Inspection·July 25, 2019

F 0550 moderate assistance for bed, chair and toilet transfers. Level of Harm - Minimal harm or potential for actual harm Review of Resident #97's care plan for falls dated 04/19/19 revealed she was at risk for falls and a listed intervention dated 04/04/19 was for the resident's bathroom door to be locked at all times as the resident was to use her call light to ask for assistance. Residents Affected - Few Observation of Resident #97 on 07/23/19 at 2:19 P.M., 07/24/19 at 12:58 P.M., 07/25/19 at 8:31 A.M. and 07/25/19 at 2:11 P.M. revealed Resident #97 either laying in bed or seated up in her wheelchair. Resident #97 was not observed trying to get up to use the bathroom during any of the above observations. Interview on 07/23/19 at 2:19 P.M. and 07/25/19 at 2:11 P.M. with Resident #97 revealed she currently could not walk at all but could stand with staff and the assistance of a walker. Resident #97 verified the bathroom door had been locked after she fell and broke her leg March 2019. Resident #97 stated her roommate Resident #26 would also try to use the bathroom unassisted and would get up to find the door locked and sit back down and turn on her call light. Resident #97 shared while she was using a bed pan for toileting at times, she would hate to mess herself waiting for staff to come unlock the door to use the bathroom. Observation of Resident #97 and Resident #26's room on 07/24/19 at 4:30 P.M. revealed State Tested Nursing Assistant (STNA) #610 was passing water on the hallway. STNA #610 pulled out a key to unlock the bathroom door. Nursing staff entered the room and the door was closed for the provision of care. Interview with STNA #610 at the time of the observation confirmed the bathroom door was locked for both Resident #26 and Resident #97 due to their fall risk. Interview on 07/24/19 at 4:32 P.M. with Licensed Practical Nurse (LPN) #524 revealed the bathroom door was locked for Resident #97 as well as Resident #26 due to falls in the bathroom. LPN #524 confirmed Resident #97 was alert and oriented. LPN #524 stated all staff had keys to unlock the bathroom doors. Interview on 07/25/19 at 2:18 P.M. with LPN #524 and Registered Nurse (RN) #605 confirmed Resident #97 and Resident #26's bathroom door was locked due to falls and revealed Resident #97 had not tried to use the bathroom without assistance since her fall with fracture in March 2019. LPN #524 and RN #605 stated during a fall investigation, nursing staff would put an immediate intervention in place. An intervention such as a locked bathroom door required the Director of Nursing (DON) to approve it as some of the doors had to have a lock placed on them. Interview with the Director of Nursing (DON) on 07/24/19 at 3:14 P.M. confirmed the bathroom door in Resident #97 and Resident #26's room was locked to discourage both residents from using the bathroom unassisted. On 07/25/19 at 2:50 P.M. the DON verified Resident #97 could not get up on her own at this time and the locked bathroom door restricted her resident rights and dignity. The DON verified five residents (Resident #26, Resident #62, Resident #72, Resident #88 and Resident #97) had locked bathroom doors. Review of the undated facility policy on interventions for fall/skin incidents revealed listed interventions for falls in the bathroom included non skid socks, shoes with transfers, scheduled toileting, change scheduled toileting and skid strips to front of toilet. The policy did not suggest the locking of any doors as a means to prevent falls or injuries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 2 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physical restraints were comprehensively assessed. This affected one resident (Resident #37) of two residents reviewed for physical restraints and had the potential to affect 10 additional residents identified as by the facility as having devices that could be considered restraints (Residents #25, #41, #43, #52, #80, #87, #95, #99, #347 and #358). The facility census was 113 residents. Residents Affected - Few Findings include: 1. Review of Resident #37's medical record revealed an admission date of 06/02/18 and diagnoses including chronic obstructive pulmonary disease, muscle weakness, depression, dementia without behavioral disturbance and anxiety. Review of physician's orders revealed an order for a pummel cushion (a cushion with a foam piece that sticks upwards out of the seat of a wheelchair between a person's legs that prevents forward sliding in the wheelchair) dated 03/23/19. Review of an annual comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact but had fluctuating inattention and disorganized thinking. Resident #37 required supervision with one person physical for her activities of daily living. No restraints were coded on the assessment. Review of a nurses' note dated 03/23/19 revealed Resident #37 was found on the floor in front of her wheelchair by a housekeeper. As a result, Resident #37's gel cushion was discontinued and a pummel cushion was placed on the wheelchair. Review of a screen and seating assessment dated [DATE] revealed Resident #37 had no change in status and a recent discharge from therapy. The assessment mentioned a gel cushion was in place. Review of a screen and seating assessment dated [DATE] revealed a gel cushion was in place for Resident #37 with no change in status. Review of a screen and