Health inspection·November 17, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, self-reported incident (SRI) review, and record review, the facility failed to ensure residents were free of misappropriation and the resident and/or family was notified of their funds being misappropriated. This affected Residents #3, #5, #6, #18, #21, 37, #41, #42, #43, #45, #51, #59, #60, #61, #63, #66, #101, #102 and #103, with the potential to affect all 64 residents who had their funds managed by the facility. The facility census was 100. Residents Affected - Some Findings include: Review of the SRI #239603 Misappropriation Investigation Statement by the Administrator revealed on 09/25/23 he was updated by Corporate Controller #207 that there was a finding of misappropriation with additional checks written by Receptionist #206 from the resident trust account without supporting documentation. He stated the checks had his signature, which were forged. On 09/27/23 the facility restored all the funds to the appropriate resident trust accounts. Review of the Police Report #202301071 dated 09/26/23 at 2:37 P.M. revealed the Administrator had contacted the police department as he felt there had been an internal theft. The Administrator stated he would be doing an additional follow-up investigation to determine exactly what the issue was. Review of the facility SRI #239603 submitted to the State Agency on 09/26/23 at 3:28 P.M. and completed by the Administrator revealed Receptionist/Office Manager (Receptionist) #206 misappropriated funds from the resident trust fund account in the amount of $11,865.00. The facility substantiated the allegation of misappropriation following their investigation. Review of the memo dated 09/27/23 from Corporate Controller #207 to the Administrator revealed on 09/22/23 Resident #41's family member called to discuss the balance of the resident's trust account. The family member believed there was an error in the amount and the Administrator believed that it was an error in accounting. On 09/25/23, the Administrator reached out to Corporate Controller #207 to have her review the account. Corporate Controller #207 began reviewing the account and stated there was a suspicion of misappropriation. A full investigation was initiated. Corporate Controller #207 investigated the timeframe from 01/01/23 through 08/31/23, the time periods where Receptionist #206 had overseen petty cash and resident trust accounts. She stated Receptionist #206 had forged the Administrator's signature on checks and would write the checks out to herself and deposit them in her personal checking account. She stated Receptionist #206 would state it was for reimbursement of personal items for the residents. Corporate Controller #207 stated based on her calculations and review of the accounts, Receptionist #206 had stolen $8,750.00 in check withdrawals and $3,115.00 in cash withdrawals for a total of $11,865.00. There was no mention of the facility updating residents or resident's representatives of misappropriation of resident funds. Page 1 of 4 365987 365987 11/17/2023 Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of an undated and untitled list of residents, revealed checks dated from 05/12/23 through 08/25/23 for personal items, clothing, shopping and spend down for Residents #3, #6, #14, #18, #21, #37, #42, #43, #45, #51, #59, #60, #61, #66, #101, #102, #103, made out to Receptionist #206 and signed by the Administrator. Review of an undated and untitled list of residents, revealed cash amounts withdrawn by Receptionist #206 from Residents #5, #13, #37, #43, #51, #60, #61, #63 and #66 trust accounts totaling $3,115.00 that had been reimbursed by the facility. Interview on 11/17/23 at 10:34 A.M. with the Administrator verified $11,865.00 had been misappropriated from Residents #3, #5, #6, #18, #21, 37, #41, #42, #41, #43, #45, #51, #59, #60, #61, #63, #66, #101, #102 and #103 trust accounts by Receptionist #206. He stated she would write a receipt for items without the resident signing it, deduct it from their trust accounts, and then remove the money from either the petty cash or write a check to herself and [NAME] his signature. He stated she would then deposit the checks into her personal account. He stated the facility had reimbursed the residents on 09/27/23 for all amounts she had taken. The Administrator stated the facility had not updated the residents or their representatives of the misappropriation from their resident trust accounts. The Administrator stated the facility had typed a notice on the bottom of the resident trust statements to call the facility biller if they had any questions regarding their accounts and balances. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, dated 2016, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of property. Administrator would orally notify the resident or the resident's representative, as appropriate, when a report has been made to the Ohio Department of Health. This deficiency represents non-compliance investigated under Complaint Number OH00147063. 