Health inspection·April 11, 2022

F 0550 collection bag was without a cover and the urine was visible from the hallway. Level of Harm - Minimal harm or potential for actual harm On 04/04/22 at 10:59 A.M. interview with Registered Nurse (RN) #129 verified the resident's indwelling urinary catheter collection bag lacked a cover and the urine in the collection bag was visible from the hallway resulting in a lack of dignity for the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 2 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to reasonably accommodate Resident #69's seating/positioning needs to address physical limitations for the resident to ensure the resident maintained her highest level of functioning. This affected one resident (#69) of three residents reviewed for positioning. Residents Affected - Few Findings Include: Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbances, anxiety, depression, bipolar disorder, unsteadiness on feet, unspecified psychosis, dysphagia, cellulitis, need for assistance with personal care, abnormal posture and delusional disorders. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 03/16/22 revealed the resident was rarely/never understood, required extensive assistance from two staff members for transfers, bed mobility and toileting and required extensive assistance from one staff member for eating. On 04/03/22 at 8:48 P.M. Resident #69 was observed sitting in the lobby in a specialized (Broda) chair. The resident's legs and feet were observed to be hanging down and were not able to touch the floor. There were no footrests connected to the Broda chair for the resident to place her feet on. On 04/04/22 at 7:40 A.M. and 10:35 A.M. Resident #69 was observed sitting in the lobby in a Broda chair. The resident's legs and feet were observed to be hanging down and were not able to touch the floor. There were no footrests connected to the Broda chair for the resident to place her feet on. On 04/05/22 at 9:35 A.M. Resident #69 was observed sitting in the lobby in a Broda chair sleeping. The resident's legs and feet were observed to be hanging down and were not able to touch the floor. There were no footrests connected to the Broda chair for the resident to place her feet on. On 04/06/22 at 10:45 A.M. observation and interview with the Director of Nursing (DON) verified Resident #69 was sitting in her Broda chair and her legs and feet were hanging down and unable to touch the floor. There were no footrests connected to the Broda chair for the resident to place her feet on. The DON removed the resident's socks to reveal both feet were swollen with pitting edema present and the resident had red/purple discoloration to the toes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 3 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #2 and Resident #25 received their preferred frequency and method of bathing. This affected two residents (#2 and #25) of four residents reviewed for choices. Findings Include: 1. Review of Resident #2's medical record revealed an initial admission date of 12/02/21 with the latest readmission of 02/19/22. Resident #2 had diagnoses including atrial fibrillation, diabetes mellitus, congestive heart failure, severe morbid obesity, repeated falls, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder and hypertension. Review of the plan of care, dated 12/13/21 revealed the resident had an activity of living (ADL) care performance deficit; required assistance with ADL care related to weakness, fracture of left ankle (non-weight bearing), morbid obesity, incontinence, cognitive deficit and difficulty walking. Interventions included the resident required extensive assistance with bathing and transfers. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/31/21 revealed the resident had clear speech, understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12. The assessment revealed the resident required physical assistance from one staff for bathing. Review of an evaluation, dated 02/19/22 revealed the resident preferred showers three times a week in the evening. Review of the facility shower schedule revealed the resident's showers were scheduled every Tuesday and Friday on day shift. Review of the resident's shower documentation for January, February and March 2022 revealed the resident received two showers weekly, despite the preferred three times a week on evening shift. On 04/04/22 at 10:21 A.M. interview with Resident #2 revealed the resident indicated a preference for daily showers in the evening. However, the resident indicated residents were only allowed two showers per week. On 04/06/22 at 1:56 P.M. interview with Registered Nurse (RN) #410 verified the resident was not receiving at least three showers per or showers in the evening per the resident's assessed preference. 2. Review of Resident #25's medical record revealed an admission date of 01/31/22 with admitting diagnoses of congestive heart failure, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, chronic ischemic heart disease, insomnia, atrial fibrillation, hypothyroidism and hypertension. Review of an evaluation, dated 01/31/22 revealed the resident preferred showers in the evening two days a week. