Health inspection·March 5, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the medical record, interview with staff, and review of the facility policy, the facility failed to ensure physician orders were followed to adequately monitor and obtain a blood pressure and heart rate prior to the administration of medication for Resident #24. This affected one resident (Resident #24) of three residents reviewed for medication administration. Residents Affected - Few Findings included: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE]. Diagnoses included hemiplegia of right side following a cerebral infarction, aphasia, convulsions, atherosclerotic heart disease, hypertensive heart disease, chronic kidney disease, peripheral vascular disease, congestive heart failure, major depressive disorder, benign prostatic hyperplasia, generalized edema, gout, and insomnia. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #24 had moderately impaired cognition and he was nonverbal. Review of the March 2025 physician orders revealed Resident #24 had on order dated 08/02/22 for Carvedilol 6.25 milligram (mg) tablet with instructions to hold the medication if the residents systolic blood pressure was less than 110 millimeters of mercury (mmHg) or if the heart rate was less than 55 beats per minute. Review of the February 2025 medication administration record (MAR) revealed no documentation that Resident #24's blood pressure and heart rate were monitored or checked prior to the administration of Carvedilol 6.25 mg. Review of the March 2025 MAR revealed no documentation that Resident #24's blood pressure and heart rate were monitored or checked prior to the administration of Carvedilol 6.25 mg. Observation of medication administration on 03/05/25 at 9:00 A.M. revealed Registered Nurse (RN) #200 administered Carvedilol 6.25 mg to Resident #24 without obtaining a blood pressure or heart rate prior to the administration. On 03/05/25 at 9:05 A.M. an interview with RN #200 verified she had not checked the blood pressure or heart rate of Resident #24 prior to the administration of Carvedilol. On 03/05/25 at 12:30 P.M. an interview with the Director of Nursing confirmed the staff were not checking the blood pressure or heart rate of Resident #24 prior to the administration of the (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 2 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 03/05/2025 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)