to his right heel which measured 2.3 centimeters (cm) by 2.7 centimeters. Review of the physician orders for Resident #9 revealed an order dated 03/03/22 to cleanse the pressure ulcer to the right heel with normal saline or sterile water, apply Medihoney to wound bed and cover with a clean dry dressing once daily at 5:00 P.M. and as needed. Review of the Treatment Administration Record (TAR) for Resident #9 revealed the treatment was signed off as completed for 03/04/22. Treatment was not documented as completed or refused for 03/05/22 and 03/06/22. Observation on 03/07/22 at 1:41 P.M. of Resident #9 revealed the resident had a dressing to his right heel which was dated 03/04/22. Interview on 03/07/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #353 confirmed the dressing in place to resident's right heel was clearly marked with the date 03/04/22. LPN #353 further confirmed Resident #9's record was silent regarding why treatment was not completed on 03/05/22 and 03/06/22. Review of the facility policy titled Pressure Ulcers Skin Breakdown Clinical Protocol, dated March 2014, revealed the physician would authorize orders for wound treatments to aid in wound healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 14 of 39 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 03/18/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy, the facility failed to conduct a thorough investigation of a resident's falls. The facility also failed to ensure a resident who was ordered bed rails, had the bed rails in place. This affected one (Resident #26) of two residents the facility identified as having bed rails ordered. This affected one (Resident #290) of five residents reviewed for accidents and falls. The facility census was 94. Findings include: 1. Review of the medical record for Resident #290 revealed an admission date of 03/03/22. Diagnoses included cerebral infarction. Review of the admission assessment for Resident #290 dated 03/03/22 revealed the resident was alert and oriented to person place and time with periods of confusion. Resident #290 required limited assistance of staff with activities of daily living (ADLs). Review of the fall risk assessment for Resident #290 dated 03/04/22 revealed resident was at high risk for falls. Review of the baseline care plan dated 03/04/22 revealed Resident #290 was at risk for falls due to cerebrovascular accident (CVA). Interventions included the following: to ensure basic needs were met, ensure call light was within reach, and ensure appropriate footwear was on. Review of the nursing progress note by Licensed Practical Nurse (LPN) #303 dated 03/04/22 revealed Resident #290 was noted to be sitting on the floor next to her bed with her legs stretched outward and her hands on her lap. The bed was in the lowest position and the wheelchair was at foot of the bed. Resident #290 stated that she was sitting on the side of the bed and slid off the edge to the floor. Review of the fall investigation for Resident #290 dated 03/04/22 completed by LPN #303 revealed it did not include a root cause analysis to determine the cause of the fall nor did it include investigation regarding whether or not care planned fall risk interventions were in place at the time of the fall. Review of the fall investigation revealed follow up intervention was to keep bed in lowest position. Review of the nursing progress note for Resident #290 by LPN #343 dated 03/06/22 revealed the nurse was notified that Resident #290 was sitting on the floor in her room and the resident was unable to account for details leading to placement on the floor and exhibited impaired cognition. Resident was sent to the hospital via 911 for evaluation. Review of the fall investigation for Resident #290 by LPN #343 dated 03/06/22 revealed it did not include a root cause analysis to determine the cause of the fall nor did it include investigation regarding whether or not care planned fall risk interventions and new intervention added following fall on 03/04/22 to keep bed in lowest position were in place. Review of the facility's incident log dated 12/10/21 through 03/10/22 revealed there were no falls (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 15 of 39 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 03/18/2022 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 0689 listed for Resident #290. Level of Harm - Minimal harm or potential for actual harm Interview on 03/15/22 at 10:00 A.M. with Corporate Director of Clinical Operations (CDCO) #410 confirmed Resident #290's falls on 03/04/22 and 03/06/22 were not included on the incident log because their investigations were not completed yet. CDCO #410 further confirmed the fall investigation for Resident #290 for the fall on 03/04/22 was completed solely by LPN #303 and it did not include a root cause analysis to determine the cause of the fall nor did it include information regarding whether the care planned fall risk interventions for Resident #290 were in place at the time of the fall. CDCO #410 confirmed the fall investigation for Resident #290 for the fall on 03/06/22 was completed solely by LPN #343 and it did not include a root cause analysis to determine the cause of the fall nor did it include information regarding whether the care planned fall risk interventions including the new intervention to keep bed in lowest position were in place at the time of the fall. Residents Affected - Few Review of the facility's policy titled Managing Falls and Fall Risk, dated March 2018, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 2. Review of the medical record for the Resident #26 revealed an admission date of 12/08/20. Diagnoses included Parkinson's disease, congestive heart failure (CHF), cardiomyopathy, atherosclerotic heart disease (ASHD), dementia, psychosis, hemiplegia, contracture of left hand, and mental disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact, had no behaviors, did not reject care, did not wander, was one person assist and required extensive and/or limited assistance with activities of daily livings (ADLs). Review of the physician's orders dated 12/15/20 revealed Resident #26 was ordered half side bed rails up on both sides by the resident's request to assist with bed mobility and to assist with turning and repositioning. Review of the plan of care dated 09/08/21 revealed Resident #26 had the potential for injuries/falls related to balance deficit, disease progression history of falls, and seizure disorder. Interventions included half side bed rails to enhance independence with bed mobility. Review of the most recent health side rail screen dated 12/16/21 revealed Resident #26 had weakness, balance deficit, used the bed rails to assist with bed mobility, improving balance, supporting self, entering, and exiting bed more safely, transferring, and to avoid rolling out of bed and both side rails were recommended. Observation and interview on 03/08/22 at 11:00 A.M. revealed Resident #26 lying in bed with no side rails on his bed. Resident #26 indicated he used to have bed rails but recently moved rooms and no longer had them. Resident #26 stated he used the bed rails for bed mobility, positioning, and getting up and down from bed. Interview with Licensed Practical Nurse (LPN) #352 on 03/08/22 at 11:05 A.M. verified Resident #26 was ordered to have bed rails. LPN #352 stated Resident #26 moved rooms on 02/23/22 and maintenance staff must have forgotten to move the bed rails to the resident's new room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 16 of 39 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 03/18/2022 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 0689 Level of Harm - Minimal harm or potential for actual harm Observations of Resident #26 on 03/08/22 at 4:25 P.M. revealed there were still no no bed rails on Resident #26's bed. Interview with LPN #352 on 03/08/22 at 5:30 P.M. verified Resident #26's bed rails were still not in place. LPN #352 stated she told administrative about the bed rails not being in place. Residents Affected - Few Review of the facility policy titled Falls and Fall Risk, Managing, dated 08/01/16, revealed the staff would identify interventions related to the residents specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling. This deficiency substantiates Complaint Number OH00130910. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 17 of 39 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 03/18/2022 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on record review, observation, staff interview, and review of facility policy, the facility failed to ensure staff labeled and dated tube feeding solution and syringe used for tube feeding. This affected one (Resident #9) of four residents with tube feedings. The facility census was 94. Findings include: Review of the medical record for Resident #9 revealed an admission date of 03/30/21 with a diagnosis of cerebral infarction. Review of the tube feeding order for Resident #9 dated 12/04/21 revealed an order for Fiber Source 75 milliliters (ml) per hour continuous and flush with 150 ml of water every four hours. Observation on 03/07/22 at 1:41 P.M. of Resident #9 revealed a bag of tube feeding was infusing via tube feeding pump at 75 ml per hour and bag was not labeled regarding contents of tube feeding bag or date the tube feeding was hung. Further observation revealed the piston syringe used for medication administration via tube was at resident's bedside and was not dated when opened. Interview on 03/07/22 at 1:41 P.M. with Licensed Practical Nurse (LPN) #353 confirmed Resident #9's tube feeding was not labeled or dated and the syringe was not dated. LPN #353 further confirmed the tube feeding was infusing when she arrived at work on 03/07/22 at 7:00 A.M. and the undated syringe was at the bedside. LPN #353 confirmed nurses should label and date the tube feeding bag prior to hanging the bag and should date syringes upon opening. Review of the facility policy titled Enteral Feedings Safety Precautions, dated November 2018, revealed to prevent errors in administration the nurse should document type of formula, initials, date and time the formula was hung, and initial that the label was checked against the order. Further review of the policy revealed nurses should maintain strict aseptic technique at all times when working with enteral nutrition systems and formulas and should change administration sets every 24 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 18 of 39 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 03/18/2022 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure residents received medications as prescribed by the physician. This affected one (#486) of five resident reviewed for medications. The facility census was 94. Findings include: Review of the medical record for Resident #486 revealed an admission date of 02/24/22. Diagnoses included hemiplegia affecting right dominant side and gastro-esophageal reflux disease without esophagitis. Review of the Brief Interview for Mental Status (BIMS) score dated 02/25/22 revealed Resident #486 had intact cognition. Review of Resident #486 physician's orders, dated 03/04/22 at 5:55 A.M., revealed an order for Penicillin V Potassium tablet (antibiotic)-500 milligrams (mg) every six hours for infection for seven days. Review of the March 2022 medication administration record (MAR) revealed Resident #486 received the first dose of the antibiotic on 03/07/22 at 12:00 P.M. Interview on 03/07/22 at 8:19 A.M. with Resident #486 stated she obtained a script for an antibiotic for a tooth infection on 03/03/22, however she had not yet received any doses of the antibiotic. Observation and interview on 03/09/22 at 12:22 P.M. with the Assistant Regional Director of Clinical Operations (ARDCO) #400 provided the box of medication, which indicated the medication was delivered on 03/03/22. ARDCO #400 confirmed Resident #486 did not receive her antibiotic until three days after the medication was prescribed and delivered to the facility. Review of the facility policy titled Administering Medications, dated 04/2019, revealed medications are to be administered in accordance with prescriber orders, including any required time frame. This deficiency substantiates Complaint Numbers OH00130589 and OH00130910. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 19 of 39 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 03/18/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to ensure a resident's pharmacy recommendations were addressed in a timely manner. This affected five (#26, #40, #49, #53, and #71) of five residents reviewed for unnecessary medications. The facility census was 94. Findings include: 1. Review of the Resident #71's medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, major depressive disorder, and generalized anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact. Review of Resident #71's pharmacy recommendation dated 01/08/22 revealed Resident #71 was on Buspirone 10 milligrams (mg) twice a day for depression and Sertraline 50 milligrams daily for depression. The pharmacy recommendation stated a dose evaluation was due per regulations and to please evaluate the continued need and consider a dose reduction or document. Resident #71's Sertraline was reduced to 25 mg per day. The pharmacy recommendation was signed by the physician 44 days later on 02/21/22. Review of Resident #71's pharmacy recommendation dated 01/08/22 revealed Resident #71 was prescribed Olanzapine 5.0 mg at bedtime for behaviors. The pharmacy recommendation stated to please evaluate for a gradual dose reduction (GDR). Further review of the pharmacy recommendation revealed a reduction was clinically contraindicated because Resident #71 was at high risk for decompensation. The pharmacy recommendation was signed by the Certified Nurse Practitioner (CNP) 44 days later on 02/21/22. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 12:45 P.M. verified Resident #71's pharmacy recommendations dated 01/08/22 were not addressed by the CNP or physician until 02/21/22. 