seating assessment dated [DATE] revealed head of bed elevated as positioning or restraint and no change in status. The assessment stated Resident #37 ambulated throughout the room independently and had a pummel cushion. The assessment did not evaluate if the pummel cushion had the potential to restrain the resident. No further documentation regarding the pummel cushion was available for review. A fall care plan dated 06/14/18 revealed Resident #37 was at risk for falls and listed the pummel cushion as part of the fall interventions effective 07/25/19. Interview and observation on 07/24/19 at 9:08 A.M. with Resident #37 revealed the pummel cushion was placed on her chair after one of her falls. Resident #37 was lying in bed during the interview; her wheelchair was off to the right of the bed with the pummel cushion in place. Interview on 07/25/19 at 10:15 A.M. with Director of Rehabilitation (DOR) #559 revealed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 3 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #37 had the pummel cushion in place due to multiple falls. DOR #559 stated Resident #37 was doing better but resistive to therapy. DOR #559 verified she completed the screen and seating assessment dated [DATE] and did not have further insight on if the pummel cushion had been assessed as a restraint or not. Interview on 07/25/19 at 10:33 A.M. with the Director of Nursing (DON) revealed he did not feel the pummel cushion was a restraint. On 07/25/19 at 11:16 A.M., the DON verified there was no documentation available indicating the facility assessed the pummel cushion as a potential restraint. Review of an undated policy on Restraint and Enabler Assessment and Application revealed the type of restraint or enabler used will be determined on physical therapy recommendations, physician recommendations, assessment tool results or appropriate sources. The least restrictive device will be applied first and evaluated for safety and effectiveness. If the quarterly restraint or enabler assessment indicated improvement in mobility or functioning the resident at that time could be considered for a restraint or enabler reduction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 4 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written notifications to the residents and the residents' representatives of the reason for transfer of residents to the hospital. This affected three (Residents #77, #97, and #107) of three residents reviewed for hospitalization. Findings include: 1. Review of Resident #77's medical record revealed diagnoses including stroke, diabetes mellitus, vascular dementia and a history of sepsis. A nursing note dated 07/18/19 at 3:41 A.M. indicated at 10:00 P.M. Resident #77 had a medium emesis (vomit). The nurse attempted to administer Zofran (for nausea) but Resident #77 refused. At 3:30 A.M. Resident #77 had another emesis that was large and yellow/green in color. Resident #77's blood pressure was 185/106, pulse was 114, and temperature was 98.0 degrees Fahrenheit (F). Resident #77's oxygen saturation level was 95% (percent) on room air. Resident #77's son requested she be sent to the emergency room for evaluation. A nursing note dated 07/18/19 at 6:57 A.M. indicated the emergency room reported Resident #77 was being admitted to the hospital for a urinary tract infection, severe sepsis, metabolic encephalopathy and high potassium levels. (Encephalopathy is a broad term used to describe abnormal brain function or brain structure.) There was no evidence a written notification was provided to Resident #77 and her representative regarding the transfer to the hospital and subsequent admission. On 07/25/19 at 2:52 P.M., Registered Nurse (RN) #609 verified the facility did not provide a written notification of discharge to Resident #77 and/or her representative when Resident #77 was sent and admitted to the hospital. 3. Review of a medical record revealed Resident #107 was admitted to the facility on [DATE] with the diagnoses of a pressure ulcer of the sacral region, adult failure to thrive, chronic obstructive pulmonary disease with exacerbation, diabetes, gout, hypertension, hyperglycemia, edema, protein-calorie malnutrition, viral hepatitis, colostomy, depression, extended spectrum beta lactamase resistance, neuromuscular dysfunction of the bladder, and abnormal vaginal and uterine bleeding. The resident was sent out to the hospital on [DATE]. Review of the closed medical record revealed Resident #107 or the resident's legal representative was not given written notification of the reason for discharge. An interview on 07/25/19 at 3:10 P.M. Licensed Practical Nurse (LPN) #560 indicated the facility did not send out a written notice of the reason for discharge to the resident or family. 