Inspection·February 13, 2020

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of physician's orders for 02/2020 revealed Resident #19 was to receive a regular diet served on a divided plate. Resident #19 was also to receive water at all meals. Resident #19's care plan identified an alteration in mood and behavior related to sad/anxious appearance, depression, crying/tearfulness, anxiety, mistrust of others especially with personal belongings. The identified goal was for Resident #19 to have reduced instances of mood indicators with interventions including, acknowledge resident mood with one to one interactions and acknowledge and convey acceptance of resident and provide repeated honest appraisals of residents strengths. Observation of Resident #19's tray card revealed she was to receive a regular diet with a divided plate. During observation of the evening meal on 02/09/20 at 5:21 P.M., 11 residents, Resident #3, #6, #7, #11, #13, #15, #16, #18, #19, #20 and #22 were observed in the dining room. All residents, with the exception of Resident #19 had been served their evening meal and were eating dinner. Resident #19 did not have a meal tray. State Tested Nursing Assistants (STNA) #116 and #137 were observed in the dining room assisting residents with their meal. Resident #19 was observed to start crying and asking where her meal was. Resident #19 was observed to be tearful/crying until 5:29 P.M. on 02/09/20 when a dinner tray was brought to her. Resident #19 received two corn dogs and french fries. No slaw (which was part of the planned menu) was served to Resident #19. On 02/09/20 at 5:30 P.M. STNA #137 reported the kitchen staff had sent Resident #19 a pureed corn dog and she was on a regular diet, so they sent the tray back to the kitchen. STNA #137 confirmed Resident #19 was tearful and crying and stated she would get tray as soon as the kitchen had prepared the food. On 02/09/20 at 5:33 P.M. [NAME] #123 reported they had ran out of corn dogs and she was preparing more. [NAME] #123 confirmed she had pureed a corn dog for Resident #19 and this was the reason she had run out of food. STNA #137 confirmed no slaw was prepared for Resident #19 and stated she did not know why she did not receive the slaw. STNA #137 confirmed she did not explain to Resident #19 the kitchen had run out of corn dogs, nor did the facility offer coleslaw or french fries to Resident #19 while waiting on the corn dog to be prepared. During an interview with Dietary Manager #118 on 02/09/20 at 5:47 P.M. she reported the facility ran out of slaw and Resident #19 was served an extra corn dog to replace the slaw. Review of the facility policy titled, Quality of Life - Dignity, dated 08/2009 revealed all resident were to be treated with dignity and respect at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 2 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure residents had access to their personal funds account. This affected one resident (#20) and had the potential to affect 12 additional residents (#3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, and #21) who had personal funds managed by the facility. Residents Affected - Some Findings include: On 02/09/20 at 3:53 P.M. during an interview, Resident #20 reported she could not get money from her personal fund account at any time requested. Resident #20 reported she had to wait until someone from the business office was in the facility to receive money from her personal funds account. On 02/13/20 at 1:54 P.M. interview with Business Office Manager (BOM) #125 and the Assistant Director of Nurses (ADON) revealed the facility did not provide residents' access to money after office hours or on the weekend. The ADON reported in the past they had left money in the medication cart, however this was not the current practice. The facility identified 13 residents, Resident #3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, #20 and #21 who had personal funds managed by the facility. Review of the facility admission packet revealed funds would be available to residents at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 3 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0568 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Based on record review and interview the facility failed maintain receipts for items purchased from resident funds. This had the potential to affect 13 residents (#3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, #20 and #21) who had personal funds managed by the facility. Findings include: During review of resident personal accounts on 02/13/20 at 2:02 P.M., Business Office Manager (BOM) #125 reported residents would sign out an amount of money (for withdrawal) and the Assistant Director of Nurses (ADON) would go to the store and get what they wanted. BOM #125 reported she did not have any receipts reflecting what the ADON had purchased for the residents. BOM #125 revealed the ADON would give the residents what items they had wanted from the store, the receipt, and any change left from the amount withdrawn. BOM #125 revealed she did not receive any receipts from items purchased nor was any change returned to the resident account. The facility identified 13 residents, Resident #3, #4, #6, #8, #11, #13, #14, #15, #16, #18, #19, #20 and #21 who had personal funds managed by the facility. On 02/13/20 at 2:05 P.M. the ADON confirmed she did shop for residents at the facility. The ADON revealed the residents would tell her what they wanted, the resident would withdraw cash from their accounts and she would go to the store and get what the resident wanted. The ADON reported when she returned to the facility, she would give the items, receipt and change to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 4 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 - Potential for minimal harm Residents Affected - Many Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify Resident #12 in writing of the facility bed hold policy and number of bed hold days the resident had available. This affected one resident (#12) and had the potential to affect all 19 residents residing in the facility. Findings include: Review of Resident #12's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included obesity, dependence on dialysis, chronic obstructive pulmonary disease, hyperlipidemia, end stage renal disease, frontal lobe and executive function deficits and osteomyelitis of right ankle and foot. Review of Resident #12's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/04/20 revealed her speech was clear, she understands, was understood and her cognition was intact. Review of Resident #12's progress notes dated 01/24/20 revealed the resident was admitted to the hospital due to possible food poisoning. There was no evidence Resident #12 was not notified in writing of the bed hold policy or days available to her. Interview with Business Office Manager (BOM) #125 on 02/13/20 at 5:50 P.M. confirmed Resident #12 was not given written notice of her behold days. Interview with the Director of Nursing and the Administrator on 02/13/20 at 4:47 P.M. revealed Resident #12 was at dialysis and ordered chicken salad. Resident #12 became ill during dialysis and was admitted to the hospital with food poisoning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 5 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to refer residents for a level II pre-admission screening and resident review (PASARR) when a newly evident or possible mental disorder was apparent. This affected two residents (#11 and #18) of two residents reviewed for PASSAR. Findings include: 1. Review of Resident # 11's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included hernia without obstruction or gangrene, osteoarthritis, chronic obstructive pulmonary disease, opioid abuse, hypothyroidism, inhalant abuse, essential hypertension, atrial fibrillation, muscle weakness, constipation, major depressive disorder and type two diabetes. Review of Resident #11's PASSAR dated 05/10/18 revealed the PASSAR was not applicable. Review of Resident #11's annual Minimum Data Set (MDS) 3.0 assessment, dated 04/28/19 revealed Resident # 11 had no level 2 PASSAR. Review of Resident #11's updated diagnoses list revealed on 05/10/19 she was newly diagnosed with bipolar disorder and Post Traumatic Stress Disorder (PTSD). Review of Resident #11 quarterly MDS 3.0 assessment, dated 12/31/19 revealed her speech was clear, she understands, was understood and her cognition was intact. Resident #11 had no indicators of psychosis, had no behaviors and did not reject care. Interview with Assistant Director of Nursing (ADON) #122 on 02/10/20 3:10 P.M. confirmed no new PASSAR was completed for Resident #11 that identified her mental disorders to determine is she required level 2 services. 2. Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, left artificial shoulder joint, overactive bladder, reactive psychosis, insomnia, type one diabetes, essential hypertension, intellectual disability, migraine, dependent personality, bipolar disorder, major depressive disorder, partial traumatic amputation of right mid foot and anxiety disorder. Resident #18's PASSAR dated 09/21/11 revealed the resident had no serious mental illness. Review of Resident #18's annual MDS 3.0 assessment, dated 04/01/19 revealed no level 2 PASSAR was completed and her cognition was intact. On 06/28/19 Resident #18 was newly diagnosed with schizophrenia. Review of Resident #18's progress note dated 10/14/19 revealed she attempted suicide. Resident #18 was admitted to a psychiatric hospital due to the attempted suicide with a plan. Resident #18 was readmitted on [DATE]. Review of Resident #18's PASSAR dated 11/11/19 revealed the resident had no serious mental illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 6 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident #18 quarterly MDS 3.0 assessment dated [DATE] revealed her speech was clear, she understands, was understood and her cognition was moderately impaired. Resident #18 had no indicators of psychosis, no behaviors and did not reject care. Interview with ADON #122 on 02/13/20 at 2:36 P.M. verified Resident #18's PASSAR did not accurately identify her mental health diagnoses to properly evaluate the resident for level 2 services. Event ID: Facility ID: 365867 If continuation sheet Page 7 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. 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 ensure Resident #6 was provided the necessary equipment to maintain/improve mobility. This affected one resident (#6) of two residents reviewed for positioning. Residents Affected - Few Findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dysphagia, diabetes mellitus, hypertension, depression and epilepsy. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, completed on 11/04/19 revealed Resident #6 had impaired cognition, required extensive assistance from staff for bed mobility, locomotion, dressing and total dependence from staff for personal hygiene, toilet use and transfers. On 02/09/20 at 11:29 A.M. Resident #6 was observed in the dining area with feet not positioned on the foot plate while in tile in space wheelchair. Resident #6's feet were observed resting against the foot place. On 02/09/20 at 1:30 P.M. Resident #6 was observed with feet not positioned on foot plate, but feet were observed dangling in air with back of right foot positioned against the foot plate. Resident #6 was observed on 02/10/20 at 11:26 A.M. with feet dangling against the foot plate of her wheelchair. Licensed Practical Nurse (LPN) #105 confimred Resident #6's feet did not rest on the foot plate of the wheelchair. During an interview with Physical Therapy Assistant (PTA) #131 on 02/10/20 at 11:45 A.M. revealed she had worked with Resident #6 in physical therapy and was familiar with the resident. PTA #131 reported the chair Resident #6 was using was provided by the facility due to Resident #6 needing a personalized chair to assist with positioning. PTA #131 confirmed the foot plate did appear to be slightly positioned behind the edge of the chair and Resident #6's feet did not rest on the foot plate. PTA #131 stated would be concerned regarding the resident's feet/ankles resting against the foot plate and could possibly cause skin tears to her feet and/or ankles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 8 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide timely and adequate nail care to Resident #14, who was assessed to be dependent on staff for activities of daily living care. This affected one resident (#14) of two residents reviewed for activities of daily living. Residents Affected - Few Findings include: Record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of cerebrovascular accident with hemiplegia left side, obesity, delusional disorder, depression, convulsions, diabetes mellitus and chronic obstructive pulmonary disease. Review of the care plan dated 03/15/16 revealed Resident #14 was dependent on staff and all activity of daily living care and the resident's needs would be met. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, completed 01/01/20 revealed Resident #14 had moderate cognitive impairment and was totally dependent on staff for activities of daily living. On 02/09/20 at 10:28 A.M. an observation of Resident #14's fingernails revealed they were long, jagged and a brown substance was observed under the nails on the right hand. Resident #14 reported her nails were longer than she liked them and needed to be trimmed. Licensed Practical Nurse (LPN) #105 confirmed on 02/10/20 at 3:32 P.M. Resident #14's fingernails were long and needed trimmed. Resident #14 reported at this time they were supposed to be trimmed on 02/06/19, however staff did no get to them that day and no one had been back to trim her nails. On 02/11/20 at 1:28 P.M. State Tested Nursing Assistant (STNA) #120 reported nail care was to be done when residents were showered or as needed. STNA #120 reported Resident #14 would refuse a shower at least one time every two weeks, however a bed bad would be completed and nail care should be performed at that time. Review of the facility policy titled, Fingernails/Toenails, Care of, dated 02/2018 revealed ail beds were to be kept clean and nails trimmed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 9 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0679 Provide activities to meet all resident's needs. 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, policy review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs of Resident #18. This affected one resident (#18) of three residents reviewed for activities. Residents Affected - Few Findings include: Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, left artificial shoulder joint, overactive bladder, reactive psychosis, insomnia, type one diabetes, essential hypertension, intellectual disability, migraine, dependent personality, bipolar disorder, major depressive disorder, partial traumatic amputation of right mid foot and anxiety disorder. Review of Resident #18's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18's speech was clear, she understands, was understood and her cognition was intact. Resident #18 had moderate depression, delusions and was verbally abuse one to three days in the past seven days which did not impact the resident or other residents. The assessment also revealed she rejected care one to three days in the past seven days. It was somewhat import for Resident #18 to have books/magazines to read, to listen to music, not very important to be around animals, to keep up with the news, it was very important to do things in groups, to do favorite activities, to go outside and get fresh air in good weather, and somewhat important to participate in religious services. Resident #18 required extensive assistance of one staff for bed mobility, extensive assistance of two staff to transfer, to walk in room, did not walk in corridor, extensive assistance of one staff for locomotion. Resident #18 used a wheelchair for mobility. Review of Resident #18's quarterly MDS 3.0 assessment, dated 01/03/2020 revealed Resident #18's cognition was moderately impaired, she had no indicators of psychosis, no behaviors, and did not reject care. Resident #18 was dependent on two staff for bed mobility, to transfer, to walk, and was dependent on one staff for locomotion. Review of Resident #18's activity participation review, dated 01/31/2020 revealed it was very important for her to participate in religious practices. Resident #18 attended most of the daily group activities. Review of the activity calendar for February 2020 revealed on 02/09/20 at 10:00 A.M. a spiritual activity was planned. Observation of the common area on the unit on 02/09/20 from 10:00 A.M. to 10:25 A.M. revealed the television was on with a Hallmark channel movie on, it was a romance movie. Interview with Resident #18 on 02/09/20 at 10:44 A.M. revealed there were not many activities on the weekends because Activity Assistant (AA) #108 was not there. Resident #18 stated there were STNA staff during the week/weekends to do activities but they just put digital video disc's (DVD's) on and call it the activity. She stated spiritual was on the calendar for 10:00 A.M. but the TV was on the hallmark channel instead. Interview with AA #108 on 02/11/20 at 3:30 P.M. confirmed the weekend activities were conducted by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 10 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0679 the STNAs and sometimes they do not follow the calendar. Level of Harm - Minimal harm or potential for actual harm Review of the facility activity policy, revised 01/2020 revealed activities were scheduled daily (including weekends) and activities were offered based on the individual