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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365987 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 11/17/2023 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)