2. Review of Resident #97's medical record revealed an admission date of 02/27/13 and diagnoses including congestive heart failure, chronic pain, adult failure to thrive, edema and protein-calorie malnutrition. Review of a discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #97's memory was intact, and Resident #97 required extensive assistance with bed mobility and transfers. Review of a nurses' note dated 03/31/19 revealed Resident #97 fell in the bathroom while transferring herself to the toilet and was sent to the hospital for evaluation. Further review of the medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 5 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few record revealed a bed hold notice was provided, and the Long-Term Care Ombudsman (LTCO) was notified of Resident #97's transfer to the hospital. The record did not indicate Resident #97 was provided with a written notification of the transfer. Review of a nurses' note dated 06/15/19 revealed Resident #97 had shortness of breath and felt her heart was racing. Resident #97 was sent to the emergency room for evaluation. Further review of the medical record revealed a bed hold notice was provided, and the LTCO was notified of Resident #97's transfer to the hospital. The record did not indicate Resident #97 was provided with a written notification of the transfer. Review of a nurses' note dated 06/30/19 revealed Resident #97 had labored breathing and was sent to the hospital for further evaluation. Further review of the medical record revealed a bed hold notice was provided, and the LTCO was notified of Resident #97's transfer to the hospital. The record did not indicate Resident #97 was provided with a written notification of the transfer. An interview with RN #600 on 07/25/19 at 5:20 P.M. verified the facility had not provided Resident #97 with written notification of transfer to the hospital on [DATE], 06/15/19 and 06/30/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 6 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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, resident and staff interview, the facility failed to administer a treatment to Resident #33 as ordered. This affected one resident (Resident #33) of four reviewed for non-pressure skin conditions. Residents Affected - Few Finding include: Review of the medical record review revealed Resident #33 was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, osteoporosis, atria fibrillation, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, edema, vitamin D deficiency, rheumatoid arthritis, dysphagia, history of falling, pseudo bulbar affect, major depressive disorder, peripheral vascular disease, and Alzheimer's disease. Review on the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #33 had intact cognition, required extensive assistance of one staff member for eating and did not have a weight loss. Observation on 07/22/19 at 1:54 P.M. and throughout the survey Resident #33 had dry, red peeling skin around her mouth and nose. An interview on 07/24/19 at 2:56 P.M. Licensed Practical Nurse (LPN) #524 indicated the staff used soap and water to Resident #33 face, no special soap or cream. She indicated the nursing assistants washed the residents face, not the nurses. She then looked at the order and stated the resident got Dial (antibacterial) soap to her face. An interview on 07/24/19 at 3:05 P.M. State Tested Nursing Assistant (STNA) #543 indicated they just washed Resident #33 face with the house soap and water. She stated there were a few residents that got special soap from the nurses, but Resident #33 was not one of them. An interview on 07/25/19 at 9:00 A.M. LPN #528 indicated the nursing assistants use the Dial soap on Resident #33, and the nurses would document it on the treatment records. An interview on 07/25/19 at 9:37 A.M. Resident #33 indicated she had a shower this morning, and the staff did not use Dial soap on her face. She stated she does not remember the last time they used Dial soap on her face. Review of a physician's order dated 12/27/18 revealed Resident #33 had an order for her face to be washed with Dial soap daily in the morning for the red, dry patches on her face. Review of the nursing assistant [NAME] revealed Resident #33 was to have her face washed with Dial soap. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 7 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and staff interview, the facility failed to implement physician orders for pressure ulcer prevention and treatment for one (Resident #358) of five residents reviewed for pressure ulcers. The facility census was 113. Residents Affected - Few Findings include: Review of Resident #358's medical record revealed an admission date of 07/13/19 with diagnoses including a malignant neoplasm of the brain, memory deficit following a stroke, low back pain and urinary tract infection. Skin and wound evaluations dated 07/13/19 and 07/23/19 indicated Resident #358 had unstageable pressure injuries (ulcers with obscured full-thickness skin and tissue loss) on the coccyx, left buttock and right buttock. a). On 07/13/19 an order was written for a gel cushion when out of bed. An acute care plan indicated Resident #358 was to have a ROHO cushion (a cushion to decrease the amount of pressure on the sitting area through a patented technology of interconnected neoprene air cells that increase and decrease in air volume to match an individuals contours) when out of bed. On 07/22/19 at 10:27 A.M., Resident #358 was observed sitting in a high back wheelchair in his room. On 07/24/19 at 8:34 A.M., 9:25 A.M., 9:28 A.M., 9:30 A.M., 10:11 A.M., 10:22 A.M., 10:26 A.M., 10:29 A.M., 10:33 A.M., and 10:39 A.M., Resident #358 was observed sitting in his wheelchair. On 07/25/19 at 9:40 A.M., 10:06 A.M. and 10:40 A.M., Resident #358 was observed sitting in his room in his wheelchair. On 07/25/19 at 11:11 A.M., State Tested Nursing Assistant (STNA) #615 looked at an electronic tablet at the desk and stated Resident #358 was supposed to have a gel