preferences and needs of residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 11 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 ensure all residents received adequate and timely treatment and care as needed. The facility failed to ensure coordinated communication and care with Hospice for Resident #7, failed to ensure adequate preventative measures were in place for a non pressure related skin ulceration for Resident #18, failed to ensure adequate bowel monitoring was completed for Resident #20, failed to monitor bruising for Resident #13 and failed to ensure Resident #1 was adequately monitored for diarrhea, nausea and vomiting prior to the resident being hospitalized for a small bowel observation. This affected five residents (#1, #7, #13, #18 and #20) of 13 sampled residents. Residents Affected - Some Findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, bipolar disorder, hypertension, dementia, anxiety, depression and suicidal ideation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/17/20 revealed Resident #1 had impaired cognition and required limited assistance from staff for activities of daily living. Review of the physician's orders revealed on 02/05/20 the physician ordered blood work including a Complete blood Count with Differential and Procalcitonin level due to nausea and vomiting. On 02/06/20 the physician ordered to start Doxycycline (an antibiotic) 100 milligrams (mg) two times daily for seven days due to nausea, vomiting, and diarrhea. On 02/09/20 a physician telephone order indicated to send to local emergency room for evaluation due to vomiting for three days. Review of the nursing progress note for 02/05/20 did not contain information regarding contacting the physician for resident complaints/symptoms of nausea, vomiting or diarrhea. Review of the task documentation did not contain information regarding Resident #1 continence, meal intake or fluid intake from 02/01/20 through 02/08/20. On 02/08/20 the documentation indicated Resident #1 was continent of stool, consumed 75 - 100% of her noon meal and 0-25% of her evening meal with fluid intake for the 1080 milliliters. The nursing notes from 02/05/20 through 02/08/20 revealed a medication administration note which indicated Resident #1 was receiving Doxycycline 100 mg for nausea, vomiting and diarrhea. On 02/09/20 at 10:00 A.M. the nursing note indicated Resident #1 was resting quietly in bed with both eyes closed. A large amount of brown dried emesis was noted on the floor beside the bed. The next note on 02/09/30 at 11:00 A.M. indicated the Director of Nursing (DON) was contacted and assessed the resident. Resident #1 was described as pale in color with cyanosis noted, blood pressure 110/67, pulse 72 and regular and respirations 16. The physician was notified and an order was received to transport to the local emergency room with family notification. A review of the emergency room (ER) documentation on 02/09/20 at 5:18 P.M. indicated Resident #1 was transferred to their facility for treatment due to a small bowel obstruction. The ER documentation indicated the family reported Resident #1 had began complaining of abdominal pain three days ago and also had emesis the past three days. The family denied knowledge Resident #1 had any fever. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 12 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 - Some During an interview with Registered Nurse (RN) #128 on 02/09/20 at 5:42 P.M. she reported she received information from the previous shift that Resident #1 had emesis for past two to three days. RN #128 stated the nurse reported Resident #1 had been vomiting again on night shift and had brown emesis this morning. RN #128 stated she then asked the DON to check Resident #1 and he felt she was dehydrated, contacted the physician and the resident was transferred to a local emergency room. RN #128 reported Resident #1 had been treated for the past few days for an intestinal infection. RN #128 confirmed brown emesis noted on the floor earlier on 02/09/20. On 02/09/20 at 5:43 P.M. Licensed Practical Nurse (LPN) #139 reported Resident #1 had taken her 8:00 P.M. medication on 02/08/20 and then returned to the nurse's station around 10:00 P.M. to 11:00 P.M., was talkative and then returned to her room. LPN #139 reported around 6:00 A.M. she noticed Resident #1 had thrown up and did not administer her morning medications. LPN #139 reported Resident #1 had no complaints of pain. On 02/12/20 at 3:27 P.M. the DON reported RN #128 did not have access to electronic charting because she was an agency nurse. The DON stated RN #128's documentation would be on paper, however all other documentation regarding Resident #1 would be noted in the electronic record. The DON confirmed no documentation regarding nausea, vomiting, emesis or abdominal pain to contact the physician for the orders of laboratory testing or antibiotic therapy. The DON revealed you could not tell if the symptoms had improved or increased and there was no indication of any further communication with the physician or assessing of the resident's bowel sounds. The DON confirmed documentation in the electronic was for the justification of the antibiotic (nausea, vomiting, puking) and no narrative was present to note if Resident #1 had complained of abdominal pain, if bowel sounds were present, or the number of emesis or diarrhea per shift. 2. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of upper lobe right bronchus or lung, malignant neoplasm, chronic obstructive pulmonary disease and atherosclerotic heart disease. Review of Resident #7 admission MDS 3.0 assessment, dated 11/29/19 revealed her speech was clear sometimes she was understood, sometimes she understands, her short- and long-term memory was impaired, she had no recall and her decision making was severely impaired. Resident #7 had no indicators of psychosis, no behaviors, and did not reject care. Resident #7 received Hospice services. Resident #7's record contained no hospice notes, care plan, or current recertification. Review of Resident #7's progress notes dated 01/01/20 revealed the resident fell in her room trying to get out of her wheelchair. Hospice was not notified of the fall until 01/02/20 when the Hospice nurse visited the resident. Interview with Licensed Practical Nurse (LPN) #105 on 02/12/20 at 10:51 A.M. revealed there was not much communication with the Hospice nurse regarding Resident #7's hospice care. Interview with State Tested Nursing Assistant (STNA) #135 on 02/12/20 at 11:26 A.M. revealed Hospice did not provide any information regarding the care for Resident #7. Interview with the Director of Nursing (DON) on 02/12/20 at 2:55 P.M. confirmed there was no evidence Hospice was notified until 01/02/20 of the resident's 01/01/20 fall. The DON confirmed the facility did not have copies of Hospice notes, a Hospice care plan, and no current recertification for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 13 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 Resident #7. Level of Harm - Minimal harm or potential for actual harm 3. Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, left artificial shoulder joint, overactive bladder, reactive psychosis, insomnia, type one diabetes, essential hypertension, intellectual disability, migraine, dependent personality, bipolar disorder, major depressive disorder, partial traumatic amputation of right mid foot and anxiety disorder. Residents Affected - Some Review of Resident #18's plan of care initiated on 03/15/16 and revised on 06/14/17 revealed she had a recurring diabetic ulcer to her left ankle. The listed interventions included turn and reposition as ordered and treatments as ordered. Resident #18's care plan dated 02/09/20 revealed she used a non-hospital bed. Review of Resident #18's physician's orders revealed on 11/06/19 an order was obtained for protective boot (Prevalon) to her left ankle for preventative measures. The order indicated the boot may remove for hygiene and as needed. Review of Resident #18's quarterly MDS 3.0 assessment, dated 01/03/2020 revealed the resident's speech was clear, she understands, was understood and her cognition was moderately impaired. Resident #18 had no indicators of psychosis, no behaviors and did not reject care. Resident #18 was dependent on two staff for bed mobility, to transfer, to walk, was dependent on one staff for locomotion and used a wheelchair for mobility. Resident #18 had a diabetic foot ulcer and had a pressure reduction mattress. Review of Resident #18 weekly skin observations revealed her skin was intact on 02/04/20. Review of Resident #18's wound evaluation flow sheet revealed on 02/07/20 her left ankle had a diabetic ulcer that measured two centimeters (cm) in length by 1.8 cm width with 0.1 cm depth. The listed preventative intervention was the Prevalon boot. On 02/07/20 a treatment was initiated to cleanse the wound