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 4 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/31/22 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10. The assessment revealed the resident was dependent on two staff for bathing. Review of the plan of care, dated 02/01/22 revealed the resident had a self care performance deficit required assistance with activities of daily living (ADL) related to weakness, unsteadiness, indwelling urinary catheter and bowel incontinence. Interventions included the resident required physical assistance with bathing and required mechanical lift and two person assist with transfers. Review of the resident's shower schedule revealed the resident's scheduled showers were every Tuesday and Friday evening. Review of the resident's shower documentation for February 2022 revealed the resident did not receive scheduled showers on 02/08/22, 02/18/22, 02/22/22 or 02/25/22. Review of the resident's shower documentation for March 2022 revealed the resident did not receive scheduled showers on 03/01/22, 03/08/22, 03/15/22 or 03/18/22. On 04/04/22 at 3:46 P.M. interview with the resident's wife revealed the facility would not shower her husband because he was transferred by a mechanical lift. On 04/05/22 at 2:40 P.M. interview with State Tested Nursing Assistant (STNA) #213 revealed the resident received a bed bath due to being a mechanical lift and the lack of a shower chair. Review of the facility policy titled Personal Bathing and Shower, last revised 02/16/22 revealed residents have the right to choose their schedules, consistent with their interests, assessments and care plans including choice for personal hygiene. This included but was not limited to choices about the schedules and type of activities for bathing that may include a shower, a bed-bath or tub bath or a combination on different days. Bathing preferences should be care planned including type and schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 5 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on record review and interview the facility failed to provide Resident #3 with a bed hold notification prior to hospital stay. This affected one resident (#3) of four residents reviewed for notification of bed hold. Residents Affected - Few Findings Include: Review of the medical record for Resident #3 revealed an admission date of 08/09/21 with diagnoses including chronic obstructive pulmonary disorder (COPD), morbid obesity, diabetes mellitus, depression, congestive heart failure and atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/01/22 revealed Resident #3 was cognitively intact with no behaviors. The resident had clear speech, was understood and understands. Review of the nursing progress notes revealed on 10/24/21 at 4:17 P.M. Resident #3 was requesting to go to the local emergency room, and was refusing to wear her bi-level positive airway pressure (BiPap machine), used to help push air into the lungs. The resident was receiving treatment for COPD exacerbation and was on oxygen at four liters per minute via nasal cannula. Vital signs included blood pressure 148/90, oxygen saturation level 90% on four liters of oxygen via nasal cannula, heart rate 94, respiratory rate 20 and temperature 98.1 degrees Fahrenheit. A note dated 10/24/21 at 4:20 P.M. revealed the nurse received an order for a chest x-ray. Resident #3 refused and demanded to go to the emergency room. The nurse attempted two times to reach a family member and was unsuccessful. A note dated 10/24/21 at 7:40 P.M. revealed the resident was being admitted to the hospital with a diagnosis of hypoxemic failure. A note dated 10/27/21 at 6:04 P.M. revealed Resident #3 was readmitted to the facility at 4:51 P.M. An interview on 04/04/22 at 1:49 P.M. with Resident #3 revealed she had a hospital stay a couple of months ago. Resident #3 said she did not remember if anyone talked to her about holding her bed while she was gone. The facility was unable to provide a bed hold notification for Resident #3 indicating the resident, and the Ombudsman were notified of the bed hold while the resident was admitted to the hospital. An interview on 04/07/22 at 10:49 A.M. with the Regional Director of Operations revealed the facility did not have evidence of bed hold notification for Resident #3 or evidence the Ombudsman was not notified. Review of the facility policy titled Bed Hold Policy, dated 04/20/17 revealed the facility would obtain the proper authorization to hold a resident bed when the resident returns to the hospital or goes on leave. The bed hold authorization form may be signed prior to the resident leaving the building or within 24 hours of the resident leaving the facility. The policy also revealed the Admissions Director or designee would notify the resident and/or the responsible party of the days available under their Medicaid benefits associated with holding and the bed hold would be explained to the resident. Also, the nurse or designee would obtain the resident's or responsible party's signature on the bed hold authorization form each time the resident leaves on a bed hold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 6 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to complete a Pre-admission Screening and Resident Review (PASARR) as required. This affected one resident (#74) of two sampled residents reviewed for PASARR Residents Affected - Few Findings Include: Review of the medical record for Resident #74 revealed an admission date of 08/17/21 with diagnoses including paranoid schizophrenia, anxiety, delusional disorder and the need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/31/22 revealed Resident #74 had clear speech, was understood and understands. The assessment revealed Resident #74 was cognitively