cushion. Prior to answering what type of cushion Resident #358 was supposed to have, she asked STNA #532. STNA #532 looked at the nurse aide book and stated Resident #358 was supposed to have a ROHO cushion. At 11:15 A.M., Resident #358's cushion was observed with STNA #532 and Registered Nurse (RN) #609 who stated the cushion was a ROHO cushion. On 07/25/19 at 12:30 P.M., Licensed Practical Nurse (LPN) #560 verified Resident #358 had a physician order for a gel cushion and the cushion in his chair was changed to a gel cushion after the discrepancy was brought to staff's attention. b). On 07/17/19, an order was written to limit seating to three times a day no longer than 60-minute intervals. On 07/24/19 at 8:34 A.M., 9:25 A.M., 9:28 A.M., 9:30 A.M., 10:11 A.M., 10:22 A.M., 10:26 A.M., 10:29 A.M., 10:33 A.M., and 10:39 A.M., Resident #358 was observed sitting in his wheelchair. On 07/24/19 at 10:45 A.M., LPN #520 verified Resident #358 had a physician's order to limit his time in the chair to one hour three times a day. LPN #520 stated Resident #358 usually received therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 8 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm for about 1/2 hour. Sometimes therapy informed nurses when Resident #358 returned to his room and sometimes they did not. On 07/24/19 at 2:53 P.M., STNA #626 stated she was not aware of any restriction to the time Resident #358 was permitted to be up in the chair. Residents Affected - Few On 07/25/19 at 12:30 P.M., LPN #560 stated the order to limit Resident #358's time up in the chair for one hour three times a day was ordered due to wounds. c). On 07/17/19, an order was written for Prevalon boots (keeps the heel off the mattress to relieve pressure for individuals spending a lot of time in bed) to both lower extremities at all times. On 07/24/19 at 8:34 A.M., 9:25 A.M., 9:28 A.M., 9:30 A.M., 10:11 A.M., 10:22 A.M., 10:26 A.M., 10:29 A.M., 10:33 A.M., and 10:39 A.M., Resident #358 was observed sitting in his wheelchair wearing shoes. On 07/25/19 at 9:40 A.M., 10:06 A.M. and 10:40 A.M., Resident #358 was observed sitting in his room in his wheelchair wearing tennis shoes. On 07/25/19 at 12:30 P.M., LPN #560 stated when Resident #358 was finished with therapy the Prevalon boots should be applied. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 9 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, medical record review, interview and review of information from the manufacturer of tube feed solution, the facility failed to administer tube feeding solution in a method which would reduce the risk of contamination. This affected one (Resident #76) of one resident reviewed for tube feedings. The facility identified six residents who received tube feedings. Findings include: Review of Resident #76's medical record revealed diagnoses including gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), stroke and difficulty swallowing. Resident #76 had a physician's order for Diabetisource AC (tube feeding supplement) to be administered through the feeding tube at 63 milliliters per hour (ml/hr) on a continuous basis. On 07/24/19 at 8:22 A.M., Resident #76 had a kangaroo bag (a disposable bag into which tube feed solution or water can be dispensed for delivery into the gastrostomy) with tube feed solution (type of solution not written on the bag) hanging on a pole with the tube feed pump. The bag was labeled 07/24/19 at 5:00 A.M., and it was running through the pump at 63 ml/hr. The bag was filled to the 1000 milliliter line. On 07/24/19 at 10:48 A.M., Licensed Practical Nurse (LPN) #520 stated night shift filled up the tube feeding bag from briks (cartons of tube feed solution). Night shift placed enough tube feed solution in the bags to last all day. LPN #520 stated she never had to mess with filling of the tube feed bag the entire 12 and a half hours she was scheduled. On 07/24/19 at 10:59 A.M., observations with LPN #520 revealed the facility had closed systems of Diabetisource AC available. LPN #520 revealed Resident #76's daughter had been providing the cartons of Diabetisource AC, but there were none left so the facility would begin using the closed systems on night shift on 07/25/19. On 07/24/19 at 3:53 P.M., Resident #76 had between 400 and 500 ml of tube feeding remaining in the kangaroo bag which was infusing. On 07/25/19 at 8:35 A.M., Resident #76 had a kangaroo bag hanging on the feeding pump labeled 07/25 at 3 A.M. The bag was full. The recommended times for tube feed solution to hang in a bag after being poured from its original container into a kangaroo bag was addressed with Registered Nurse (RN) #609. On 07/25/19 at 11:10 A.M., RN #609 stated the facility called the manufacturer of the tube feed solution and was told once it was poured into the bag it should hang a maximum of eight hours. Review of information from the manufacturer of the Diabetisource AC, titled Hang Time: Open and Closed Systems, revealed for a commercially sterile, liquid formula decanted from a can or brik-pak, an eight hour hang time was recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 10 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm Based on observation, medical record review, review of the facility's pain management protocol and staff interview, the facility failed to conduct a comprehensive pain assessment and provide interventions to prevent and/or alleviate