with wound cleanser, pack with prism cover with a clean dry dressing change daily and as needed. No physician order for treatment to the left ankle was obtained until 02/10/20. The ordered treatment was cleansing the wound to the left outer ankle with wound cleaner, pat dry, apply antibiotic ointment cover with a clean dry dressing, change every three days and as needed. Observation of Resident #18 on 02/10/20 at 8:30 A.M. revealed she was in bed on her right-side ankle on the mattress, left ankle covered with sheet and comforter, there were no measures to prevent skin breakdown applied to either feet or ankles. Observation of Resident #18's mattress revealed it was a regular mattress and was not a preventative skin mattress. Resident #18 was observed at 11:32 A.M., she was in bed on her back with no protective skin measures in place. At 1:19 P.M. Resident #18 was still in bed on her back with no protective skin measures in place. Resident #18 was observed in bed until 2:29 P.M. Observation of Resident #18 on 02/10/20 at 3:01 P.M. revealed she was up, in her wheelchair and she was wearing a Prevalon boot on her left foot. Observation of Resident #18 on 02/11/20 at 3:13 P.M. revealed she was in bed on her back with no protective skin measures in place. Interview with STNA #107 on 02/10/20 at 3:01 P.M. confirmed the resident had been in bed all morning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 14 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 - Some Interview with STNA #117 on 02/11/20 at 2:24 P.M. revealed Resident #18 only wore the Prevalon boot when she was up in the wheelchair. The STNA revealed the boot was to protect her ankle from being bumped. Interview with LPN #105 on 02/11/20 at 2:30 P.M. revealed Resident #18 only wore the boot when she was out of bed. Interview with Corporate Registered Nurse #115 on 02/12/20 at 2:50 P.M. confirmed Resident #18 had no protective skin measures in place. Review of the facility wound care policy, dated 09/2019 revealed treatments would be implemented by the nurse as required by the physician. 4. Review of Resident #13's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included epilepsy, intellectual disability, and depressive disorder and mood disorder. Review of Resident #13's quarterly MDS 3.0 assessment, dated 08/28/19 revealed her speech was clear, she was rarely/never understood, usually understands, her short- and long-term memory was impaired, she had no recall and her cognition was severely impaired. Resident #13 required extensive assistance of two staff for bed mobility, was dependent on two staff to transfer, she did not walk and she was dependent on two staff for locomotion and used a wheelchair for mobility. Resident #13 had no falls and no skin problems. Review of Resident #13's progress notes revealed on 02/03/20 at 11:16 A.M. an order was obtained for an x-ray of right lower leg and right foot related to bruising. Resident #13's medical record was silent to what caused the resident's right leg and foot bruising. Observation of Resident #13 on 02/10/20 at 11:29 A.M. and 1:17 P.M. revealed she was seated in a wheelchair at a table in dining room, her feet were dangling with no support. On 02/11/20 at 8:55 A.M. and 3:14 P.M. Resident #13 was in her wheelchair and her feet were dangling. Resident #13 was observed on 02/12/20 at 8:54 A.M. and on 02/13/20 at 9:53 A.M. seated in her wheelchair and her feet were dangling with not support. There were no footrests on the resident's wheelchair. Interview with LPN #105 and Corporate RN #115 on 02/13/20 at 4:38 P.M. revealed on 02/03/20 Resident #13's leg and ankle were caught between the receiving lever for the footrest and the front wheel of the chair on the right side, about a 4-inch gap. This accident resulted in bruising of the lower leg and foot. An x-ray was obtained with no signs of a fracture. These staff members confirmed there was no documentation in the medical record of the incident and no evidence of monitoring of the leg and ankle bruising. Review of the facility assistive device and equipment policy, dated July 2017 revealed the facility would address the appropriateness of devices and equipment for each resident to avoid the risk of injury. 5. Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypothyroidism, major depressive disorder, gastro-esophageal reflux, generalized anxiety and vertigo. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 15 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 - Some Review of Resident #20's annual MDS 3.0 assessment, dated 01/20/2020 revealed Resident #20's speech was clear, she understood, she understands and her cognition was intact. Resident #20 had no behaviors and did not reject care. Resident #20 required extensive assistance of one staff for bed mobility, was dependent on two staff to transfer, to walk, for locomotion on and off the unit, for dressing, toilet use and personal hygiene. Resident #20 was always incontinent of bowel and bladder and was not on a toileting program. Review of Resident #20's bowel records revealed she had no bowel movement from 01/17/20 until 01/22/20 and from 01/24/20 until 02/09/20. There was no evidence Resident #20 was treated for the lack of bowel movement. Interview with Resident #20 on 02/13/20 at 10:28 A.M. revealed sometimes she does not have a bowel movement for several days and does not receive any treatment for it. Interview with LPN #105 on 02/13/20 at 11:19 A.M. revealed Resident #20 had a little problem with her bowels moving, the resident received pain medications. LPN #105 confirmed the resident did not receive treatment for lack of bowel movements. Interview with Corporate RN #115 on 02/13/20 at 4:48 P.M. revealed the facility had a bowel protocol, but it was not implemented for Resident #20. The protocol indicated if the resident did not have a bowel movement in three days then the resident would receive treatment for the lack of a bowel movement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 16 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review and interview, the facility failed to provide adequate supervision to ensure safety during smoking, prevent falls, and prevent injuries from resident care equipment. Actual Harm occurred on 01/01/2020 when the facility failed to have effective interventions in place and provide Resident #7, who was at high risk for falls and had a history of falls, adequate supervision resulting in the resident sustaining an unwitnessed fall from her wheelchair and sustaining a fractured left hip and pelvis. This affected one resident (#7) of three residents reviewed for accidents. Additionally, one resident (#11) of one sampled resident reviewed for smoking was not provided adequate supervision during smoking, and one resident (#13) of three residents reviewed for accidents did not have their wheelchair modified to prevent injuries. Findings include: 1. Review of Resident #7's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of upper lobe right bronchus or lung, malignant neoplasm, chronic obstructive pulmonary disease and atherosclerotic heart disease. Review of Resident #7's fall risk assessment dated [DATE] revealed she was at high risk for falls. Review of Resident#7's progress notes revealed on 11/13/2019 at 5:45 P.M. the resident fell from her bed onto the floor. Resident #7 was unable to answer questions due impaired cognition and communication. A floor mat was placed on the floor beside her bed. Review of Resident #7's plan of care regarding falls initiated on 11/27/2019 revealed she was at risk for falls and to have commonly used articles within easy reach, maintain a clear pathway and her bed locked. Review of Resident #7's Minimum Data Set (MDS) 3.0 assessment, dated 11/29/2019 revealed her speech was clear, sometimes she was understood, sometimes she understands, her short-term and long-term memory was impaired, she had no recall and her decision making was severely impaired. Resident #7 had no indicators of psychosis, no behaviors and did not reject care. Review of Resident #7's progress notes revealed on 01/01/2020 the resident was found on the floor of her room. There was no evidence a floor mat was in place at the time of the fall (as implemented after the 11/2019 fall). The note stated Resident #7 was encouraged to eat meals in dining area, educated on proper use of call light, and encouraged to ask for help. It could not be determined what fall safety interventions were in place prior to and at the time of the fall and following the fall it could not be determined that new interventions were individualized and effective for the resident. Resident #7's fall resulted in a skin tear to right inner and outer knee, right forearm and right elbow. On 01/02/20 at 1:45 P.M. Resident #7 complained to the Hospice nurse that she had left leg and hip pain. The Hospice nurse directed the staff to send the resident to the