Inspection·May 12, 2022

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews, and policy review the facility failed to ensure medication error rate was less than 5%. The medication error rate was 12%. This affected one (Resident #75) of seven residents observed during medication administration. The facility census was 104. Residents Affected - Few Findings include: Record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including legally blind and lagophthalmos of unspecified eye and eyelid. Review of Resident #75's orders dated 05/2022 revealed the resident was ordered Artificial tears solution 0.4% instill one drop in both eyes every two hours for dry eyes. May keep at beside. The Artificial tears were scheduled at midnight, 2:00 A.M., 4:00 A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., noon, 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00 P.M., and 10:00 P.M. The Lumify Solution 0.025% (decrease redness) was ordered to instill one drop in both eyes every six hours (midnight, 6:00 A.M., noon, and 6:00 P.M.) for red eyes. May keep at bedside. The Erythromycin ointment (antibiotic) 5 milligrams (mg) per gram (gm) was ordered to instill one application in both eyes every four (midnight, 4:00 A.M., 8:00 A.M., noon, 4:00 P.M., and 8:00 P.M.) related to unspecified lagophthalmos. May keep at bedside. Observation on 05/09/22 at 4:46 P.M., of Resident #75's medication administration with Licensed Practical Nurse (LPN) #3 revealed the residents eye drops and eye ointments were kept at the resident's bedside. LPN #3 first administered Artificial Tears Solution 0.4% two drops in both eyes. She then immediately opened the Lumify Solution 0.025% and applied one drop in both eyes, and without waiting she applied Erythromycin ointment 5 mg per gm a ribbon on both lower eyelids and moved the eyelids around with her gloved finger due to the resident was not able to blink or close his eyelids. Interview on 05/09/22 at 5:00 P.M., and 5:37 P.M., with LPN #3 verified she had administered two drops of Artificial tears solution in both eyes and the orders was for only one drop in each eye. The LPN #3 also verified she applied the Artificial tears solution, Lumify, and Erythromycin directly one after another without a waiting period. Interview on 05/11/22 at 12:37 P.M., with the Director of Nursing (DON) confirmed per the pharmacies policy the nurse should have waited 10 minutes between each eye drop/ointment administration. The surveyor requested drug information on the Lumify and Erythromycin; however, the DON reported the facility no longer had reference books and the nurses could either goggle the information or call the pharmacy for information on administration. The DON instructed the surveyor to use whatever information she could find on the drugs, but he would follow the pharmacy policy titled Eye Drop Administration. Review of facilities policy titled Eye Drop Administration, dated 11/2011, revealed if another drop of the same or different medication was prescribed for administration in the same eye at the same time, wait ten minutes, then repeat. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 2 of 7 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 05/12/2022 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and staff interview the facility failed to ensure laboratory tests were obtained as ordered for Resident #2. This affected one (Resident #2) of six residents reviewed for infection control. The facility census was 104. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, adult failure to thrive, diabetes, chronic kidney disease, pacemaker, generalized anxiety disorder, hypothyroidism, atherosclerotic heart disease, and protein calorie malnutrition. Review of the physician's order dated 01/29/22 revealed Resident #2 received an order to obtain a stool for Clostridium Difficile (C-Diff) due to diarrhea. Further review of the record revealed the stool was never obtained. Interview on 05/12/22 at 10:11 A.M., Registered Nurse #104 verified there was no stool sent to the laboratory for Resident #2 to be tested for C-Diff and there was never no order obtained to discontinue the stool specimen order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 3 of 7 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 05/12/2022 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview the facility failed to honor the food preference for Resident #80. This affected one resident (Resident #80) of two reviewed for food. The facility census was 104. Findings include: Review of the medical record revealed Resident #80 was admitted to the facility on [DATE]. Diagnoses included herpes zoster, spondylosis, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, diabetes, vascular dementia, chronic kidney disease, peripheral vascular disease, atrial fibrillation, enterocolitis due to clostridium difficile, congestive heart failure, and anemia. Review of the food preferences and diet history dated 09/23/21 revealed Resident #80 had a dislike for scrambles eggs. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had intact cognition. He required limited assistant with all activities of daily living. Observation on 05/10/22 at 9:17 A.M. revealed Resident #80 was served a breakfast sandwich with scrambled eggs on it. The staff offered him a substitution and he ate it. Review of the facility's menu revealed on 05/10/22 the facility served egg and cheese breakfast sandwiches for breakfast. Interview on 05/10/22 at 9:17 A.M. Resident #80 indicated he did not like scrambled eggs, and the kitchen sends them to him all the time. Review of the facility's menu revealed on 05/12/22 the facility served scrambled eggs with ham and cheese for breakfast. Observation on 05/12/22 at 8:30 A.M. revealed Resident #80 received scrambled eggs and sausage for breakfast. Interview on 05/12/22 at 8:32 A.M. State Tested Nursing Assistant (STNA) #50 verified Resident #80 received scrambled eggs, and his diet ticket indicated he disliked scrambled eggs. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 4 of 7 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 05/12/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy review the facility failed to ensure food items were stored appropriately in the nursing unit refrigerators to prevent contamination and/or spoilage. This affected two residents (Resident's #56 and #58) and had to potential to affect all residents who received oral intake. The facility identified four residents (Resident's #16, #31, #59, and #79) who had orders for nothing by mouth. The facility census was 104. Findings include: 1. On 05/10/22 at 9:34 A.M. observations of the nutrition room refrigerator revealed three unnamed and undated cartons of ice cream, one unnamed and undated box of waffles, and multiple unnamed and undated prepackaged meals. Interview on 05/10/22 at 9:34 A.M. with Registered Nurse (RN) #75 stated any food items in the nursing unit refrigerators should have a resident's name and the date the food was to be used or discarded by. RN #75 verified the three cartons of ice cream, the box of waffles, and the prepackaged meals should have had a resident's name and use by/discard date on them. 2. On 05/10/22 at 9:44 A.M. observations of the nutrition refrigerator on the orthopedic wing revealed a resealable bag of sliced cheese with a sell by date of 05/06/22, a resealable bag with two rolls with a sell by date of 04/25/22, and a resealable bag with sliced ham with a sell by date of 05/09/22; all items labeled for Resident #56. In addition, there was an undated container of ham, macaroni and cheese, and broccoli labeled for Resident #58. Interview on 05/10/22 at 9:44 A.M. with Licensed Practical Nurse (LPN) #5 verified Resident #56 had a resealable bag of cheese with a sell by date of 05/06/22, a resealable bag with two rolls with a sell by date of 04/25/22, and a resealable bag with sliced ham with a sell by date of 05/09/22. LPN #5 also verified the undated container of ham, macaroni and cheese, and broccoli labeled for Resident #58. LPN #5 stated all food in the nutrition refrigerators were supposed to be labeled with the resident's name and date food was supposed to be used by/discarded. LPN #5 also stated any undated food found in the nursing unit refrigerators was supposed to be disposed of immediately. Review of the facility policy titled Foods Brought by the Family/Visitors, dated December 2008, indicated perishable foods must be stored in a resealable container with tightly fitting lids in the refrigerator and containers would be labeled with the resident's name, the item, and the use by date. The nursing and/or any other staff assigned was responsible for discarding perishable foods on or before the use by date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 5 of 7 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 05/12/2022 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, review of the medical record, manufactures instructions, and staff interview the facility failed to clean the isolation room of Resident #80 with the appropriate disinfectant and failed to maintain appropriate infection control practice while performing tracheostomy care for Resident #75. This affected two residents (Resident's #75 and #80) of six residents reviewed for infection control. The facility census was 104. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE]. Diagnoses included herpes zoster, spondylosis, osteoarthritis, benign prostatic hyperplasia, obstructive and reflux uropathy, chronic obstructive pulmonary disease, moderate protein-calorie malnutrition, diabetes, vascular dementia, chronic kidney disease, peripheral vascular disease, atrial fibrillation, enterocolitis due to clostridium difficile, congestive heart failure, and anemia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #80 had intact cognition. He required limited assistant with all activities of daily living. Review of the nursing note dated 03/01/22 at 8:41 A.M. revealed the physician was made aware Resident #80 was having frequent loose, foul-smelling stools and an order was received to obtain a stool for clostridium