pain for one resident (Resident #358). Actual Harm occurred for Resident #358 on 07/24/19 at 10:22 A.M. when Resident #358 was grimacing, fidgeting, twisting his trunk around, yelling repeatedly this is terrible, and pulling on the hemi-tray on his wheelchair. This affected one (Resident #358) of one residents reviewed for pain. All 113 residents were screened for signs of unrelieved pain. Residents Affected - Few Findings include: Review of Resident #358's medical record revealed an admission date of 07/13/19. Diagnoses included a malignant neoplasm of the brain, memory deficit following a stroke, low back pain, and urinary tract infection. Skin and wound evaluations dated 07/13/19 indicated Resident #358 had unstageable pressure injuries (ulcers with obscured full-thickness skin and tissue loss) on the coccyx, left buttock and right buttock. The admission nursing assessment indicated Resident #358 had moderate pain in the lower back, hips and both arms which affected sleep, mood, socialization, activities of daily living and physical activity/mobility. The nurse documented not applicable for information regarding what non-pharmacological interventions alleviated the pain, what aggravated the pain and what medications and modalities had been effective in managing his pain. Resident #358's pain tolerance goal on a scale of 1-10 for comfort was a one. Resident #358 had a physician order for Roxicodone 5 milligrams (mg), a narcotic pain medication, every four hours as needed for moderate to severe pain. On 07/16/19 an order was written for Morphine Sulfate 20 milligrams per milliliter (mg/ml), a narcotic pain medication: give 5 mg every three hours as needed for pain. On 07/17/19 an order was written to limit seating to three times a day no longer than 60-minute intervals. Review of Resident #358's July 2019 Medication Administration Record (MAR) indicated Morphine Sulfate was last administered 07/23/19 at 10:21 A.M., and Roxicodone was administered 07/24/19 at 5:49 A.M. On 07/24/19 at 8:34 A.M., Resident #358 was propelled into his room in his wheelchair by therapy who updated his wife on Resident #358's progress and the difference wearing shoes made. Resident #358 had a left hemi-tray on his wheelchair. The therapist reported other than Resident #358 stating the gait belt was a little uncomfortable he denied pain. At 9:25 A.M., Resident #358's wife continued to visit with Resident #358 sitting in the wheelchair while he ate breakfast. At 9:28 A.M., Resident #358's wife informed Resident #358 she was leaving and would return that afternoon. Resident #358 was wearing tennis shoes on both feet and had tubigrips (a multi-purpose tubular bandage designed to provide tissue support in treating strains, sprains, soft tissue injuries, general edema, post-burn scarring, joint effusions and ribcage injuries) on both arms. A mechanical lift sling was under Resident #358. At 9:30 A.M., Resident #358 was occasionally moaning out. When interviewed, Resident #358 stated he had pain all over, but he did not want pain medication at that time because he was not sure how much pain medication he had in his system and pain was part of the disease process. A prior request had been made to observe dressing changes to Resident #358's wounds. On 07/24/19 at 9:50 A.M., Licensed Practical Nurse (LPN) #560 stated Resident #358 usually experienced a lot of pain with movement and she planned to wait until after Resident #358 was medicated for pain prior to changing his dressings. LPN #560 stated Resident #358 last received his pain medication at around 5:50 A.M. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 11 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 0697 Level of Harm - Actual harm Residents Affected - Few On 07/24/19 at 10:11 A.M., Resident #358 remained in his wheelchair in his room and continued to moan. At 10:22 A.M., Resident #358 was sitting in his room in his wheelchair calling out repeatedly, This is terrible, this is terrible. and moving his trunk around. Resident #358 was grimacing and pulling at the hemi tray on his wheelchair. No staff were observed addressing the calling out and Resident #358 did not activate his call light. Resident #358 requested the surveyor tell someone he wanted something for pain. Registered Nurse (RN) #608 was observed sitting at the nursing station and was informed of Resident #358's request. RN #608 stated Resident #358's nurse was on break and should return at any time. At 10:26 A.M., Resident #358 was moaning louder and was able to be heard five rooms down on the same side of the hall. Resident #358 was attempting to move the tray on the wheelchair so he could get out of the wheelchair independently. Resident #358 was encouraged to wait on staff for safety reasons. Resident #358 stated he would like to get his head down. Resident #358 stated he thought it would help if he could lie down. On 07/24/19 at 10:29 A.M., LPN #520 arrived in Resident #358's room and asked Resident #358 if he was in pain. Resident #358 responded he was. When asked to rate the pain, Resident #358 responded about a 4 or 5 and described the pain as jagged. LPN #520 asked Resident #358 if he wanted a pain pill and he responded yes. After exiting Resident #358's room, LPN #520 stated she tried to get an increase in Resident #358's pain medicine on 07/23/19 but the doctor refused to increase the pain medication without the power of