emergency department. Resident #7 was assessed to have a fractured left hip and pelvis. Review of the post fall investigation dated 01/02/2020 revealed on 01/01/2020 at 3:30 P.M., Resident #7 fell when she tried to get out of her wheelchair. The investigation failed to include evidence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 17 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0689 Level of Harm - Actual harm of effective and individualized fall safety interventions being in place at the time of the fall. Following the fall, new interventions were to educate and encourage Resident #7 to use her call light and encourage her to eat in the dining area. (However, the resident was assessed to have severely impaired decision making skills, no recall ability and long and short term memory impairment). Residents Affected - Few Record review revealed Resident #7 sustained a fall on 01/11/20. Review of the post fall investigation dated 01/13/2020 revealed on 01/11/2020 at 12:57 P.M. the resident had fallen from the bed to the floor. There was no evidence the fall mat was in place to the floor at the time of the fall. A new intervention was added for half side rails and a new wheelchair with working brakes. Review of Resident #7's undated post fall investigation revealed on 01/28/2020 at 4:23 P.M. the resident fell from her wheelchair trying to self-transfer to her recliner chair. There was no evidence of any fall safety interventions being in place and effective at the time of the fall. Following the fall, the new safety intervention was Resident #7 being educated on the use of the call light and to ask for help. However, again the resident was assessed to be cognitively impaired and this interventions would not be effective or individualized for the resident. Observation of Resident #7 on 02/10/2020 at 1:15 P.M. revealed her feet were off the footrest of her wheelchair and Resident #11 asked the Director of Nursing (DON) to reposition Resident #7 as she looked uncomfortable. The DON placed Resident #7's feet on the footrest but her feet were then hanging over the footrest. The DON pushed Resident #7 back to her room telling her they would bring her back out. At 1:20 P.M. the DON went to the administrative area and Resident #7 was still in her room. At 1:37 P.M. Resident #7 was observed in her room in her recliner chair with her feet elevated. Her call light was not within reach. Observation of Resident #7 on 02/12/2020 at 9:57 A.M. revealed she was in her room in her recliner chair, asleep, leaning to the right and her feet were elevated. Resident #7's call light was not in reach. Interview with the DON on 02/12/2020 at 10:08 A.M. confirmed Resident #7's call light was not in reach (which was a safety intervention for the resident). The DON gave the call light to Resident #7 and instructed her to use it to call for help, asked the resident if she needed pain medication or to be repositioned. Resident #7 was sleepy and did not respond. Interview with Licensed Practical Nurse (LPN) #105 on 02/12/2020 at 10:51 A.M. revealed she was not aware of Resident #7 using a call light. LPN #105 revealed staff needed to check on the resident a lot when she was no in a common area (due to her fall risk and inability to use her call light for assistance). Interview with State Tested Nursing Assistant (STNA) #135 on 02/12/2020 at 11:26 A.M. revealed Resident #7 did not use a call light. STNA #135 revealed staff assisted the resident to bed to sleep at night and the resident frequently sat in her recliner chair during the day. Interview with Corporate Registered Nurse #115 on 02/12/2020 at 3:00 P.M. confirmed educating Resident #7 on the use of the call light to prevent falls was not an appropriate intervention for her. Corporate Registered Nurse #115 confirmed limited interventions to prevent falls were implemented with Resident #7 and also verified Resident #7 sustained a fall with fracture on 01/01/20 due to a lack of adequate supervision and effective and individualized fall safety interventions being in place for the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 18 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0689 Review of the facility assistive device and equipment policy, dated July 2017 revealed the facility would address the appropriateness of devices and equipment for each resident to avoid the risk of injury. Level of Harm - Actual harm Residents Affected - Few 2. Review of Resident #13's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included epilepsy, intellectual disability, and depressive disorder and mood disorder. Review of Resident #13's quarterly MDS 3.0 assessment, dated 08/28/2019 revealed her speech was clear she was rarely/never understood, usually understands, her short- and long-term memory was impaired, she had no recall and her cognition was severely impaired. Resident #13 required extensive assistance of two staff for bed mobility, was dependent on two staff to transfer, she did not walk and she was dependent on two staff for locomotion and used a wheelchair for mobility. Resident #13 had no falls and no skin problems. Review of Resident #13's progress notes revealed on 02/03/2020 at 11:16 A.M. an order was obtained for an x-ray of the right lower leg and right foot related to bruising. Resident #13's medical record had no evidence of what caused the resident's right leg and foot bruising. Observation of Resident #13 on 02/10/2020 at 11:29 A.M. and 1:17 P.M. revealed she was seated in wheelchair at table in dining room and her feet were dangling with no support. On 02/11/2020 at 8:55 A.M. and 3:14 P.M., Resident #13 was observed in her wheelchair and her feet were dangling. Resident #13 was observed on 02/12/2020 at 8:54 A.M. and on 02/13/2020 at 9:53 A.M. seated in her wheelchair and her feet were dangling with no support. There were no footrests on the resident's wheelchair. Interview with LPN #105 and Corporate Registered Nurse #115 on 02/13/2020 at 4:38 P.M. revealed on 02/3/2020, Resident #13's leg and ankle were caught between the receiving lever for the footrest and the front wheel of the chair on the right side, about a 4-inch gap. This accident resulted in bruising of the lower leg and foot. An x-ray was obtained with no signs of a fracture. These staff members confirmed there was no documentation in the medical record of the incident, no evidence of monitoring of the leg and ankle bruising, and there were no preventive measures were put into place to prevent Resident #13 from being injured again. Review of the facility assistive device and equipment policy, dated July 2017 revealed the facility would address the appropriateness of devices and equipment for each resident to avoid the risk of injury. 3. Review of Resident #11's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included hernia without obstruction or gangrene, osteoarthritis, chronic obstructive pulmonary disease, bipolar disorder, opioid abuse, hypothyroidism, inhalant abuse, essential hypertension, atrial fibrillation, post-traumatic stress disorder, muscle weakness, constipation, major depressive disorder and type two diabetes. Review of Resident #11's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #11's speech was clear, she understands, was understood and her cognition was intact. Resident #11 had no indicators of psychosis, had no behaviors, and did not reject care. Resident #11 required limited assistance of one staff for bed mobility and to transfer. Review of Resident #11's smoking assessment dated [DATE] revealed the resident can carry her own (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 19 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0689 lighter and cigarettes. Level of Harm - Actual harm Observation of Resident #11 on 02/09/2020 at 5:50 P.M. revealed the resident went outside to smoke with STNA #137. Resident #11 pulled cigarettes and lighter out of her jacket pocket. Residents Affected - Few Interview with LPN #139 on 02/09/2020 at 6:03 P.M. revealed Resident #11 and #8 kept their cigarettes and lighters on them. Interview with the DON on 02/10/2020 at 3:05 P.M. revealed residents were not supposed to keep lighters or cigarettes on them. The DON stated the lighters and cigarettes were kept at the nurse's station and a STNA would give them to the resident and goes out with the resident to smoke. She stated this had changed a month ago or so (residents not being permitted to maintain possession of cigarettes and/or lighters). Review of the facility smoking policy, dated 08/22/2019 revealed residents must store smoking materials with staff, except when they are under the supervision of staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 20 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0692 Provide enough food/fluids to maintain a resident's health. 