2. Review of the record for Resident #53 revealed he was admitted to the facility on [DATE]. Diagnoses included unspecified psychosis and dementia with behavioral disturbance. Review of his quarterly MDS assessment dated [DATE] revealed Resident #53 had short and long term memory loss and was severely impaired for daily daily decision making. Review of Resident #53's pharmacist recommendation dated 08/25/21 revealed a recommendation for a reduction of Risperdal. The recommendation was signed as contraindicated as a reduction may cause psychiatric instability by the CNP approximately three months later on 11/22/21. During an interview with the Corporate Business Office Manager (CBOM) #405 on 03/09/22 at 3:45 P.M., he verified the recommendation was not signed timely. He stated the psychiatric doctor in place at the time of the recommendation was not answering calls and emails and his services were terminated. The practitioner from the new practice then signed the recommendation when they started in November 2021. 3. Review of the medical record for the Resident #26 revealed an admission date of 12/08/20. Diagnoses included dementia and psychosis. Review of the MDS assessment dated [DATE] revealed Resident #26 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 20 of 39 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 03/18/2022 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 0756 was cognitively intact. Level of Harm - Minimal harm or potential for actual harm Review of Resident #26's pharmacy recommendations dated 12/16/21 revealed the resident was on Trazodone 25 mg once a day at night for depression. The pharmacist recommended a dose evaluation and considered a GDR or document criteria if no dose reduction is elected. Response notes by CNP dated 01/15/22 indicated for Trazodone to be discontinued. The CNP addressed the same pharmacist recommendations again on 02/18/22 and indicated the CNP disagreed with the recommendations due to insomnia. Residents Affected - Some Review of the physician orders for Resident #26, dated 08/04/21, revealed the resident was ordered Trazodone 25 mg at bedtime for depressive disorder. The Trazadone was not discontinued timely per the CNP note on 01/15/22 to discontinue the Trazodone. The Trazadone was not discontinued until 02/21/22. The CNP recommendations on 02/18/22 were not addressed by the facility to not discontinue the Trazodone. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 12:45 P.M. verified Resident #26's pharmacy recommendations dated 12/16/21 were addressed on 01/15/22 and CNP indicated for Trazodone to be discontinued. Assistant Regional Director of Clinical Operations #400 verified the CNP addressed the same pharmacist recommendations again on 02/18/22 and indicated CNP disagreed with recommendations due to insomnia. Assistant Regional Director of Clinical Operations #400 verified Resident #26's Trazodone was discontinued on 02/21/21. Assistant Regional Director of Clinical Operations #400 stated they were not sure why the discrepancy and delay in discontinuing of Trazodone. 4. Review of the medical record for the Resident #40 revealed an admission date of 08/30/21. Diagnoses included dementia. Review of the MDS assessment dated [DATE] revealed Resident #40 was cognitively intact. Review of Resident #40's pharmacy recommendations dated 09/27/21 revealed the resident was on Trazodone 50 mg once a day at night for dementia. The pharmacist recommended a dose evaluation and considered a GDR or document criteria if no dose reduction is elected. Response notes by CNP dated 11/22/21 indicated a GDR was clinically contraindicated due to persistent symptoms of anxiety. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 1:00 P.M. verified the CNP did not timely respond until two months to the pharmacy recommendations made on 09/27/21. 5. Review of the medical record for the Resident #49 revealed an admission date of 07/20/21. Diagnoses included anxiety, schizophrenia, and dementia. Review of the MDS assessment dated [DATE] revealed Resident #49 had severely impaired cognition. Review of the physician orders for Resident #49 dated 08/14/21 and discontinued on 02/10/22 revealed the resident was ordered Risperdal 0.5 mg twice daily for schizophrenia. Review of Resident #49's pharmacy recommendations dated 08/25/21 revealed the resident was on Risperdal 0.5 mg twice daily for schizophrenia. The pharmacist recommended a GDR evaluation and if no dose reduction is elected, document criteria. Response notes by CNP dated 11/22/21 indicated a GDR was clinically contraindicated due to potential cause for psychiatric instability. Interview with Assistant Regional Director of Clinical Operations #400 on 03/09/22 at 1:00 P.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 21 of 39 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 03/18/2022 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete verified the CNP did not respond until three months later to the pharmacy recommendations made on 08/25/21. Review of the facility policy titled Antipsychotic Medication Use revealed the facility physician shall respond appropriately by changing, stopping problematic doses of medications, or clearly documenting why the benefits of the medication outweigh the risk or suspected confirmed adverse consequences. Event ID: Facility ID: 366145 If continuation sheet Page 22 of 39 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 03/18/2022 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's policy, the facility failed to ensure the resident's received their medications without any significant medication errors. Resident #442 did not receive his anti-seizure medication, Vimpat and Resident #290 did not receive her MS Contin (a strong prescription paid medication). This affected one (Resident #442) of three facility identified residents with orders for Vimpat and one (Resident #290) of one facility-identified residents with orders for MS Contin. The facility census was 94. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #442 revealed an admission date of 02/28/22 with a diagnosis of encephalopathy and acute respiratory failure with hypoxia. Review of Minimum Data Set (MDS) assessment for Resident #442 dated 03/02/22 revealed the resident had a death in the facility. Review of the admitting orders for Resident #442 dated 02/28/22 revealed an order for the anti-seizure medication, Vimpat, to be administered twice daily at 6:00 A.M. and 6:00 P.M. Review of the nursing progress note for Resident #442 dated 02/28/22 timed at 6:26 P.M. revealed Resident #442 was admitted to the facility. The nursing progress note dated 03/01/22 timed at 6:00 A.M. revealed Resident #442 did not receive Vimpat as ordered because it had not arrived from the pharmacy. Review of the February and March 2022 Medication Administration Records (MARs) for Resident #442 revealed Vimpat was not administered on 02/28/21 or 03/01/22. Interview on 03/09/22 at 4:57 P.M. with Corporate Director of Clinical Operations (CDCO) #410 confirmed Resident #442 did not receive Vimpat as ordered by the physician on 02/28/22 and 03/01/22. 