attorney's (POA) approval. The POA did not want Resident #358 to take the pain medication. LPN #520 was informed of Resident #358 stating he would like to lie down and of his behavior of attempting to get out of the wheelchair independently. LPN #520 walked down the hall and returned at 10:33 A.M. and administered medication. LPN #520 offered to get someone to assist Resident #358 to bed. Resident #358 responded it was okay and that she did not need to bother anybody. At 10:39 A.M., LPN #520 exited Resident #358's room and stated Resident #358 did not wish to go to bed. Safety concerns related to his behaviors were once again addressed with LPN #520 and she asked another staff member (unidentified) to find a nursing assistant and the mechanical lift. LPN #520 returned to Resident #358's room and told him staff were going to lay him down which he agreed to. LPN #520 monitored Resident #358 until other staff arrived in his room. Resident #358 was overheard moaning out and stating oh, this chair. On 07/24/19 at 10:45 A.M., LPN #520 verified Resident #358 had a physician's order to limit his time in the chair to one hour three times a day. LPN #520 stated Resident #358 usually received therapy for about a half hour. Sometimes therapy informed nurses when Resident #358 returned to his room and sometimes they did not. On 07/24/19 at 11:15 A.M. Resident #358 was observed lying in bed with his eyes closed with no signs of distress. On 07/24/19 at 2:53 P.M., State Tested Nursing Assistant (STNA) #626 stated she was not aware of any restriction to the time Resident #358 was permitted to be up in the chair. On 07/25/19 at 12:30 P.M., LPN #560 stated the order to limit Resident #358's time up in the chair for one hour three times a day was ordered due to wounds. On 07/25/19 at 4:00 P.M., RN #600 stated residents were assessed for pain during admission and then a minimum of every shift (twice a day) and with pain medication administration. RN #600 stated the doctor has refused to increase pain medication without Resident #358's wife's approval, and one time Resident #358's wife refused to have pain medication administered stating Resident #358 might just be bored. RN #600 verified the admission assessment was not comprehensive regarding alleviating or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 12 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 0697 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete aggravating factors. At 4:35 P.M., RN #600 stated she interviewed Resident #358 about his pain and he reported rest and repositioning helped alleviate his pain and movement aggravated the pain. RN #600 stated Resident #358 told her the prescribed pain medication was effective in managing his pain. Review of the facility's pain management protocol indicated staff were to assess factors that may cause pain and administer analgesics as prescribed to prevent severe pain from reoccurring and prophylactically prior to activities associated with discomfort such as therapy, consider around the clock basis for administration of analgesics for continual pain as ordered by attending physician when necessary to meet resident's needs, provide individualized non-pharmacologic interventions such as, but not limited to, position change. Event ID: Facility ID: 365987 If continuation sheet Page 13 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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. 2. Review of Resident #10 revealed an admission date of 01/21/14 with diagnoses including dementia, hypertension, Alzheimer's disease, heart failure, peripheral vascular disease, depression, anxiety, atrial fibrillation, osteoporosis, gastro-esophageal reflux disease, hyperlipidemia, Vitamin D deficiency, chronic obstructive pulmonary disease, sinusitis and cerebrovascular disease. Review of the 04/08/19 significant change Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making and medications included antianxiety, antidepressant, anticoagulant and diuretic. A pharmacy recommendation on 03/20/19 revealed the resident had been on Floraster, a probiotic, for at least two years. The recommendation stated Would you please evaluate the continued need for this medication and consider discontinuing, if clinically relevant? The physician disagreed by just saying don't. Interview 07/25/19 at 11:23 A.M. with RN #609 revealed the physician did not give rationale when disagreeing with the 03/20/19 pharmacy recommendation. Based on medical record review and interview, the facility failed to ensure a pharmacist conducted a review of every resident's drug regimen on a monthly basis and failed to ensure physicians provided a rationale for declining a pharmacist's recommendation. This affected two (Residents #10 and #77) of six residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #77's medical record revealed diagnoses including stroke, hypertension, type 2 diabetes mellitus, peripheral vascular disease, hyperlipidemia, vascular dementia, depression, chronic kidney disease, adult failure to thrive, atrial fibrillation, and chronic obstructive pulmonary disease. There were no pharmacist recommendations in the medical record for June 2019. Review of a list of residents with medication regimen reviews conducted in June 2019 revealed Resident #77's name was not included on the list. On 07/25/19 at 3:07 P.M., Registered Nurse (RN) #600 verified the pharmacist did not review Resident #77's medications in June 2019. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 14 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 medical record review and interview, the facility failed to ensure medical necessity of an anti-anxiety medication ordered for one (Resident #76) of six residents reviewed for unnecessary medications. The facility census was 113. Findings include: Review of Resident #76's medical record revealed an admission date of 04/18/19. Diagnoses included chronic obstructive pulmonary disease, stroke and dementia. An admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #76 was rarely/never able to make himself understood and rarely/never understood others. Resident #76 was assessed with short and long term memory problems and severely impaired cognitive skills for daily decision making. During a monthly medication review conducted 04/25/19, the pharmacist addressed Resident #76's order for Ativan (anti-anxiety) to be administered on an as necessary basis and requested the physician re-evaluate its use after 14 days. On 05/06/19, an area for the physician response revealed an order for Resident #76 to be evaluated by a psychiatrist who would assess the need for the Ativan. A psychiatrist's note dated 05/06/19 indicated Resident #76 was awake, alert, and sitting in the dining area. The note indicated Resident #76 appeared to be happy/content. Nursing reported Resident #76's speech was very limited but he laughed and smiled often. Resident #76 had not used the Ativan ordered on an as necessary basis and there was no behavioral disturbance. The psychiatry note indicated the anti-depressant would continue but the Ativan ordered on an as necessary basis was to be discontinued. Review of nursing notes and Medication Administration Records (MAR) between 05/06/19 and 05/22/19 revealed no documentation of anxiety. On 05/22/19 an order was written for Ativan 0.5 milligram (mg) twice a day. A note by a certified nurse practitioner dated 05/30/19 indicated Resident #76 was alert but his psychological condition, including anxiousness, was unable to be assessed secondary to his lack of speech. The note indicated Resident #76 had generalized anxiety related to a stroke and the Ativan was to be continued. The note indicated Resident #76's use of Ativan was chronic and she had no plans to change the order. On 07/25/19 at 12:40 P.M., Licensed Practical Nurse (LPN) #560 was interviewed regarding the necessity of Ativan when the psychiatrist had recommended it be discontinued. No documentation of anxiety was located prior to the Ativan being ordered on 5/22/19 on a routine basis. Registered Nurse (RN) #600 was present and stated she would look into it. On 07/25/19 at 2:20 P.M., LPN #560 verified there was no documentation indicating Resident #76 exhibited signs of anxiety between 05/06/19 and 05/22/19 that justified the use of the Ativan. LPN #560 stated Resident #76's daughter had requested the Ativan because Resident #76 used it at home and that was how it was ordered. LPN #560 stated when Resident #76 was anxious he would chew on his gown and verified there was no documentation indicating Resident #76 exhibited those behaviors between the time the Ativan ordered on an as necessary basis was discontinued and the routine Ativan was ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 15 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 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 Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, meal ticket review, resident and staff interviews, the facility failed to honor food preferences. This affected two residents (Resident #16 and Resident #33) of six residents reviewed for nutrition. Findings Include: 1. Review of the medical record review revealed Resident #33 was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, osteoporosis, atrial fibrillation, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, edema, vitamin D deficiency, rheumatoid arthritis, dysphagia, history of falling, pseudo bulbar affect, major depressive disorder, peripheral vascular disease, and Alzheimer's disease. Review on the quarterly Minimum Data Set (MDS) 3.0 assessment revealed Resident #33 had intact cognition, required extensive assistance of one staff member for eating and did not have a weight loss. An observation on 07/23/19 at 8:23 A.M. Resident #33 was in the main dining not eating her meal. She received a breakfast sandwich with egg, cheese, bacon and toast, in which she did not eat. Review of her meal ticket dated 07/23/19 revealed Resident #33 disliked eggs and fried foods. An interview on 07/24/19 at 8:44 A.M. State tested Nursing Assistant (STNA) #617 verified Resident #33 received eggs when her meal ticket indicated she did not like eggs. Review of the Patient Diet Preference Sheet revealed Resident #33 disliked eggs. 2. A medical record review revealed Resident #16 was admitted to the facility on [DATE] with the diagnoses of low back pain, muscle weakness, hypertension, pacemaker, diabetes, glaucoma, history of falling, osteoporosis, constipation, and dysphagia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #16 had moderately impaired cognition, required extensive assistance of one staff member for eating, was on a mechanically altered diet, and did not have a weight loss. An observation on 07/23/19 at 8:30 A.M. Resident #16 was being assisted to eat