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 ensure residents received nutritional interventions to prevent weight loss and fluids were not needlessly restricted. This affected two residents (#7 and #18) of seven residents reviewed for nutrition and hydration. Residents Affected - Few Findings include: 1. Review of Resident #7's medical record revealed she was admitted to the faciliy on 11/13/2019 with diagnoses that included malignant neoplasm of upper lobe right bronchus or lung, malignant neoplasm, chronic obstructive pulmonary disease and atherosclerotic heart disease. Review of Resident #7's admission Minimum Data Set (MDS) 3.0 assessment, dated 11/29/2019 revealed her speech was clear, sometimes she was understood, sometimes she understands, her short- and long-term memory was impaired, she had no recall and her decision making was severely impaired. Resident #7 had no indicators of psychosis, no behaviors, and did not reject care. Resident #7 required extensive assistance of one staff for bed mobility, extensive assistance of two staff to transfer, did not walk, was dependent on one staff for locomotion and required limited assistance of one staff to eat. Review of Resident #7's weights revealed on 11/20/2019 she weighed 124.3 pounds. On 12/20/2019 Resident #7 weighed 117.8 pounds. On 12/24/19 a physician's order was obtained for ice cream with every dinner meal due to unplanned weight loss. Observation of Resident #7 at the evening meal on 02/09/2020 at 5:21 P.M. revealed she did not receive ice cream. Observation of Resident #7 at the evening meal on 02/12/2020 at 5:12 P.M. revealed she did not receive ice cream. Interview with State tested Nursing Assistant (STNA) #117 on 02/12/2020 at 5:12 P.M. revealed Resident #7 did not receive ice cream all the time. However, Resident #7 did like ice cream and always ate her ice cream when she got it Interview with Dietary Supervisor (DS) #118 on 02/13/2020 8:27 A.M. revealed Resident #7 was on the list for ice cream at dinner, but it was not her tray card. DS #118 revealed there was a new dietary staff serving in the evening and she did follow the lists. 2. Review of Resident #18's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, left artificial shoulder joint, overactive bladder, reactive psychosis, insomnia, type one diabetes, essential hypertension, intellectual disability, migraine, dependent personality, bipolar disorder, major depressive disorder, partial traumatic amputation of right mid foot and anxiety disorder. Review of Resident #18's quarterly MDS 3.0 assessment dated [DATE] revealed Resident #18's speech was clear, she understands, was understood and her cognition was moderately impaired. Resident #18 had no indicators of psychosis, no behaviors and did not reject care. Resident #18 was dependent on two staff for bed mobility, to transfer and required limited assistance of one staff to eat. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 21 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #18's progress notes dated 02/05/2020 revealed the resident was placed on a 2000 milliliter (ml) fluid restriction. No reason was documented in Resident #18's medical record for the fluid restriction. Interview with Resident #18 on 02/09/2020 at 10:49 A.M. revealed she was told today she was on a 2000 ml fluid restriction and for breakfast she received a 1/2 cup coffee with her breakfast meal. Observation of the lunch meal on 02/09/2020 at 11:57 A.M. revealed STNA #116 reminded Resident #18 she was on a fluid restriction and she could have six ounces of tea. Interview with STNA #120 on 02/11/2020 at 1:41 P.M. revealed Resident #18 was on a 2000 ml fluid restriction. STNA #120 revealed Resident #18 could have a six-ounce cup of tea at each meal. Interview with STNA #117 on 02/11/2020 at 2:24 P.M. revealed Resident #18 was on a 2000 ml fluid restriction and she could have 6 ounces each shift for the 2000 ml per shift. Interview with the Director of Nursing (DON) on 02/11/2020 at 3:08 P.M. revealed Resident #18 was not supposed to be on a 2000 ml fluid restriction. The DON revealed he made an error as to which resident was on a fluid restriction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 22 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 ensure Resident #14 was administered oxygen per physician order. This affected one resident (#14) of one resident reviewed for oxygen therapy. Residents Affected - Few Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of cerebrovascular accident with hemiplegia left side, obesity, delusional disorder, depression, convulsions, diabetes mellitus and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #14 had moderate cognitive impairment and was totally dependent on staff for activities of daily living. Review of the current physician's orders included an order for oxygen at three liters per nasal cannula with humidified air for chronic obstructive pulmonary disease. The current care plan for Resident #14 revealed the facility would provide oxygen therapy per physician orders. On 02/09/2020 at 10:16 A.M., Resident #14 was observed with oxygen at three liters per nasal cannula via oxygen concentrator. No humidification was observed. Resident #14 reported on 02/10/2020 at 11:19 A.M. her nose often gets dry from the oxygen and she will move it to the side of her nose so it feels better. No humidification was observed for Resident #14 at this time. On 02/10/2020 at 3:32 P.M., Licensed Practical Nurse (LPN) #105 confirmed Resident #14's order indicated oxygen was to be humidified, however no humidification was provided for Resident #14 oxygen. Review of the facility policy titled Respiratory Therapy, dated 08/01/2018 revealed cool aerosol was to be ordered by a physician and the equalizer was to be placed to the air compressor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 23 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure annual performance evaluations and in-service education was completed as required. This affected two employees, STNA #116 and #120 who had worked in the facility for more than one year and had the potential to affect all 19 residents residing in the facility. Residents Affected - Many Findings include 1. STNA #116 started to work at the facility on 02/03/16. Review of STNA #116's personal file revealed an employee evaluation dated 02/01/19, however it was not signed by STNA #116 indicating agreement with or review of the evaluation. The Assistant Director of Nurses (ADON) confirmed on 02/13/20 at 10:35 A.M. that STNA #116's evaluation had not been signed by the employee as required. Review of the facility policy, titled Performance Evaluation, dated 06/2010 revealed performance evaluations would be completed after 90 days of employment, yearly, and would be dated and signed by the employee acknowledging receiving the evaluation. In addition, review of STNA #116's annual in-service training documentation revealed no evidence the employee completed at least 12 hours of in-service training between 02/03/19 and 02/03/20. On 02/13/20 at 10:35 A.M. during an interview with the Assistant Director of Nursing (ADON) she reported she had not kept record of STNA in-service training/hours and could not produce documentation of STNA #116 completing at least 12 hours of in-service annually as required. 2. STNA #120 started to work at the facility on 08/01/18. Review of STNA #120's personal file revealed the file did not contain a yearly performance evaluation. The Assistant Director of Nurses (ADON) confirmed on 02/13/20 at 10:35 A.M. STNA #120 did not have a yearly evaluation completed and maintained in the employee's personal file. Review of the facility policy, titled Performance Evaluation dated 06/2010 revealed performance evaluations would be completed after 90 days of employment, yearly, and would be dated and signed by the employee acknowledging receiving the evaluation. In addition, review of annual in-service training documentation revealed no evidence the employee completed at least 12 hours of in-service training between 08/01/18 and 08/01/19. On 02/13/20 at 10:35 A.M. during an interview with the Assistant Director of Nursing (ADON) she reported she had not kept record of STNA in-service training/hours and could not produce documentation of STNA #120 completing at least 12 hours of in-service annually as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 24 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, record review and interview the facility failed to ensure monthly pharmacy reviews were completed for Resident #1 and failed to ensure a pharmacy recommendation for Resident #14 was acted upon timely. This affected two residents (#1 and #14) of five residents reviewed for unnecessary medication use. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, Alzheimer's disease, bipolar disorder, hypertension, dementia, anxiety, depression and suicidal ideations. The quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/17/2020 revealed Resident #1 had impaired cognition and required limited assistance with activities of daily living. Resident #1's physician's orders for February 2020 included an order for Lamotrigine (a medication used to treat bipolar disorder) 100 milligrams (mg) one tablet daily for bipolar disorder and Zoloft (an anti-depressant) 25 mg one tablet daily for depression. Review of Resident #1's medical record did not contain evidence of pharmacy reviews completed for March 2019, April 2019, May 2019, June 2019, July 2019 or November 2019. On 02/06/2020 at 2:43 P.M., Registered Nurse (RN) #115 confirmed the facility was unable to provide pharmacy recommendations or evidence the pharmacist had reviewed Resident #1's medical record and had no recommendations for these months as noted above. Review of the facility policy titled Pharmacy Services - Medication Monitoring, dated November 2018, revealed the consultant pharmacist would perform a comprehensive review of each resident's medical record and findings/recommendations would be reported to the physician and/or the Director of Nurses. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, delusional disorder, depression, convulsions, diabetes mellitus and chronic obstructive pulmonary disease. Review of quarterly MDS 3.0 assessment completed on 01/01/2020 revealed the resident had moderate cognitive impairment, hallucinations and delusions and required two person physical assistance for activities of daily living. The physician's orders for February 2020 included an order for Celexa (a medication used to treat depression) 20 mg daily. The medical record contained a pharmacy recommendation dated 01/17/2020 for a gradual reduction (GDR) for Celexa 20 mg to Celexa 10 mg, and a physician telephone order dated 01/20/2020 to discontinue Celexa 20 mg daily and start Celexa 10 mg daily. Review of the Medication Administration record from 01/20/2020 through 01/31/2020 and 02/01/2020 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 25 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few through 02/10/2020 revealed Resident #14 continued to receive Celexa 20 mg daily during this time period. Observation of the medication cards for Resident #14 revealed she only had Celexa 20 mg daily available for administration. On 02/10/2020 at 2:25 P.M. the Director of Nurses (DON) confirmed the pharmacist had recommended a GDR for Celexa 20 mg daily to Celexa 10 mg daily and the physician approved the GDR and ordered to discontinue Celexa 20 mg daily and start Celexa 10 mg daily; however the facility continued to administer Celexa 20 mg daily. Review of the facility policy titled Pharmacy Services - Medication Monitoring, dated November 2018 revealed the consultant pharmacist would perform a comprehensive review of each resident's medical record and findings/recommendations would be reported to the physician and/or the DON and the facility would follow the physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 26 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #14's psychoactive medication, Celexa was being administered at the most effective dose and as prescribed by the physician. This affected one resident (#14) of five residents reviewed for unnecessary medications. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, history of cerebrovascular accident with hemiplegia left side, obesity, delusional disorder, depression, convulsions, diabetes mellitus and chronic obstructive pulmonary disease. Review of quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/01/2020 revealed Resident #14 had moderate cognitive delay, hallucinations and delusions, and was totally dependent on staff for activities of daily living. Review of the physician's orders dated 01/20/2020 revealed to discontinue Celexa (a medication used to treat depression) 20 milligrams (mg) daily and start Celexa 10 mg daily. Review of the Medication Administration Record (MAR) from 01/21/2020 through 01/31/2020 and 02/01/2020 through 02/10/2020, revealed Celexa 20 mg was administered daily during this time period. Observation of the medication the facility provided for Resident #14 revealed Celexa 20 mg was being provided. Licensed Practical Nurse (LPN) #105 confirmed on 02/10/2020 at 1:19 P.M. the facility did not have any Celexa 10 mg tablets for Resident #14. On 02/10/2020 at 2:25 P.M. during an interview with the Director of Nursing (DON), the DON confirmed the physician order on 01/20/2020 indicated he agreed with the gradual dose reduction and ordered to discontinue Celexa 20 mg daily and start administering Celexa 10 mg daily. The DON confirmed Resident #14 continued to receive Celexa 20 mg daily. Review of the facility policy titled Pharmacy Services, dated November 2018 revealed medications would be administered per physician order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 27 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0803 Level of Harm - Minimal harm or potential for actual harm 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 observation, menu review and staff interview the facility failed to ensure the written menu was followed. This had the potential to affect all 19 residents residing in the facility. Residents Affected - Many Findings include: Observation of the preparation of the ground chicken on 02/11/2020 at 11:00 A.M. revealed [NAME] #106 placed 12.8 ounces of chicken in the food processor to chop. According to the menu 21.2 ounces were needed for four servings of chicken for the lunch meal. Observation of tray line at 11:33 A.M. revealed [NAME] #106 served residents a four-ounce serving of chicken. Review of the menu revealed residents on a mechanical soft diet should receive 5.3 ounces. The menu did not identify the serving size for the chicken for the other diets served in the facility. [NAME] #106 served other diets a four-once portion. Interview with Dietary Supervisor (DS) #118 on 02/11/2020 at 12:00 P.M. confirmed the menus did not specify the serving size for chicken for the regular diet, the no added salt diet, and the carbohydrate-controlled diet. The menu for mechanical soft diet called for 5.3 ounces of chicken not the 4 ounces that was served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 28 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #20 received fresh water daily as desired. This affected one resident (#20) of two sampled residents reviewed for hydration. Findings include: Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypothyroidism, major depressive disorder, gastro-esophageal reflux, generalized anxiety and vertigo. Review of Resident #20's plan of care, dated 05/14/2019 revealed she had the potential for alteration in hydration. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20's speech was clear, she understood, she understands and her cognition was intact. Resident #20 had no behaviors and did not reject care. Resident # 20 required extensive assistance of one staff for bed mobility, was dependent on two staff to transfer and required limited assistance of one staff to eat. Review of Resident #20's nutrition assessment dated [DATE] revealed her estimated fluid needs were 1400-1600 milliliters (ml)/per day. Interview with Resident #20 on 02/09/2020 at 3:58 P.M. revealed she did not get fresh ice water daily. Observation at the time of the interview revealed Resident #20 did not have a water cup in her room. Resident #20 stated she wanted fresh ice water in the morning and evening. Observation of Resident #20 on 02/12/2020 at 9:00 A.M. revealed she was in bed and had a cup of water dated 02/11/2020 on her over bed table, which did not contain ice. Resident #20 said she had water this morning, but night shift did not always pass water. Observation on 02/13/2020 at 9:59 A.M. revealed a water cup (without ice) on her over bed table dated 02/11/2020. Interview with State Tested Nursing Assistant (STNA) #120 on 02/13/2020 at 10:27 A.M. revealed residents were to receive a fresh cup every three days and ice water should be passed each shift. During a follow up interview with Resident #20 on 02/13/2020 at 10:28 A.M., the resident revealed she did not get fresh water each shift, her cup had no ice in it and it was 3/4 full with water. Resident #20 stated sometimes her water tasted stale/old. Interview with Licensed Practical Nurse (LPN) #105 on 02/13/2020 at 11:19 A.M. revealed ice water was to be passed once a day. Interview with corporate Registered Nurse (RN) on 02/13/2020 at 11:32 A.M. revealed the facility did not have a policy related to passing water or the use of foam cups for water delivery. The RN revealed it was the facility protocol to change the cup every three days. An additional interview at 4:48 P.M. revealed ice water should be passed on each shift and the cup should be changed daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 29 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on medical record review, menu