intact with no behaviors. Resident #74 required two person physical assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Review of the 04/2022 physician's orders revealed Resident #74 received Meditelecare health visits for psychiatric and psychological health and the antipsychotic medication Risperidone one milligram by mouth in the morning and at bed time. Resident #74 had the following behaviors: wandering, exit seeking and calling 911. Non-pharmacological interventions included one to one care, redirection, snacks, fluids and activities. Review of the plan of care revealed Resident #74 had behavior problems such as refusing showers, refusing weights, non compliance with diet, and refusing to wear her bi-level positive airway pressure (BiPap) machine, used to help push air into the lungs. Interventions included administer medications as ordered, observe and document the effectiveness of medications and the side effects, approach the resident and speak in a calm manner, behavioral health consult as needed and encourage the resident to express her feelings. Review of the PASARR, dated 08/05/21 revealed recommendations for a Level II screening due to mental health diagnoses of paranoid schizophrenia and delusional disorder. However, no Level II assessment was completed. Review of the progress notes for Resident #74 revealed no documentation of social service interactions or counseling in lieu of Level II services. On 04/05/22 at 2:12 P.M. interview with the Director of Nursing (DON) revealed Resident #74 had an initial PASARR completed on 08/05/21. However, the DON revealed neither she or the facility had received the recommendations regarding a Level II assessment and said assessment had not been completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 7 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #25 and Resident #8, who required staff assistance for activities of daily living receiving timely and adequate assistance with bathing, nail care and/or dressing to maintain proper hygiene and grooming. This affected two residents (#8 and #25) of six residents reviewed for activities of daily living (ADL) care. Residents Affected - Few Findings Include: 1. Review of Resident #25's medical record revealed an admission date of 01/31/22 with admitting diagnoses of congestive heart failure, asthma, benign prostatic hyperplasia with lower urinary tract symptoms, chronic ischemic heart disease, insomnia, atrial fibrillation, hypothyroidism and hypertension. Review of an evaluation, dated 01/31/22 revealed the resident preferred showers in the evening two days a week. Review of the resident's comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 01/31/22 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10. The assessment revealed the resident was dependent on two staff for bathing. Review of the plan of care, dated 02/01/22 revealed the resident had a self care performance deficit required assistance with activities of daily living (ADL) related to weakness, unsteadiness, indwelling urinary catheter and bowel incontinence. Interventions included the resident required physical assistance with bathing and required mechanical lift and two person assist with transfers. Review of the resident's shower schedule revealed the resident's scheduled showers were every Tuesday and Friday evening. Review of the resident's shower documentation for February 2022 revealed the resident did not receive scheduled showers on 02/08/22, 02/18/22, 02/22/22 or 02/25/22. Review of the resident's shower documentation for March 2022 revealed the resident did not receive scheduled showers on 03/01/22, 03/08/22, 03/15/22 or 03/18/22. On 04/04/22 at 3:46 P.M. interview with the resident's wife revealed the facility would not shower her husband because he was transferred by a mechanical lift. On 04/05/22 at 2:40 P.M. interview with State Tested Nursing Assistant (STNA) #213 revealed the resident received a bed bath due to the resident required the assistance of a mechanical lift and the lack of a shower chair. Review of the facility policy titled Personal Bathing and Shower, last revised 02/16/22 revealed residents have the right to choose their schedules, consistent with their interests, assessments and care plans including choice for personal hygiene. This included but was not limited to choices about the schedules and type of activities for bathing that may include a shower, a bed-bath or tub bath or a combination on different days. Bathing preferences should be care planned including type and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 8 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 schedule. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #8 revealed an admission date of 01/31/17 with diagnoses including Parkinson's disease, congestive heart failure, bipolar disorder, schizophrenia disorder, and chronic obstructive pulmonary disorder. Residents Affected - Few Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/22 revealed Resident #8 had clear speech, was understood and understands. Resident #8 was cognitively intact with no behaviors. Resident #8 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Resident #8 was incontinent of bowel and bladder. Review of the plan of care revealed Resident #8 needed assistance to complete activities of daily living including dressing, bathing, and personal hygiene. On 04/04/22 at 2:05 P.M., 04/05/22 at 9:17 A.M., and 04/06/22 at 2:24 P.M. Resident #8 was observed wearing the same