in the assisted dining room. The resident was served scrambled eggs, pureed sausage, and cream of wheat cereal. She refused to eat her sausage and cream of wheat but ate her scrambled eggs. Review of the meal ticket dated 07/23/19 revealed Resident #16 disliked eggs. An interview on 07/23/19 at 8:35 A.M. STNA #532 verified Resident #16 received eggs when her meal ticket indicated she disliked eggs. An interview on 07/23/19 at 9:30 A.M. Resident #16 indicated when asked the reason she ate her eggs when she did not like them was because she didn't have anything else to eat and she was hungry. She indicated she does not like the sausage and she hates the cream of wheat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 16 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to ensure sanitary measures were followed during hydration pass and failed to maintain a comprehensive water management program to ensure residents were not exposed to Legionella. This had the potential to affect all 113 residents residing in the facility. Residents Affected - Many Findings include: 1. Observation 07/24/19 at 7:56 P.M. of State Tested Nurse Aide (STNA) #542 revealed she was passing ice and filling cups with water. STNA #542 was removing a Styrofoam cup from the inside of the ice chest and filling it with ice using a scoop. STNA #542 was then dropping the scoop into the chest onto the ice before she closed the lid to take the Styrofoam cups into the room. The Styrofoam cups had black magic marker writing on the outside of the cups. Review of the facility's undated Serving Drinking Water policy included to roll the cart to the outside entrance of the residents room. Place current date and residents names on the Styrofoam cup. Take the ice cart outside of room. Fill the Styrofoam cup with ice. Do not let the ice scoop touch the water pitcher/Styrofoam cup. Interview on 07/24/19 at the time of the observation with STNA #542 verified she was storing the ice scoop in the ice exposing the handle she touched to the ice that was going into the residents Styrofoam drinking cups. STNA #542 also verified the Styrofoam cups she wrote on were in the ice chest on the top of the ice creating an unsanitary environment. STNA #542 was passing ice to rooms 100-124 affecting Resident #56, Resident #15, Resident #2, Resident #19, Resident #61, Resident #98 Resident # 8 Resident # 97 Resident # 32 Resident # 73 Resident # 74 Resident # 74 Resident #60, Resident #36, Resident #307, Resident #18, Resident #3, Resident #25, Resident #25, Resident #72, Resident #45, Resident #29, Resident #42, Resident #101, Resident #31, Resident #62, Resident #70, Resident #34, Resident #102, Resident #91, Resident #26, Resident #47, Resident #48, Resident #52, Resident #64, Resident #57, Resident #78, Resident #49, Resident #9, Resident #87, Resident #69, Resident #88, Resident #39, Resident #37, Resident #71, Resident #86, Resident #89 and Resident #54. 2. On 07/22/19 during the onsite investigation, a request to review the facility current water management plan was made. The facility provided a six page, water management plan dated September 2017 and titled Calcutta Health Care Center Infections disease- Legionnaires Disease. The plan included Control Measures and Corrective Actions including low use areas of the water system (if not used longer than seven days) will be flushed to avoid stagnation risk. Sinks and showers will be checked quarterly for disinfectant levels. [NAME] Free Chlorine Checker will be used to monitor disinfectant levels. Free Chlorine Levels will be checked and documented. There was no documentation as to whether the facility had areas of non use for seven days and if so documentation they had been flushed. There was no evidence the sinks and showers had been checked quarterly per policy. Evidence revealed one sink had been checked a month with chlorine free levels ranging from 0.4 to 2.4. There was no documentation on the program form as to what acceptable parameters (control limits) would be of the Free Chlorine levels. The water management program was to be reviewed and revised as necessary. However, it did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 17 of 18 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 365987 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many include the frequency of which the program should be reviewed. There was no evidence of the program ever being reviewed or revised since 10/18/17. Review of the facility policy included under Special Considerations for Healthcare Facilities Our facility will test patients with healthcare associated pneumonia (pneumonia with onset greater or equal to hours after admission) for Legionnaires disease, or if any of the following. The policy and procedure did not include how many hours after admission with the onset of health-care associated pneumonia would testing for Legionnaires' disease take place. Interview 07/25/19 at 5:34 P.M. with the Administrator revealed they did not test all the sinks and showers quarterly, the level of sanitation acceptable parameters was not stated in the policy and the pneumonia policy did not identify the number of hours post admission healthcare associated pneumonia would be tested for Legionella. Registered Nurse (RN) #609 verified no residents with healthcare associated pneumonia were tested. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 18 of 18