review and staff interview the facility failed to provide therapeutic diets to residents as ordered. This affected two residents (#11 and #17) of 19 residents residing in the facility. Findings include: Review of Resident #11 and Resident #17's medical records revealed both residents had a current physician order for an 1800 calorie American Diabetic Association (ADA) diet. Review of the facility menu revealed the facility did not have a planned 1800 calorie ADA diet available to provide. Interview with Dietary Supervisor (DS) #118 on 02/11/2020 at 12:00 P.M. confirmed the facility did not have a menu for an 1800 calorie ADA diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 30 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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** 2. Review of Resident #13's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included epilepsy, intellectual disability, and depressive disorder and mood disorder. Review of Resident #13's quarterly MDS 3.0 assessment, dated 08/28/2019 revealed her speech was clear, she was rarely/never understood, usually understands, her short- and long-term memory was impaired, she did not have recall and her cognition was severely impaired. Resident #13 required extensive assistance of two staff for bed mobility, was dependent on two staff to transfer, she did not walk, she was dependent on two staff for locomotion and used a wheelchair for mobility. Resident #13 had no falls and no skin problems. Review of Resident #13's progress notes revealed on 02/03/2020 at 11:16 A.M. an order was obtaining for an x-ray of right lower leg and right foot related to bruising. Resident #13's medical record was silent as to what caused the resident's right leg and foot bruising. Interview with Corporate Registered Nurse #115 on 02/13/2020 at 4:38 P.M. confirmed there was no documentation in the medical record of any type of incident resulting in bruising. Based on observation, record review and interview the facility failed to ensure resident medical records were maintained in a complete and accurate manner. This affected two residents (#19 and #13) of 13 sampled residents. Findings include: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, anxiety, depression, malignant neoplasm of colon, malignant neoplasm of hepatic flexure and altered mental status. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment completed on 01/01/2020 revealed Resident #19 had moderate cognitive impairment. The physician's orders for February 2020 indicated Resident #19 was to receive a regular diet. Resident #19's care plan identified she was non-compliant at times with refusal of personal care and refusal of diet orders. The care plan also identified Resident #19 was at risk for choking, however refused a special diet. During observation of noon meal on 02/09/2020 at 12:03 P.M., Resident #19 was observed sitting at a table with two other residents. On 02/09/2020 at 12:21 P.M. Resident #19 was observed feeding herself a large spoon of ground chicken. Resident #19 choked on the chicken and State Tested Nursing Assistant (STNA) #116 took a napkin and assisted Resident #19 to expel a large bolus of chicken from her mouth on 02/09/2020 at 12:25 P.M. Resident #19 continued to eat her meal. On 02/09/2020 at 12:28 P.M. State Tested Nursing Assistant (STNA) #137 reported Resident #19 had choked on food before while eating and they just remove the food from her mouth and she is okay. Review of the nursing progress notes for Resident #19 from 02/09/2020 through 02/13/2020 did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 31 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 include information regarding choking in the dining room or the physician being notified of the choking. Level of Harm - Minimal harm or potential for actual harm On 02/13/2020 at 1:54 P.M. the Assistant Director of Nurses (ADON) confirmed there was no documentation in the medical record regarding Resident #19 choking on the chicken nor evidence the physician was notified. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 32 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review review, review of the facility Hospice contract and staff interview the facility failed to ensure the Hospice contract contained all of the required elements. This affected one resident (#7) of one resident reviewed for Hospice services. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE] and she received Hospice services. Review of the facility Hospice contract revealed it did not contain all required elements. The contract did not contain a provision stating Hospice assumed responsibility for determining the appropriate course of Hospice care. The contract did not include a statement the Long Term Care (LTC) facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by Hospice personnel, to the Hospice administrator immediately when the LTC facility becomes aware of the alleged violation. The contract did not included a delineation of the responsibilities of the Hospice and the LTC facility to provide bereavement services to LTC facility staff. The LTC facility did not designate a member of the facility's interdisciplinary team who was responsible for working with Hospice representatives to coordinate care to the resident provided by the LTC facility staff and Hospice staff. Interview with the Administrator on 02/13/2020 at 4:59 P.M. confirmed the Hospice contract did not contain the required elements and no facility staff were designated as responsible to work with Hospice representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 33 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure an effective antibiotic stewardship program was implemented to identify the appropriate use of antibiotics for Resident #20. This affected one resident (#20) of one resident reviewed for urinary tract infections. Residents Affected - Few Findings include: Review of Resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, hypothyroidism, major depressive disorder, gastro-esophageal reflux, generalized anxiety and vertigo. Review of Resident #20's Minimum Data Set (MDS) 3.0 assessment, dated 01/20/2020 revealed Resident #20's speech was clear, she understood, she understands and her cognition was intact. Resident #20 had no behaviors and did not reject care. Resident #20 required extensive assistance from one staff for bed mobility and was dependent on two staff to transfer. Resident #20 was always incontinent of bladder. Review of Resident #20's progress notes revealed on 12/19/19 the resident went to the emergency department (ED) due to complaints of lower left stomach pain. Resident #20 returned from the ED with a diagnosis of a urinary tract infect (UTI) and was placed on an antibiotic, Ciprofloxacin. On 02/01/2020 Resident #20 requested to go to the ED as she had cold chills. Resident #20 returned from the ED with a diagnose of a UTI and placed on an antibiotic, Levaquin. Record review revealed no urinalysis or urine reports to support Resident #20's had a UTI on 12/19/2019 or 02/01/2020. On 02/13/2020 at 4:00 P.M. upon surveyor request, he facility received copies of the urine testing preformed on 12/19/2019 and 02/01/2020 which revealed no bacterial growth in either specimen. Review of the revised McGeer criteria for infection surveillance checklist dated 02/01/2020 revealed the criteria had not been completed for either of Resident #20's possible UTI's or antibiotic use. Interview with Corporate Registered Nurse #115 on 02/13/2020 at 4:48 P.M. confirmed Resident #20 did not meet McGeer criteria for antibiotic treatment as the urine testing completed on both 12/19/19 and 02/01/20 revealed no evidence of bacterial growth. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 34 of 35 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 365867 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Run Healthcare of Portsmouth 1319 Spring 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 - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation and interview the facility failed to maintain the floor in the 100 hall and dining area in a clean and sanitary manner and to ensure the surface was safe for those who walk through this area. This had the potential to affect all 19 of 19 resident residing at the facility. Findings include: On 02/13/20 at 4:26 P.M. during tour of the facility with Registered Nurse (RN) #115 the flooring in the 100 Hall and part of the dining area was observed to be loose and in poor repair. Gaps between the laminate flooring up to two inches were noted, preventing cleaning due to exposure of the sub floor. The finish was coming off of some pieces of the laminate flooring exposing the particle board. Interview with RN #115 confirmed the above findings at the time of the observation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365867 If continuation sheet Page 35 of 35