clothes. The clothes were observed to be soiled with food. In addition, the resident's fingernails were observed to be long, jagged and dirty. On 04/05/22 at 9:17 A.M. interview with Resident #8 revealed a staff person (he did not know the name) was supposed to trim his fingernails after his shower yesterday but the staff person did not come back. On 04/06/22 at 2:24 P.M. interview with Unit Manager #308 confirmed the resident had on soiled clothing and the resident's fingernails needed trimmed. Review of the facility policy titled Nail and Hair Hygiene Services, dated 02/15/22 revealed the facility would provide routine care for the resident for hygienic purposes including but not limited to nail hygiene. Nail hygiene included routine trimming, cleaning and filing. Routine nail hygiene may be performed in conjunction with bathing or performed separately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 9 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 observation, record review and interview the facility failed to timely identify new areas of non-pressure related skin impairment for Resident #69 and failed to ensure non-pressure related wound care treatments were completed as ordered for Resident #67. This affected two residents (#67 and #69) of three residents reviewed for non-pressure related skin conditions. Residents Affected - Few Findings Include: 1. Record review for Resident #67 revealed the resident was admitted to the facility on [DATE] and had diagnoses including iron deficiency anemia, acute gastritis with bleeding, type two diabetes mellitus with hyperglycemia, insomnia, presence of cardiac pacemaker, history of falls, unsteadiness on feet, weakness, need for assistance with personal care, gastrointestinal hemorrhage, unspecified dementia with behavioral disturbances, atrial fibrillation and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 03/14/22 revealed the resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 09. This assessment revealed the resident required extensive assistance from one staff member for transfers, bed mobility and toileting. This MDS 3.0 assessment revealed the resident had two venous/arterial ulcers. Review of the care plan, revised 03/29/22 revealed the resident had potential/actual impairment to skin integrity. Interventions included to assess pain related to skin impairments and offer medication as ordered, monitor bruising to bilateral upper extremities every shift until resolved, pressure reducing cushion to wheelchair as ordered, pressure reducing/relieving mattress, turn/reposition frequently as tolerated and weekly skin assessment as ordered. Review of the physician's orders revealed an order, dated 03/29/22 for Aquaphor Advanced Therapy Ointment to be applied topically to bilateral lower extremities, apply abdominal (ABD) pads and wrap with Kerlix every shift. On 04/03/22 at 9:01 P.M. Resident #67 was observed lying in bed with no treatment in place to the bilateral lower extremities. On 04/04/22 at 7:45 A.M. and 9:45 A.M. Resident #67 was observed lying in bed with no treatment in place to the bilateral lower extremities. On 04/04/22 at 9:45 A.M. observation and interview with State Tested Nursing Assistant (STNA) #107 verified Resident #67 did not have a treatment in place to the bilateral lower extremities. STNA #107 verified the resident's legs were both observed to be discolored from the knee to the ankle with multiple scabbed areas noted. On 04/05/22 at 11:15 A.M. Resident #67 was observed lying in bed with no treatment in place to the bilateral lower extremities. On 04/05/22 at 11:15 A.M. interview with Licensed Practical Nurse (LPN) #212 verified Resident #67 did not have a treatment in place to the bilateral lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 10 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Record review for Resident #69 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia with behavioral disturbances, anxiety, depression, bipolar disorder, unsteadiness on feet, unspecified psychosis, dysphagia, cellulitis, need for assistance with personal care, abnormal posture and delusional disorders. Review of the annual MDS 3.0 assessment, dated 03/16/22 revealed the resident was rarely/never understood. This assessment revealed the resident required extensive assistance from two staff members for transfers, bed mobility and toileting and required extensive assistance from one staff member for eating. This resident was assessed to have moisture associated skin damage. Review of the care plan, most recently revised on 03/31/22 revealed the resident had potential/actual impairment to skin integrity related to fragile skin and continually scratching self. Interventions included administer medications per order, encourage good nutrition and hydration, encourage resident to wear geri-sleeves/long sleeves as tolerated, fingernail care/keep nails trimmed and treatments as ordered. On 04/03/22 at 8:48 P.M. Resident #69 was observed to be in the lobby sitting in a specialized (Broda) chair and was observed rubbing two open areas to the back of her right shoulder. On 04/03/22 at 8:48 P.M. interview with State Tested Nursing Assistant (STNA) #224 revealed Resident #69 frequently rubbed and scratched at areas causing her skin to open. STNA #224 verified Resident #69 had two open areas to the back of the right shoulder which were open at that time. On 04/05/22 at 3:00 P.M. Resident #69 was observed to have two open areas to the back of her right shoulder which did not have any type of treatment in place. On 04/05/22 at 3:00 P.M. interview with STNA #107 verified Resident #69 had two open skin areas on the back of her right shoulder with no treatment in place. Review of facility skin assessments and progress notes from 03/01/22 through 04/05/22 revealed no documentation of any skin alterations to the back of the resident's right shoulder. On 04/06/22 at 10:30 A.M. Resident #69 was observed to continue to have two open areas to the back of the right shoulder. On 04/06/22 at 10:30 A.M. interview with Registered Nurse (RN) #402 verified Resident #69 had two open areas to the back of her right shoulder. RN #402 verified there was no documentation of the areas or orders for treatment. This deficiency substantiates Complaint Number OH00131356. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 11 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 Based on observation, record review, facility policy and procedure review and interview the facility failed to provide routine dental services for Resident #8. This affected one resident (#8) of one resident reviewed for dental services. Residents Affected - Few Findings Include: Review of the medical record for Resident #8 revealed an admission date of 01/31/17 with diagnoses including Parkinson's disease, congestive heart failure, bipolar disorder, schizophrenia disorder, and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/10/22 revealed Resident #8 had clear speech, was understood and understands. Resident #8 was cognitively intact with no behaviors. Resident #8 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Resident #8 did not have discomfort or difficulty chewing related to dental status identified on the MDS assessment. Review of the plan of care for Resident #8 revealed the resident was at risk for oral/dental health problems related to being edentulous and refusing to go to the outpatient dentist. Interventions included coordinate arrangements for dental care, transportation as needed monitor/document/report to the physician signs and symptoms of oral dental problems needing attention such as pain, abscess, bleeding and missing teeth and loose, broken, eroded and decayed teeth. Provide mouth care as needed. Review of the progress notes revealed a social service late entry, dated 03/04/22 at 2:33 P.M. indicating Resident #8 requested a dental appointment and an appointment was scheduled with a local dentist on 03/17/22 at 11:00 A.M. The resident and physician were made aware. A note dated 03/17/22 at 1:30 P.M. indicated the resident returned to the facility from an appointment. The nursing notes were silent related to the appointment, any new orders or treatments or if resident refused care. On 04/04/22 at 2:31 P.M. observation of Resident #8 revealed the resident had few teeth on the bottom gum. The teeth were eroded, decayed and dark in color. On 04/04/22 at 2:31 P.M. interview with Resident #8 revealed the resident indicated his teeth hurt at times and he had gone to the dentist but was not sure when he was getting the teeth removed. On 04/06/22 at 3:17 P.M. interview with social services revealed Resident #8 refused to be seen by the in house dentist and therefore an outside dental appointment was made on 03/17/22. However, Resident #8 refused care at the dentist office. Resident #8 was placed on the list for the in house dentist to assess on 04/20/22. The social services employee confirmed there was no documentation in regards to resident refusing care, the extent of the previous appointment or the dental plan for the resident. During the onsite survey, the facility failed to provide a consult sheet from the dentist or any documentation Resident #8 went to the appointment at the outside dental services, any refusal or care provided or recommended. Review of the facility policy titled Dental Care, dated 02/15/22 revealed the facility would provide dental services to the residents on an annual basis and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 12 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #2's medical record was complete and accurate related to the resident's diagnoses. This affected one resident (#2) of 25 sampled residents whose medical records were reviewed. Findings Include: Review of Resident #2's medical record revealed an initial admission date of 12/02/21 with the latest readmission of 02/19/22. Resident #2 had diagnoses including atrial fibrillation, diabetes mellitus, congestive heart failure, severe morbid obesity, repeated falls, chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder and hypertension. Review of the acute care hospital Discharge summary, dated [DATE] failed to identify a diagnoses of seizures. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 12/31/21 revealed the resident had clear speech, understood others, made herself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 12. The assessment indicated the resident did not have seizures as a current diagnoses. Review of the resident's monthly physician's orders for April 2022 revealed an order (initiated 02/19/22) for Depakote (a medication used to prevent seizures) 500 milligrams (mg) by mouth three times a day. Review of the resident's plan of care failed to identify a care plan for seizures. Review of a pharmacy recommendation, dated 03/23/22 revealed the pharmacist recommended a diagnoses be added for the use of the medication Depakote 500 mg by mouth three times a day. Further review revealed the diagnosis of seizures was handwritten beside the medication. On 04/06/22 at 3:50 P.M. interview with Registered Nurse (RN) #410 verified Resident #2 had no history of seizure activity and the diagnosis of seizures was inaccurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 13 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 observation, record review, facility policy and procedure review, review of the Centers for Disease Control (CDC) guidance and interview the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE) and isolation precautions to prevent the potential spread of COVID-19. This affected two residents (#49 and #185) and had the potential to affect all 84 residents residing in the facility. Residents Affected - Many Findings Include: 1. Review of Resident #49's medical record revealed an initial admission date of 01/21/22 with the latest readmission of 04/01/22 with the admitting diagnoses of non-pressure chronic ulcer of foot, diabetes mellitus, plantar fascia affirmations, constipation, obstructive sleep apnea and chronic peripheral venous insufficiency. Review of the plan of care, dated 02/15/22 revealed the resident was at risk for COVID-19 related to declination of (COVID-19) vaccine or vaccine administration contraindicated. Interventions included droplet isolation. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 03/20/22 revealed the resident had clear speech, understands others, makes herself understood and had no cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 15. Review of the mood and behavior section of the MDS revealed the resident rejected care. The assessment revealed the resident required extensive assistance from two staff for bed mobility, transfers and ambulation. Review of the monthly physician's order for April 2022 revealed orders for COVID-19 testing on the day of admission and day seven. The order indicated the resident was to be on droplet precautions for seven days and may come out of isolation on day eight after a negative COVID-19 test. On 04/04/22 at 10:45 A.M. Registered Nurse (RN) #129 was observed to enter Resident #49's room. The RN failed to apply the proper PPE (i.e. gown, gloves, eye protection and N95 mask) at the time she entered the room. The RN was wearing a surgical mask. At the time the RN entered, the resident was noted to have a physician order for droplet isolation (for COVID-19) following the hospital re-admission on [DATE]. RN #129 proceeded to check the resident's blood sugar upon entering the room. Interview with RN #129 at the time of the observation verified the resident was in droplet precautions for COVID-19 and she failed to utilize any PPE when in the resident's room. On 04/04/22 at 10:47 A.M. RN #129 attempted to obtain a disposable gown from the plastic PPE cabinet outside Resident #49's room. However, there were no disposable gowns in the cabinet. The RN then obtained a disposable gown from a cabinet down the hallway and applied the gown and a pair of gloves. RN #129 entered Resident #49's room, administered the resident's insulin and exited the room. The RN did not remove/discard or change her surgical mask upon exiting and walked down the hallway. No protective eyewear was worn by the RN while in Resident #49's room. On 04/04/22 at 2:56 P.M. interview with RN #402 verified Resident #49 was on droplet precautions and indicated all staff should be wearing a gown, gloves, eye protection and an N95 mask when entering (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 14 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 the resident's room. Level of Harm - Minimal harm or potential for actual harm Review of the facility's policy titled, Standard Precautions and Transmission Based Precautions (TBP), last revised 06/25/21 revealed isolation precautions were the method of preventing the spread of contagious disease and microorganism transfer to others following Center for Disease Control (CDC) recommendations and guidelines. TBP were designed for residents documented or suspected to be infected with highly transmissible or epidemiological important pathogens for which additional precautions beyond Standard Precautions were needed to interrupt transmission of disease causing microorganism. For droplet precautions, staff would utilize the proper PPE upon entering the room or cubical area including gloves, mask and eye protection before contacting the resident or environment. Residents Affected - Many Review of the current CDC guidance related to COVID-19 in nursing homes revealed newly-admitted residents and residents who had left the facility for greater than 24 hours, regardless of vaccination status, should have a series of two viral tests for SARS-COV-2 infection; immediately and, if negative, again 5-7 days after their admission. In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and were new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered. 2. Record review revealed Resident #185 was admitted to the facility on [DATE] with a latest re-admission of 04/01/22. Resident #185 had diagnoses including diabetes mellitus type two, anxiety, hemiplegia and hemiparesis, aphasia, hypertension, altered mental status, gastroesophageal reflux disease, gout, bipolar disorder, suicidal ideations, chronic kidney disease stage 2, hyperlipidemia, depression, epilepsy, myocardial infarction, reduced mobility, difficult ambulation and muscle weakness. Review of the MDS 3.0 assessment, dated 03/04/22 revealed the resident had