2. Review of the medical record for Resident #290 revealed an admission date of 03/03/22 with diagnoses including cerebral infarction and cancer with metastases to the brain. There was a discharge from the facility on 03/06/22. Review of the admission assessment dated [DATE] revealed Resident #290 was alert and oriented to person place and time with periods of confusion. Resident #290 had severe generalized pain which included headaches and pain to her extremities which was chronic in nature over the past several years. Resident #290 was receiving radiation therapy for cancer which had metastasized (spread) to her brain. Resident had an order for MS Contin (morphine) twice daily routinely for pain. Review of the baseline care plan dated 03/04/22 revealed Resident #290 was at risk for pain related to cerebrovascular accident (CVA). Interventions included the following: administer analgesia as per orders, anticipate need for pain relief and respond in kind, administer medications as ordered and monitor for changes in condition. Review of the nursing progress notes for Resident #290 dated 03/03/22 through 03/06/22 revealed Resident #290's MS Contin was not available. Review of the controlled substance records for Resident #290 revealed Resident #290 did not receive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 23 of 39 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 03/18/2022 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 0760 any doses of MS Contin during her stay at the facility form 03/03/22 to 03/06/22. Level of Harm - Minimal harm or potential for actual harm Review of the March 2022 Medication Admiration Record (MAR) for Resident #290 revealed there were no doses of MS Contin signed off as administered for Resident #290 for 03/03/22 through 03/06/22. Residents Affected - Few Interview on 03/14/22 at 4:14 P.M. with Corporate Director of Clinical Operations (CDCO) #410 confirmed Resident #290 did not receive MS Contin as ordered by the physician on 02/28/22 from 03/03/22 to 03/06/22. Review of the facility's policy titled Administering Medications, dated April 2019, revealed medications would be administered in a safe and timely manner and as prescribed. This deficiency substantiates Complaint Numbers OH00130910 and OH00130589. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 24 of 39 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 (X3) DATE SURVEY COMPLETED A. Building 03/18/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interviews, and review of the facility's policy, the facility failed to secure a medication room on the second floor. This had potential to affect all 44 residents who resided on the second floor. The facility also failed to ensure prescription medications were properly stored and labeled with dates. This affected eight residents (#23, #30, #40, #48, #51, #53, #58, and #77). The facility also failed to ensure medication carts were locked when unattended. This had the potential to affect all 50 residents who resided on the first floor. The facility censes was 94. Findings included: 1. During an observation of the second floor medication room on 03/07/22 at 8:00 A.M. with Licensed Practical Nurse (LPN) #353 revealed the door was unsecured. Further observation revealed a magnetic across the door lock assembly and paper stuffed in the door lock opening. Interview with Licensed Practical Nurse (LPN) #353 on 03/07/22 at 8:01 A.M. verified the medication door was unsecured. LPN #353 stated the door should always be secure and additionally stated the night shift normally leaves it unsecured. 2. During an observation of 200 Hall North medication cart on 03/08/22 at 4:30 P.M. with LPN #351 revealed the following: a. Resident #58 had a vial of Novolog (insulin) 100 unit/milliliter (mL) opened/dated 02/04/22. b. Resident #23 had a vial of Lantus (Insulin) 100 unit/mL opened and undated. c. Resident #23 had a vial of Novolog 100 unit/mL opened and undated. d. Resident #77 had a vial of Novolog 100 unit/mL opened and undated. e. Resident #77 had three Basaglar (insulin) KwikPen opened and undated. f. Resident #51 had a vial of Novolog 100 unit/mL opened and undated. Interview with LPN #351 immediately afterwards, verified the above information. LPN #351 stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 25 of 39 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 03/18/2022 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 0761 medications should be dated when opened. Level of Harm - Minimal harm or potential for actual harm 3. During an observation of 200 Hall South medication cart on 03/08/22 at 4:45 P.M. with LPN #353 revealed the following: Residents Affected - Some a. Resident #40 had a Lantus pen 100 unit/mL opened and undated. b. Resident #40 had a Novolog 100 unit/mL pen opened and undated. c. Resident #40 had a Basaglar KwikPen 100 unit/mL opened and undated. d. Resident #30 had a bottle of Brimonidine solution (glaucoma) 0.2 percent opened and undated. e. Resident #30 had a bottle of Timolol Maleate (glaucoma) solution 0.5 percent opened and undated. f. Resident #30 had a bottle of Dorzolamide (glaucoma) Solution two percent opened and undated. g. Resident #53 had two bottles of Combigan (Brimonidine tartrate -Timolol solution) 0.2-05 percent opened and undated. h. Resident #53 had two bottles of Dorzolamide solution two percent opened and undated. i. Resident #48 had a bottle of Latanoprost solution 0.005 percent opened and undated. j. Resident #48 had a bottle of Combigan 0.2-0.5 percent opened and undated. k. Resident #48 had a bottle of Timolol Maleate solution 0.5 percent opened and undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 26 of 39 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 03/18/2022 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 0761 Level of Harm - Minimal harm or potential for actual harm Interview with LPN #353 immediately afterwards, verified the above information. LPN #353 stated medications should be dated when opened. Review of the facility policy titled Storage of Medications, dated 04/01/17, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Residents Affected - Some 4. Observation on 03/07/22 at 2:31 P.M., revealed a medication cart in front of the nurse's station on the facility's first floor. The medication cart was observed to be unlocked and the key to the medication cart was in the lock of the cart. Registered Nurse (RN) #415 and another unidentified staff member were observed seated behind the nurse's station working on their computers. Continued observation on 03/07/22 between 2:31 P.M. and 2:40 P.M. revealed the cart remained unlocked and unattended. Observation on 03/07/22 at 2:40 P.M. revealed an unidentified staff member take the keys from the medication cart, lock the cart, and give them to RN #415. Interview on 03/07/22 at 2:40 P.M. with RN #415 verified she had left the medication cart unlocked with the keys in the lock. RN #415 further verified the medication cart should be locked and the keys taken when walking away from the cart. Review of the facility policy titled Storage of Medications, dated 04/2007, revealed carts containing medications shall not be left unattended if open or otherwise potentially available to others, and only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 27 of 39 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 03/18/2022 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, record review, and resident and staff interview, the facility failed to ensure a resident received routine dental services. This affected one (#6) of two residents reviewed for dental care. The facility census was 94. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed Resident #6 admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, major depressive disorder, fibromyalgia, and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact and Resident #6 required limited with personal hygiene. Resident #6 also required supervision with eating and Resident #6 had no mouth pain or difficulty chewing. Review of Resident #6's dental care plan dated 06/15/21 revealed Resident #6 had missing teeth and complained of trouble with chewing her food. Resident #6 would like her teeth pulled and to be fitted for dentures. Interventions included dental or oral exams yearly and as needed for any issues that arise. Review of Resident #6's medical record from 06/14/21 to 03/08/22 revealed Resident #6 had not received any dental services while at the facility. Observation and interview with Resident #6 on 03/07/22 at 2:46 P.M. revealed Resident #46 had missing teeth and teeth with a black substance on them on the top and bottom of her mouth. Resident #6 stated he had rotten and missing teeth. Resident #6 stated she needed to go to the dentist, but she had not seen the dentist since he had been to the facility. Interview on 03/09/22 at 10:20 A.M. with Regional Business Office Manager #405 verified Resident #6 did not have any dental visits since being admitted to the facility. Regional Business Office Manager #405 stated Resident #6 did not have a dental consent prior to 03/09/22. Review of the facility's dental services policy dated December 2016 revealed routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 28 of 39 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 03/18/2022 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure the resident was provided the correct diet as ordered. This affected one (Resident #26) of the 10 residents who was ordered a puree diet. The facility census was 94. Findings include: Review of the medical record for Resident #26 revealed an admission date of 12/08/20. Diagnoses included Parkinson's disease, dementia, cerebral vascular accident (CVA/stroke) with hemiplegia, and moderate protein calorie malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was cognitively intact, had no behaviors, and did not reject care. Review of the plan of care for Resident #26 revealed the resident had a swallowing impairment, had potential for aspiration, choking, swallowing difficulties and the resident had an alteration in completing required activities of daily living (ADLs). Interventions included to provide ordered puree diet/honey thick liquids. Review of the physician orders dated 01/20/21 revealed Resident #26 was ordered a no added salt pureed texture diet with honey thick liquid consistency for dysphagia. Review of the Speech Therapist (ST) Discharge summary dated [DATE] revealed Resident #26 had diagnosis of Parkinson's Disease and dysphagia oropharyngeal phase. Notes indicated the resident requested a diet upgrade but based on signs and symptoms of aspiration and recent barium swallow study results, the ST recommend puree/honey thick liquids. Notes indicated ST notified the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the resident's request and DON stated she would speak to the physician in order to determine if physician would change diet based on residents wishes as patient is his own person and had not been deem incompetent. Review of the nurse's progress notes for Resident #26 dated 02/26/21 revealed the resident had a barium swallowing appointment scheduled on 03/03/21. On 03/15/21, Resident #26 refused to go to the appointment for barium swallow. On 06/15/21, Resident #26 was scheduled for barium swallow on 06/16/21. The nurse's notes were silent for indication facility received the results of the barium swallow study from 06/16/21 or any nurses notes which indicated resident's purred diet was discontinued and resident was ordered a mechanical soft diet. Review of the dietary progress notes for Resident #26 dated 04/20/21, 06/23/21, 09/23/21, 10/28/21, and 11/10/21 indicated the resident was ordered no added salt, pureed with honey thick liquids diet. Review of the nutrition assessment by Registered Dietitian (RD) for Resident #26 dated 12/16/21 indicated the resident had a swallowing disorder, was ordered a no added salt, pureed, honey thick liquids. Review of the physician notes for Resident #26 dated 06/11/21 and 03/08/22 reveled no documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 29 of 39 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 03/18/2022 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 0805 evidence the physician changed the diet. Level of Harm - Minimal harm or potential for actual harm Observation of Resident #26's lunch tray being collected on 03/08/22 at 12:45 P.M. revealed the resident's meal ticket indicated Resident #26 was delivered and consumed a mechanical soft diet per ticket on tray. Residents Affected - Few Observation of Resident #26's dinner tray delivered 03/08/22 at 5:26 P.M. by State Tested Nursing Aide (STNA) #327 revealed Resident #26 was delivered a mechanical soft diet tray which contained a ham sandwich, bag of potato regular chips, small package of two crackers, bowl of cheese puffs, bowl of pineapples, cup of potato soup, and juices. Resident #26 was observed seated in wheelchair and started eating soon as meal was delivered. Interview with Licensed Practical Nurse (LPN) #352 on 03/08/22 at 5:31 P.M. verified Resident #26 was delivered a mechanical soft tray with contents listed above. During review of the physician orders with LPN #352, she verified Resident #26 was ordered a puree diet due to dysphagia. LPN #352 stated resident's dinner tray was not even a mechanical soft with the bag of chips on the tray. LPN #352 stated she would have to fix Resident #26's tray. Observation revealed LPN #352 continued to allow Resident #26 to eat the delivered tray. Review of meal ticket dated 03/08/22 dinner revealed Resident#26 was delivered a mechanical soft diet. Ticket indicated Resident #26 was served baked potato soup, crackers, ground ham and cheese on a bun, cheese puffs, tropical fruit, milk, and beverage of choice. During an interview with Dietary Manager #306 on 03/09/22 at 11:04 A.M. indicated she was alerted to the diet yesterday and immediately changed the diet to a puree diet. Dietary Manager #306 indicated she was not sure why Resident #26 had been getting a mechanical soft and could not find any documentation to show the change from pureed diet. Dietary Manager #306 indicated if a resident has a diet change, the nursing staff was tasked with notifying the kitchen staff. Review of the undated policy titled