Health inspection·September 20, 2024

F 0689 insomnia. Level of Harm - Minimal harm or potential for actual harm Review of quarterly MDS assessment, with an ARD of 07/17/24, revealed Resident #02 had a BIMS score of 13, which indicated the resident had intact cognition. According to the MDS, the resident did not use tobacco during the assessment period. Residents Affected - Few Review of Resident #02's care plan included a focus area initiated on 10/23/23, indicating the resident was a smoker and required supervision due to poor decision making and judgement and for the safety of the resident and others. The care plan revealed the resident had a history of noncompliance with the smoking policy. Per the care plan, the resident's family had been educated that the resident was unable to keep cigarettes and/or a lighter and that the facility was required to hold the items and supervise the resident while smoking. According to the care plan, the resident remained non-compliant with the smoking policy and became increasingly agitated and aggressive when staff attempted to redirect the resident, which led to a history of staff calling the police. Interventions initiated on 10/23/23 directed staff to supervise all smoking activities; keep the resident's smoking materials in a safe, secure area; make the resident's legal representative, friends, and other visitors aware of the facility's smoking policy; monitor the resident's room for any prohibited materials and report to the nurse; re-educate the resident on the facility's smoking policy; ensure a smoking apron was utilized; remind the resident of the smoking schedule and distribute cigarettes appropriately; and supervise smoking in designated areas only. The care plan did not specify the frequency at which staff should monitor the resident's room for prohibited materials. Review of Resident #02's admission Smoking Safety Evaluation, dated 12/22/23, revealed supervision would be required for all residents during designated smoking times. Review of Resident #2's quarterly Smoking Safety Evaluation, completed 03/12/24, revealed supervision would be required for all residents during designated smoking times. Observation on 09/18/24 at 8:26 A.M., revealed a metal ashtray was observed on a concrete ledge at the front doorway of the facility. There were approximately 15 cigarette butts in the ashtray and ashes were observed along the concrete wall. Interview on 09/18/24 at 8:38 A.M., with the Director of Nursing (DON), indicated there was a dedicated smoking area in the back of the building, but some residents wandered to the front to smoke. The DON indicated there was a designated smoking room on the second floor of the building for the residents on the secured unit. Interview on 09/18/24 at 8:50 A.M., with the DON stated the ashtray was placed on the ledge at the front door so that Resident #02 would not throw cigarette butts on the ground. Interview on 09/18/24 at 11:05 A.M., with State Tested Nurse Aide (STNA) #01 indicated she was aware that Resident #02 who had been smoking at the front of the facility. STNA #01 indicated when that occurred, staff tried to redirect the resident. Interview on 09/18/24 at 1:44 P.M., with Licensed Practical Nurse (LPN) #04 indicated Resident #02 was non-compliant with the designated smoking times. Observation on 09/18/24 at 3:04 P.M., revealed Resident #02 was sitting on the ledge, under the covered driveway, near the front entrance of the facility. The resident had a cigarette, lighter, and a (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 09/20/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few small metal ashtray sitting on the ledge beside them. The resident proceeded to smoke while not wearing a smoking apron and with no staff supervision. Interview on 09/19/24 at 9:07 A.M., with Assistant Director of Nursing (ADON) #05 indicated Resident #02 required redirection and staff had to take the resident's smoking materials and lock them up. ADON #05 indicated the resident had a lot of visitors and was unsure whether family members were bringing smoking materials to the resident. ADON #05 indicated the ability to take smoking materials from the resident depended on the resident's mood. She stated if she was not able to redirect the resident, she waited outside with the resident until they were finished smoking. Interview on 09/19/24 at 9:39 A.M., with Activity Aide (AA) #02 stated Resident #02 smoked during designated smoking times, but the resident had their own cigarette and lighter and refused to wear an apron. AA #02 stated she notified nursing staff of the resident's refusals, but she was not sure what they did with the information. AA #02 also stated she felt Resident #02 was a safe smoker and had never seen the resident drop any ashes on themselves or burn themselves. Interview on 09/19/24 at 9:55 A.M., the Administrator stated Resident #02 was very independent and when addressing the resident's non-compliance, he felt they had to be careful. The Administrator stated he felt giving the resident a 30-day discharge would escalate the situation and confronting the resident each time they violated a rule would only make the situation worse. The Administrator stated there had been discussions about allowing independent smokers to be able to smoke on their own, and from what he observed of Resident #2 everyday, the resident was a safe smoker. The Administrator stated he had never seen any burn holes in the resident's clothing or burns on the resident's body. Interview on 09/19/24 at 10:17 A.M., with LPN #06 stated she observed Resident #02 smoking at the front and back of the facility, unsupervised, but the resident never appeared unsafe. LPN #06 revealed she had never seen the resident drop ashes or burn themselves. Interview on 09/19/24 at 10:51 A.M., with the Social Service Director (SSD) indicated she witnessed Resident #02 be noncompliant with designated smoking times and designated areas for smoking. The SSD stated the facility tried to redirect the resident each time and she had taken the resident's smoking materials. The SSD indicated she had never observed the resident being an unsafe smoker. Interview on 09/20/24 at 9:10 A.M., Resident #02 stated they used to turn over cigarettes to the facility staff, but now they keep their own cigarette and lighter. Resident #02 indicated the facility tried to make them follow the rules, but they did not have to take orders from staff and would smoke whenever they wanted. Interview on 09/20/24 at 3:18 P.M., with the DON and Administrator, the Administrator stated the facility wanted everyone to abide by facility policy, but this was the residents' home and if they were not doing something egregious, they tried to work with the resident by educating them and going over the policy. Review of the undated policy titled Resident Smoking/Use of Electronic Cigarette Policy, revealed, this facility shall establish and maintain safe resident smoking/use of electronic cigarette practices. The policy specified, No resident shall hold on their person or in their room; cigarettes, cigars, tobacco, lighters, matches or electronic cigarettes. Per the policy. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking/use of electronic cigarettes based on observation and completion of Smoking (continued on next page) 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 09/20/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Assessments. - Any smoking/use of electronic cigarette-related restrictions and concerns shall be noted on the care plan, including the ramifications if Smoking/Use of Electronic Cigarette Policy is not followed. All personnel caring for the resident shall be alerted to any potential issues. Per the policy, All residents shall wear a smoking apron while smoking; it is the responsibility of the staff to secure and remove apron, as necessary. Residents who refuse to wear a smoking apron will not be provided smoking/electronic cigarette supplies. Event ID: Facility ID: 366145 If continuation sheet Page 4 of 4