Health inspection·May 7, 2024

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of the menu, review of the substitution log, observation, staff interview, and policy review, the facility failed to ensure the menu was followed. This affected all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: Review of the breakfast menu, dated 05/06/24, revealed residents on a regular diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. Residents on a mechanical diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. Residents on a pureed diet were to be served six ounces of pureed cereal, a number sixteen scoop or two ounces of pureed cheesy scrambled eggs, and a number sixteen scoop or two ounces of pureed toast. Review of the substitution log from 02/23/24 to 05/06/24 revealed English muffins as a substitution for toast was not on the substitution log. Observation of Dietary Manager (DM) #68 serving meals on 05/06/24 at 8:18 A.M. revealed DM #68 served residents on a regular diet six ounces (oz) of oatmeal, a number ten scoop of eggs, two sausage links and a whole English muffin. DM #68 served residents on a mechanical diet six oz of oatmeal, a number ten scoop of eggs, a number eight scoop of mechanical sausage and a whole English muffin. DM #68 served residents on a pureed diet six oz of oatmeal, a number ten scoop of pureed eggs, a number eight scoop of pureed sausage and a number eight scoop of pureed bread. Interview with DM #68 on 05/06/24 at 8:18 A.M. verified DM #68 served residents on a regular diet six oz of oatmeal, a number ten scoop of eggs, two sausage links and a whole English muffin. The interview verified DM #68 served residents on a mechanical diet six oz of oatmeal, a number ten scoop of eggs, a number eight scoop of mechanical sausage and a whole English muffin. Additionally, the interview verified DM #68 served residents on a pureed diet six oz of oatmeal, a number ten scoop of pureed eggs, a number eight scoop of pureed sausage and a number eight scoop of pureed bread. DM #68 stated he did not have the correct scoop sizes for the regular eggs, mechanical eggs, pureed eggs, and pureed bread because he was missing the correct scoops sizes and had to order them. The interview verified the number ten scoop size was a different portion size than the number sixteen scoop size. DM #68 also reported sausage was not on the menu, but he liked to add a different protein to the daily menu because the menu from the company did not have a lot of variety for protein at breakfast besides eggs. Observation of tray line on 05/06/24 at 8:45 A.M. revealed DM #68 was serving a full English muffin with two halves to residents that were on mechanical diets and regular diets. Part of the way through tray line, DM #68 started to serve one half or one slice of a English muffin to residents. Resident #52, #53, #54, #56, #57, #58, #59, #62, #63 and #88 were observed to receive only one half or one slice of an English muffin. Interview with DM #68 on 05/06/24 at 8:45 A.M. verified DM #68 served one half or one slice of an English muffin to Residents #52, #53, #54, #56, #57, #58, #59, #62, #63 and #88. DM #68 stated he stopped serving a whole or two halves of an English muffin because he thought he was going to run out of English muffins. DM #68 stated he was going to give residents more eggs instead of a whole English (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 2 of 4 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 05/07/2024 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 0803 muffin. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 05/06/24 at 10:57 A.M. verified English muffins were served instead of toast on 05/06/24, the English muffins were not listed on the substitution log, and there was no documentation that the dietitian was aware of the substitution. Residents Affected - Many Review of the facility Substitutions policy, dated April 2007, revealed the food service manager in conjunction with the dietitian may make food substitutions as appropriate and necessary. All substitutions are noted on the menu and filed in accordance with established dietary policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 3 of 4 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 05/07/2024 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, staff interview and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and the dishwasher had the appropriate level of chemicals in order to prevent foodborne illness. This had the potential to affect all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: 1. Observation of the kitchen on 05/06/24 at 8:15 A.M. revealed there were food debris built up in the oil and on the edges of the fryer. There was also food debris on the fryer basket and a brown splatter on the side of the fryer. There was brown water on the floor of the kitchen on the opposite side of the steam table where food was served during tray line. Interview with Dietary Manager (DM) #68 on 05/06/24 at 8:15 A.M. verified there was food debris built up in the oil, food basket and on the edges of the fryer. DM #68 also confirmed there was brown splatter on the side of the fryer and brown water on the floor of the kitchen on the opposite side of the steam table where food was served during tray line. 2. Observation of the facility's dishwasher on 05/06/24 at 9:15 A.M. revealed the dishwasher temperature was 125 degrees fahrenheit for the wash and rinse cycles. DM #68 was observed testing the chemical levels in the dishwasher and the dishwasher tested at zero parts per million (ppm). Dietary staff were observed actively running dishes in the dishwasher from 05/06/24 at 8:15 A.M. to 9:15 A.M. Interview with DM #68 on 05/06/24 at 9:15 A.M. verified the dishwasher temperature was 125 degrees fahrenheit for the wash and rinse cycles. DM #68 confirmed the dishwasher was a low temperature dishwasher and required chemicals to sanitize the dishes. DM #68 verified the dishwasher was running at zero ppm of chemical sanitizer and dietary staff were actively running dishes in the dishwasher on 05/06/24 from 8:15 A.M. to 9:15 A.M. Review of the Food Preparation and Service policy, dated November 2022, revealed all food service equipment and utensils will be sanitized according to current guidelines and manufacturer instructions. This deficiency represents non-compliance investigated under Complaint Number OH00152883. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366145 If continuation sheet Page 4 of 4