minimal cognitive impairment and was able to make his needs known at all times. Resident #185 was re-admitted to the facility on [DATE] following a hospitalization from 03/16/22 through 04/01/22. This resident had been vaccinated for COVID-19 with a first dose on 09/24/21 and second dose on 10/12/21. On 04/03/22 a physician's order was obtained for droplet precautions (for COVID-19). The order was discontinued on 04/04/22. On 04/03/22 at 8:05 P.M. observation of Resident #185's room revealed there was no isolation cart or signage near the room indicating the resident was in any type of isolation. On 04/04/22 at 8:00 A.M. observation of Resident #185's room revealed there was an isolation cart and signage posted identifying the resident was on droplet precautions. At the time of the observation, Resident #185 was observed exiting his room via wheelchair. The resident was returned to his room by a facility staff and educated he was on isolation precautions. On 04/04/22 at 8:15 A.M. interview with Social Service Director (SSD) #406 revealed she had spoken with Resident #185 on 04/03/22 at approximately 8:05 A.M. in the main lobby. SSD #406 revealed she was unaware the resident was on any type of isolation precautions at that time as the resident was in the lobby and there were no indications of the resident being on droplet precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 15 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 On 04/04/22 at 8:25 A.M. interview with the Director of Nursing revealed Resident #185 had been placed on droplet precautions on 04/03/22 due to being re-admitted following the hospitalization even though the resident returned on 04/01/22. The DON then indicated since the resident had been vaccinated for COVID-19 the precautions weren't necessary and therefore an order had been obtained this morning (on 04/04/22) to discontinue the isolation. The DON was unable to provide any evidence of COVID-19 testing for the resident following the resident's re-admission. In addition, there was no evidence the facility followed the isolation precautions during the time they were ordered. Review of the facility's policy titled, Standard Precautions and Transmission Based Precautions (TBP), last revised 06/25/21 revealed isolation precautions were the method of preventing the spread of contagious disease and microorganism transfer to others following Center for Disease Control (CDC) recommendations and guidelines. TBP were designed for residents documented or suspected to be infected with highly transmissible or epidemiological important pathogens for which additional precautions beyond Standard Precautions were needed to interrupt transmission of disease causing microorganism. For droplet precautions, staff would utilize the proper PPE upon entering the room or cubical area including gloves, mask and eye protection before contacting the resident or environment. Review of the current CDC guidance related to COVID-19 in nursing homes revealed newly-admitted residents and residents who had left the facility for greater than 24 hours, regardless of vaccination status, should have a series of two viral tests for SARS-COV-2 infection; immediately and, if negative, again 5-7 days after their admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 16 of 17 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 365313 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bridgeport Health Care Center 2125 Royce Street Portsmouth, OH 45662 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 - Some 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 observation and interview the facility failed to maintain a clean and functional environment for all residents with evidence of poor repair to five rooms that required wall repairs and paint. This affected seven residents who resided in Rooms 38, 32, 28, 157 and 165. The facility census was 84. Findings Include: On 04/06/22 at 4:35 P.M. observation of room [ROOM NUMBER] revealed the west wall of the room had paint that was visually bubbled up and peeling away from the wall. Some areas had exposed dry wall and other exposed areas from missing paint. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:38 P.M. observation of room [ROOM NUMBER] revealed the south wall and the west wall of this room had bubbled paint that extended from the ceiling to the floor. Some areas of exposed dry wall were observed as well. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:42 P.M. observation of room [ROOM NUMBER] revealed the south wall of the room had bubbled paint that extended from the ceiling to the floor. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:46 P.M. observation of room [ROOM NUMBER] revealed multiple areas of exposed dry wall, with multiple holes in places along the baseboard of the room. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. On 04/06/22 at 4:52 P.M. observation of room [ROOM NUMBER] revealed the south wall was partially exposed with multiple large cracks in the paint. Dry wall was exposed in multiple areas where the paint was peeling away. Observation and interview with Maintenance Director #237 and Maintenance Technician #318 at the time of the observation verified the finding. In addition, interview with Maintenance Director #237 and Maintenance Assistant #318 on 04/06/22 at 5:00 P.M. again verified the findings made during the above observations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365313 If continuation sheet Page 17 of 17