difficile (C-Diff). Review of the facility's infection control log revealed Resident #80 tested positive for C-Diff on 03/01/22 and still had C-diff on 05/10/22. Review of the laboratory report dated 03/01/22 revealed Resident #80 tested positive for C-diff. Review of the laboratory report dated 03/16/22 revealed Resident #80 tested positive for C-diff. Review of the nursing note dated 03/17/22 at 10:50 A.M. revealed Resident #80 tested positive for C-Diff, the physician was notified, and Resident #80 was placed in contact isolation. Review of the laboratory report dated 04/24/22 revealed Resident #80 tested positive for C-diff. Review of the infection notes dated 04/26/22 at 8:33 A.M. revealed Resident #80 tested positive for C-Diff. The physician was notified and gave orders to continue Vancomycin 125 milligrams (antibiotic) three times daily. Interview on 05/10/22 at 8:45 A.M. Housekeeper #79 indicated the rooms were cleaned with peroxide disinfectant, and she held up a bottle of a yellow liquid labeled peroxide disinfectant. Observation on 05/10/22 at 9:15 A.M. Housekeeper #79 was observed in the room of Resident #80 in full personal protective equipment spraying the yellow solution in his room to clean. Interview on 05/10/22 at 2:30 P.M. Housekeeper #79 verified she used the peroxide disinfectant in all the isolation room even rooms with C-diff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 6 of 7 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 05/12/2022 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 - Few Interview on 05/10/22 at 3:00 P.M. Housekeeping Supervisor #85 stated they use the Peroxide Multi surface cleaner on the isolation and C-diff rooms. However, at 3:20 P.M. she indicated she misunderstood, and the staff was supposed to be use Virsept in the C-Diff rooms. Review of the manufacture's instruction for Peroxide Multi Surface Cleaner and Disinfectant received from Housekeeping Supervisor #85 revealed it was not effective on cleaning for C-diff and did not kill the organism. Review of the undated facility policy titled Cleaning and Disinfection of Environmental Surface, revealed environmental surfaces would be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Health and Safety Administration Bloodborne Pathogens Standard. In units with Clostridium difficile infection dilute solutions of 5.25 percent to 6.15 percent of hypochlorite, example dilute 1:10 dilution of household bleach would be used for routine environmental disinfectant. 2. Review of the medical record revealed Resident #75 was admitted to the facility 01/28/20. Diagnoses included chronic respiratory failure, convulsions, tracheostomy, dependent of respirator, gastrostomy, congenital malformation, asthma, malformation of corpus callosum, arthrogryposis multiplex congenita, severe intellectual disabilities, congenital malformation of peripheral vascular system, microcephaly, psychomotor deficit, spastic quadriplegic cerebral palsy, hypoxic ischemic encephalopathy, and hypothermia. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #75 had severely impaired cognition. He required total assistance for all activities of daily living. Further review of the assessment revealed Resident #75 required oxygen, suctioning, tracheostomy, and mechanical ventilator. Observation on 05/11/22 at 1:20 P.M. Licensed Practical Nurse (LPN) #42 and Registered Nurse (RN) #105 provided tracheostomy care to Resident #75. LPN # 42 gathered her equipment and set it on the three-tiered cart in the resident's room. The cart had his ventilator machine and ventilator vest machine on it. She never cleaned the top of the cart off or established a clean field. LPN #42 washed her hands, donned gloves, removed the old tracheostomy dressing, threw the soiled tracheostomy dressings and her gloves away. LPN #42 never washed her hands before donning a new pair of gloves. LPN #42 proceeded to change Resident #75's tracheostomy tie strap and clean his neck folds with a four-by-four dressings soaked in normal saline. LPN #42 placed the soiled four-by-four dressing and the soiled tracheostomy tie strap directly on the bed of Resident #75 on top his blankets. LPN #42 proceeded to change her gloves, did not wash her hands, donned a new pair of gloves and cleaned his ostomy site with cotton applicators. Interview on 05/11/22 at 2:08 P.M. LPN #42 verified she had not established a clean field, place the soiled dressings and tracheostomy tie strap on Resident #75's bed, and did not wash her hand after removing her soiled gloves before donning clean gloves. Review of the facility policy titled Trach Care, dated 08/05/19 revealed the purpose was to maintain airway patency by keeping the tracheostomy tube free of mucous, to maintain membrane and skin integrity, to help prevent infection and help provide psychological support. Although the supplies used in completing tracheostomy care are sterile the actual procedure when performed would follow the practice of a clean procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365987 If continuation sheet Page 7 of 7