365987 Page 2 of 4 365987 11/17/2023 Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, self-reported incident (SRI) review, and record review, the facility failed to implement the facility Abuse, Mistreatment, Neglect, Exploitation and Misappropriation policy and procedures to ensure residents and/or representatives were notified of misappropriation of resident funds. This affected 19 (Residents #3, #5, #6, #18, #21, 37, #41, #42, #43, #45, #51, #59, #60, #61, #63, #66, #101, #102 and #103) of 19 residents reviewed for misappropriation. The facility census was 100. Residents Affected - Some Findings include: Review of the SRI #239603 Misappropriation Investigation Statement by the Administrator on 9/25/23 revealed he was updated by Corporate Controller #207 that there was a finding of additional checks written by Receptionist #206 from the resident trust account without supporting documentation. He stated the checks had his signature, which were forged. On 09/27/23 the facility restored all the funds to the appropriate resident trust accounts. There was no mention of the facility updating residents or resident's representatives of misappropriation of resident funds. Review of the facility SRI #239603 submitted to the State Agency on 09/26/23 at 3:28 P.M. and completed by the Administrator revealed Receptionist/Office Manager (Receptionist) #206 misappropriated funds from the resident trust fund account in the amount of $11,865.00. The facility substantiated the allegation of misappropriation following their investigation. Review of the Police Report #202301071 dated 09/26/23 at 2:37 P.M. revealed the Administrator had contacted the police department as he felt there had been an internal theft. The Administrator stated he would be doing an additional follow-up investigation to determine exactly what the issue was. Review of the memo dated 09/27/23 from Corporate Controller #207 to the Administrator revealed on 09/22/23 Resident #41's family member called to discuss the balance of the resident's trust account. The family member believed there was an error in the amount and the Administrator believed that it was an error in accounting. On 09/25/23, the Administrator reached out to Corporate Controller #207 to have her review the account. Corporate Controller #207 reviewed the account and stated there was a suspicion of misappropriation. A full investigation was initiated. Corporate Controller #207 investigated the timeframe from 01/01/23 through 08/31/23, the time periods where Receptionist #206 had overseen petty cash and resident trust accounts. She stated Receptionist #206 had forged the Administrator's signature on checks and would write the checks out to herself and deposit them in her personal checking account. She stated Receptionist #206 would state it was for reimbursement of personal items for the residents. Corporate Controller #207 stated based on her calculations and review of the accounts, Receptionist #206 had stolen $8,750.00 in check withdrawals and $3,115.00 in cash withdrawals for a total of $11,865.00. There was no mention of the facility updating residents or resident's representatives of misappropriation of resident funds. Review of Resident Trust Statements dated 10/01/23 for Residents #3, #5, #6, #18, #21, 37, #41, #42, #43, #45, #51, #59, #60, #61, #63, #66, #101, #102 and #103 revealed a notice on the bottom stating if the resident of resident representative had any questions regarding their account activity or balance, they were to contact Facility Biller #208. The notice did not reveal the facility identified issues with misappropriation of the residents' funds. Interview on 11/17/23 at 10:34 A.M. with the Administrator verified $11,865.00 had been 365987 Page 3 of 4 365987 11/17/2023 Calcutta Health Care Center 48444 Bell School Road Calcutta, OH 43920

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some misappropriated from Residents #3, #5, #6, #18, #21, 37, #41, #42, #41, #43, #45, #51, #59, #60, #61, #63, #66, #101, #102 and #103 trust accounts by Receptionist #206. He stated she would write a receipt for items without the resident signing it, deduct it from their trust accounts, and then remove the money from either the petty cash or write a check to herself and [NAME] his signature. He stated she would then deposit the checks into her personal account. He stated the facility had reimbursed the residents on 09/27/23 for all amounts she had taken. The Administrator stated the facility had not updated the residents or their representatives of the misappropriation from their resident trust accounts. The Administrator stated the facility had typed a notice on the bottom of the resident trust statements to call the facility biller if they had any questions regarding their accounts and balances. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation and Misappropriation, dated 2016, revealed the Administrator would orally notify the resident or the resident's representative, as appropriate, when a report has been made to the Ohio Department of Health. 365987 Page 4 of 4