Nutrition Assessment revealed a nutrition assessment would be conducted for impaired nutrition for each resident and once current conditions and risk factors for impaired nutrition were identified and analyzed, the individual care plans would be developed and implement which addressed or minimized to the extent possible the resident's risk for complications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 30 of 39 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 03/18/2022 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Based on observation and staff interview, the facility failed to provide drinks per resident preference. This affected four residents (Resident #25, #62, #85, and #536) of 93 residents who received drinks with meals. The facility census was 94. Findings: An observation of breakfast trays being passed on 03/07/22 at 8:30 A.M. revealed coffee was not being served. Resident #25 was observed at 8:35 A.M. requesting coffee and was told by State Tested Nurse Aide (STNA) #342 there was no coffee available. At 8:48 A.M., Resident #62 also requested coffee. During an interview on 03/09/22 at 8:39 A.M., STNA #342 reported she had asked the kitchen for coffee for the resident's breakfast and was told they had run out. An observation on 03/07/22 at 12:17 P.M., revealed Resident #85 asked an unidentified staff member for coffee. The unidentified staff member stated there was no coffee available for the residents to have with their lunch meal. An interview on 03/07/22 at 1:58 P.M. with Resident #536 confirmed coffee was not available with the breakfast and lunch meal, and he was upset because he preferred to drink a cup of coffee at meals, especially at breakfast. During an interview on 03/09/22 at 2:21 P.M. with the Dietary Manager (DM) #306, she confirmed no coffee was served to residents for breakfast or lunch as 03/07/22 due to a shortage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 31 of 39 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 03/18/2022 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 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, record review and staff interview, the facility failed to ensure food items were stored in a sanitary manner, the ice machine was kept in a sanitary manner and food items were held at the proper temperature. This affected all residents except Resident #9 that received no food by mouth. The facility census was 94. Findings include: Observation of the facility's ice machine located outside of the kitchen doors on 03/07/22 at 7:36 A.M. revealed there to be a brown and red substance on the white ledge on the inside of the ice machine. Further observation of the kitchen revealed [NAME] #347 took a paper towel and wiped the white ledge of the ice machine and the brown and red substance came off the inside of the ice machine and onto the paper towel. Interview with [NAME] #347 on 03/07/22 at 7:36 A.M. verified there was a brown and red substance on the inside of the ice machine. Observation of the kitchen on 03/08/22 at 4:45 P.M. revealed Dietary Manager #306 to take the temperature of the pureed soup on the tray line. The pureed soup was 120 degrees Fahrenheit (F). After taking the temperature of the soup, [NAME] #346 started to serve pureed diets eight ounces of pureed soup. Interview with Dietary Manager #306 on 03/08/22 at 4:45 P.M. verified the soup was 120 degrees F after she took the temperature of the soup a second time. Dietary Manager #306 stated she did not realize the soup was being held at 120 degrees F on the steam table and she had the pureed soup that was portioned out put back into the pan and placed into the oven to be heated up to temperature. Review of the facility's list of diets dated 03/10/22 revealed Resident #9 received no food by mouth. Review of the facility's food preparation and service policy dated April 2019 revealed the danger zone for food temperatures was between 41 and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats and milk. The longer the food remains in the danger zone the greater the risk for growth of harmful pathogens. Therefore, food must be maintained below 41 or above 135 degrees F. This deficiency substantiates Complaint Number OH00113672. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 32 of 39 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 03/18/2022 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on record review, staff interview, and review of the facility policy, the facility failed to ensure staff documented intravenous (IV) medications administered. This affected one (Resident #487) of 19 residents reviewed for medical record accuracy. The facility census was 94. Findings include: Review of the medical record for Resident #487 revealed an admission date of 02/17/22 with a diagnosis of osteomyelitis. Review of the admitting physician orders, dated 02/17/22, revealed an order for Resident #487 to receive the intravenous (IV) antibiotic Ertapenem once daily until 03/24/22. Review of the February and March Medication Administration Records (MARs) for Resident #487 revealed the following daily doses of Ertapenem were not documented as given on the four following dates: 02/21/22, 02/26/22, 03/03/22, and 03/04/22. Interview on 03/08/22 at 4:17 P.M. with the Assistant Regional Director of Clinical Operations (ARDCO) #600 confirmed the doses of IV antibiotic for Resident #487 for 02/21/22, 02/26/22, 03/03/22, and 03/04/22 doses were not documented as completed. ARDCO #600 confirmed Licensed Practical Nurse (LPN) #302 administered these doses but did not document the administration in the MARs. Review of the policy titled Administering Medications, dated April 2019, revealed the individual administering the medication should initial the resident's MAR on the appropriate line after giving each medication and before administering the next one. An individual administering a medication should include the following information in the resident's record: the date and time the medication was administered, the dosage, the route of administration, the signature and title of the person administering the drug. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 33 of 39 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 03/18/2022 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance and review of the facility's policy, the facility failed to perform proper hand hygiene during a dressing change for a pressure ulcer. This affected one (Resident #23) of four facility-identified residents with pressure ulcers. The facility also failed to implement quarantine precautions for Resident #486 which had the potential to affect all of the residents residing in the facility. The facility also failed to ensure staff performed appropriate hand hygiene while serving the resident meals which affected seven residents (Resident #16, #30, #55, #57, #75, #83, and #536). The facility census was 94. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #23 revealed an admission date of 04/15/99 with diagnoses including multiple sclerosis (MS) and diabetes mellitus (DM). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively impaired and was required extensive assistance of one to two staff with personal hygiene. Review of the care plan for Resident #23 dated 06/01/18 revealed Resident #23 had DM and received insulin. Interventions included refer to podiatrist and/or nurse for nail care and to cut long nails. Review of the March 2022 monthly physician orders for Resident #23 revealed an order dated 02/27/22 to cleanse pressure ulcers to the resident's right and left buttocks with normal saline, apply Medihoney to wound bed and cover with clean dry dressing daily and as needed. Review of the wound grid for Resident #23 revealed resident had a stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the right buttock measuring 1.5 centimeters (cm) by 0.5 cm by 0.5 cm in depth. Stage II pressure ulcer to the left buttock measured 1.5 cm by 2.0 cm by 0.5 cm in depth. Observation on 03/07/22 at 2:52 P.M. of Licensed Practical Nurse (LPN) #420 perform wound care for Resident #23 revealed LPN #420 washed her hands and donned gloves and removed the soiled dressings from the pressure ulcers to resident's right and left buttocks. LPN #420 then cleansed the wounds with wound cleanser (normal saline) in a spray bottle. While nurse was cleansing the wounds, Resident #23 began to have a bowel movement (BM). LPN #420 did not change gloves and perform hand hygiene. LPN #420 then applied Medihoney to wound by squirting a small amount from the tube onto the wound bed and then used her gloved finger, still wearing the same gloves donned prior to the procedure, and distributed the Medihoney to each wound bed. LPN #420 did not change gloves and perform hand hygiene. LPN #420 then applied a clean dry dressing to the right and left buttock wounds still wearing the same gloves donned prior to the procedure. LPN #420 then provided incontinence care and removed the small amount of BM from resident's perianal area and applied a clean incontinence brief. Interview on 03/07/22 at 3:10 P.M. with LPN #420 confirmed she did not provide incontinence care prior to performing dressing change and attempted instead to work around the BM Resident #23 was having during the procedure. LPN #420 confirmed she did not remove gloves and perform hand hygiene during the dressing change after she removed the soiled dressing and after she cleansed the wound. LPN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 34 of 39 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 03/18/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many #420 confirmed she used a contaminated gloved finger to distribute Medihoney to the resident's wound beds. Review of the policy titled Handwashing/Hand Hygiene, dated 2021, revealed the use of gloves did not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. Hand hygiene should be performed in the following instances which include: before handling clean or soiled dressings, gauze pads, etc. before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin, after contact with blood or bodily fluids, after handling used dressings, contaminated equipment, etc., after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, after removing gloves. 2. Review of the medical record for Resident #486 revealed an admission date of 02/24/22. Diagnoses included hemiplegia affecting right dominant side, gastro-esophageal reflux disease without esophagitis, essential hypertension, hypothyroidism, and hyperlipidemia. Review of Resident #486's immunization record revealed Resident #486 refused the COVID-19 vaccination. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #486 had intact cognition. Observation on 03/07/22 at 8:17 A.M. revealed no signs nor bin outside of Resident #486's room to indicate she was under any type of transmission-based precautions. Interview on 03/07/22 at 8:29 A.M. with LPN #310 stated Resident #486 was was under quarantine precautions related to being a new admission. LPN #310 further confirmed there were no signs nor bin containing PPE outside Resident #486's room to indicate the need for PPE upon entrance. LPN #310 further confirmed Resident #486 was not in her room at the time of the observation and should remain in the room while under transmission-based precautions. Observation on 03/07/22 at 8:43 A.M. revealed Resident #486 was observed walking on the first floor, near the dining room, not wearing a mask. Observation and interview on 03/07/22 at 10:26 A.M. with Resident #486 was observed in the hallway outside of her room without a mask. Resident #486 stated nobody had talked to her about the need for her to quarantine in her room because she was a new admission and not vaccinated. Observation on 03/08/22 at 4:13 P.M., revealed Resident #486 out in the hallway, not wearing a mask, and talking with an unidentified nurse. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, last updated 02/02/22, revealed under 'Create a Plan for Managing New Admissions and Readmissions', in general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission. Review of the policy titled, Isolation-Categories of Transmission-Based Precautions, dated 10/2018, revealed, when a resident is placed on transmission-based precautions, appropriate notification is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 35 of 39 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 03/18/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many to be placed on the room entrance door so personnel and visitors are aware of the need for and the type of precaution. The signage is to inform staff of the CDC precaution (s), instructions for use of PPE, and/or instructions to see a nurse before entering. 3. During a continuous observation of breakfast trays service on 03/07/22 beginning at 8:32 A.M. revealed the breakfast food cart was delivered to the second floor and State Tested Nurses Aide (STNA) #327 pushed the cart down the hallway. Observation revealed STNA #327 removed a tray for Resident #16, delivered and placed the tray on resident's bedside table. STNA #327 repositioned the bed side table over Resident #16, opened the milk carton, juice carton and jelly. STNA #327 exited resident's room, returned to the food cart and pushed the cart down the hallway and delivered a tray to Resident #83, repositioned the bed side table and opened the milk and juice. STNA #327 exited Resident #83's room, pushed the cart down the hallway and delivered a tray to Resident #75. STNA #327 continued with delivery of trays to Residents #55 and #57, then delivered a tray to Resident #536. STNA #327 was observed delivering and setting up all the trays without any hand hygiene observed. During continued observation at 8:43 A.M. revealed STNA #327 was standing at the food cart in the common dining area, used his right hand to wipe off sweat from his forehead and wiped his hands on his pants. Continued observation revealed STNA #327 wiped sweat off forehead again and wiped his hands on his pants. STNA #327 removed and delivered a tray to Resident #30 who was seated at the dining room table. Continued observation revealed STNA #327 picked up each piece of bread, used contaminated hands and buttered and returned the bread to resident's trays. Observations revealed STNA #327 never used any hand hygiene during the breakfast tray service. Interview with STNA #327 on 03/07/22 at 8:49 A.M. verified above findings and verified he did not complete any hand hygiene during the breakfast service of trays. STNA #327 additionally verified he wiped sweat off his forehead and buttered Resident #30's bread with his contaminated hands. STNA #327 stated he should have used hand hygiene throughout the breakfast service, but stated he forgot. This deficiency substantiates Complaint Numbers OH00114269, OH00114137, OH00113672, and OH00111296. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 36 of 39 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 03/18/2022 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, review of facility policy, observations, and staff interviews, the facility failed to ensure residents had call lights. This affected two residents (#9 and #60) of 24 residents reviewed for call lights. The facility census was 94. Residents Affected - Few Findings include: 1. Review of the Resident #60's medical record revealed Resident #60 admitted to the facility on [DATE]. Diagnoses included muscle weakness, vascular dementia with behavioral disturbance, contracture of the left hand and contracture of the left knee. Review of Resident #60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was severely cognitively impaired and Resident #60 required extensive assistance for bed mobility, dressing, and personal hygiene. Resident #60 required total dependence for transfers and toileting and limited assistance for eating. Review of the care plan for Resident #60 dated 02/09/22 revealed resident was at risk for falls. Interventions included to keep call light within reach and encourage Resident #60 to use the call light to ask for assistance. Observation on 03/07/22 at 11:03 A.M. of Resident #60 revealed the resident did not have a functioning call light in his room. Resident #60 had a wall panel for a call light but there was no call cord. Subsequent observation on 03/08/22 at 3:45 P.M. of Resident #60 revealed the resident did not have a functioning call light in his room. Resident #60 had a wall panel for a call light but there was no call cord. Interview with Licensed Practical Nurse (LPN) #310 on 03/08/22 at 3:45 P.M. verified Resident #60 did not have a functioning call light. LPN #310 confirmed Resident #60 was able to use the call light and she was going to give him a bell to use to call for assistance. 2. Review of the medical record for Resident #9 revealed an admission date of 03/30/21 with a diagnosis of cerebral infarction. Review of the MDS assessment dated [DATE] revealed Resident #9 was cognitively impaired and was totally dependent on staff for activities of daily living (ADLs). Review of the care plan for Resident #9 dated 04/05/21 revealed Resident #9 was at risk for falls that could lead to injury related to decline in mobility, self-performance deficit, right sided weakness due to recent cerebrovascular accident (CVA). Interventions included to keep call light within reach. Observation on 03/07/22 at 1:41 P.M. of Resident #9 revealed the resident did not have a functioning call light in his room. Resident #9 had a wall panel for a call light but there was no call cord. Interview on 03/07/22 at 1:41 P.M. with State Tested Nursing Assistant (STNA) #342 confirmed Resident #9 did not have a call cord in his room and she thought he had pulled it out of the wall panel a few weeks ago and they had decided not to replace it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 37 of 39 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 03/18/2022 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 0919 Level of Harm - Minimal harm or potential for actual harm Interview on 03/07/22 at 1:45 P.M. with Licensed Practical Nurse (LPN) #353 confirmed Resident #9 did not have a functioning call light in his room and she was not sure why it wasn't there. Interview on 03/07/22 at 1:48 P.M. with Housekeeping Supervisor (HS) #333 confirmed Resident #9 did not have a functioning call light in his room and she would ensure he got one. Residents Affected - Few Subsequent observation on 03/08/22 at 9:20 A.M. of Resident #9 revealed the resident did not have a functioning call light in his room. Interview on 03/08/22 at 9:20 A.M. with LPN #310 confirmed Resident #9 did not have a functioning call light in his room and facility staff were evaluating him for use of sensor pad style call light. Interview on 03/08/22 at 3:50 P.M. with LPN #310 confirmed she tried to place a sensor pad style call cord for Resident #9 but it didn't fit into the call light panel properly so she was going to place a bell at resident's bedside until his call light could be replaced. Review of the policy titled Answering the Call Light, dated March 2021, revealed staff should be sure that the call light is plugged in and functioning at all times and should report all defective call lights to the nurse supervisor promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 38 of 39 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 03/18/2022 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, observation, record review, and staff interview, the facility failed to ensure a resident's oxygen tank was stored in a secured manner. This affected one (#71) of nine residents that used oxygen at the facility. The facility census was 94. Findings include: Review of Resident #71's medical record revealed Resident #71 admitted to the facility on [DATE]. Diagnoses included congestive heart failure, acute respiratory failure and vascular dementia without behavioral disturbance. Review of Resident #71's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact and Resident #71 required extensive with dressing, toileting, bed mobility, transfers and personal hygiene. Resident #71 also required one person physical assistance with bathing. Review of Resident #71's physician order dated 06/01/21 revealed Resident #71 may be oxygen at two to three liters per minute per nasal cannula as needed to maintain oxygen saturation above 90 percent. Observations of Resident #71's room on 03/07/22 at 11:09 A.M. and on 03/08/22 at 3:45 P.M. revealed Resident #71 had an oxygen tank leaning against the wall in her room. The oxygen tank had a bag on it for strapping it to a wheelchair, but the tank was not secured to the wall or in an oxygen tank holder. Interview with Licensed Practical Nurse (LPN) #310 on 03/08/22 at 3:45 P.M. verified there was an oxygen tank leaning against the wall in Resident #71's room. LPN #310 confirmed Resident #71's oxygen tank was not secured properly. Review of the facility's fire safety and prevention policy, dated May 2011, revealed the facility should store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. The facility should never leave oxygen cylinders free standing, and the facility should not store oxygen cylinders in any resident room or living area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 39 of 39