Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Calcutta Health Care Center during CMS and state inspections, most recent first.
A resident with dysphagia, prior aspiration pneumonitis, and on antiplatelet therapy experienced multiple episodes of dark brown/black emesis overnight. The assigned LPN notified the POA but did not obtain repeat VS, perform a documented physical assessment, notify the physician, or inspect the oral cavity, and proceeded to administer multiple oral “rise” medications despite ongoing emesis. Staff reports indicated several significant emesis events requiring gown and bed changes. Later that morning, another LPN found the resident poorly responsive with severe hypoxia, tachypnea, hypotension, and dark emesis, initiated oxygen, notified the physician and POA, and arranged transfer to the hospital, where the resident was diagnosed with aspiration pneumonia, GI bleed, and severe sepsis and subsequently died. The facility’s policies required thorough assessment, VS monitoring, and timely physician notification for acute condition changes, which were not followed.
A resident with multiple comorbidities, dysphagia, and a DNRCC-A order experienced repeated episodes of dark brown/black emesis overnight. An LPN notified the resident’s POA but did not obtain additional vital signs, did not perform or document further assessments, and did not notify the physician despite several significant emesis episodes requiring gown and bed changes. The LPN also administered the morning medication pass without documented reassessment. Later, another LPN found the resident unresponsive compared to baseline, with hypotension, tachycardia, tachypnea, very low O2 saturation, and dark emesis, then notified the physician and POA and arranged transfer to the ER. Facility leadership and the medical director stated that policy and standard practice required immediate vital sign monitoring and physician notification for such acute changes, which did not occur during the night.
A facility failed to follow physician orders for monitoring a resident's vital signs before administering Carvedilol. The resident, with multiple health conditions, had specific instructions to withhold the medication if certain vital sign thresholds were not met. However, records showed no documentation of these checks, and an RN confirmed not obtaining the required measurements before administration.
The facility failed to maintain adequate staffing ratios during the 4th quarter of 2023, affecting all 93 residents. A review of staffing data revealed low weekend staffing, with specific dates in October and December showing inadequate levels. Interviews confirmed awareness of the issue, although initial doubts about non-compliance were expressed.
The facility failed to maintain sanitary conditions in food preparation and storage, affecting 89 residents. Observations included unsealed and undated food items, expired products, and a dish machine not reaching sanitizing temperatures. Additionally, improper manual sanitization and handling of food with bare hands were noted, violating facility policies.
The facility failed to follow the menu and serve correct portion sizes for residents on a mechanical soft diet during lunch, affecting 13 residents. A dietary staff member used an incorrect scoop size, resulting in smaller portions of vegetables than specified. This discrepancy was confirmed by the dietary supervisor.
The facility failed to serve food and drink at appetizing temperatures, affecting 89 residents. Observations revealed that while hot food items were served warm, cold items like milk and dessert were too warm and unpalatable. The Dietary Supervisor and Corporate Chef confirmed the temperatures were inappropriate, with cold items exceeding the recommended 50 degrees F.
A resident with multiple medical conditions was denied the opportunity to attend a bingo activity because an LPN insisted on completing a dressing change first. The resident expressed a desire to participate in activities, but was upset when told she could not attend until the treatment was completed. Facility policy supports the resident's right to refuse treatment and participate in activities.
A resident with Alzheimer's and other conditions was not provided with required skin protection interventions, leading to a skin tear. Despite orders to apply geri-sleeves at all times, the resident was observed without them, and staff were unaware of the oversight.
A resident with a right-hand contracture did not receive assistance with applying her splint as per her care plan, which was necessary to maintain her range of motion. Despite being cognitively intact and dependent on assistance, the splint was not offered or applied, and staff were unaware of its location. The LPN later found the splint in the resident's closet, highlighting a lapse in care.
A facility failed to document the date and time a tube feeding product was hung for a resident with severe cognitive impairment and multiple medical conditions. The resident's care plan required enteral feeding, but during an observation, it was found that the feeding bag lacked proper documentation. An LPN confirmed the deficiency, which affected one resident and potentially impacted others receiving continuous enteral feedings.
A facility failed to ensure proper communication with a dialysis center and did not document weights as ordered for a resident receiving dialysis. The resident's medical record lacked proof of communication on several dates, and weights were not recorded as required. The facility's policy mandates following physician orders and documenting any deviations, which was not adhered to in this instance.
Failure to Assess and Respond to Repeated Emesis and Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and respond to an acute change in condition for a resident with significant aspiration and bleeding risks. The resident had a history of oral phase dysphagia, prior pneumonitis due to inhalation of food and vomit, protein-calorie malnutrition, asthma, atherosclerotic heart disease, and was on antiplatelet therapy with aspirin. The care plan identified risks for bruising/bleeding related to antiplatelet therapy and impaired air exchange related to asthma and aspiration pneumonia, with interventions including monitoring for abnormal bleeding, nausea and vomiting, shortness of breath, and changes in mental status, and obtaining and reporting vital signs per order. The resident was ordered vital signs every shift and had a DNRCC-A status, indicating standard care and life-extending measures up to the point of arrest. On the night in question, vital signs were documented once late in the evening, showing stable readings. At approximately 1:40 A.M., an LPN documented an episode of dark watery emesis and notified the resident’s daughter/POA, who, according to the note, did not want the resident sent to the ER at that time. There was no documentation of a physical assessment, repeat vital signs, or further monitoring in response to this change in condition. Interviews later revealed that the resident had multiple episodes of brown or black emesis throughout the night, described by staff as three to four episodes by the LPN and approximately six episodes by the CNA, including at least one large episode requiring a full bed change and placement of a towel by the resident’s mouth. Despite these repeated episodes and the resident’s known aspiration and bleeding risks, the LPN did not obtain additional vital signs, did not reassess the resident’s condition, did not inspect the oral cavity before giving medications, and did not notify the physician during the night. During the early morning “rise” medication pass window, the same LPN administered multiple oral medications, including aspirin and other routine medications, without documented assessment of the resident’s swallowing ability or airway status and without evidence of checking the oral cavity despite ongoing emesis. The LPN texted the primary care physician around the end of the shift and documented at 7:20 A.M. that the daughter was notified of more dark emesis and wanted to wait for the physician’s direction. At 7:49 A.M., the LPN documented additional dark emesis and that the physician was notified and ordered a CBC, but still no assessment findings or vital signs were recorded. Shortly thereafter, another LPN was called to the room when a lab technician could not obtain blood; this nurse found the resident poorly responsive with dark brown/black emesis, oxygen saturation of 67% on room air, respirations of 40, tachycardia, and hypotension. Supplemental oxygen was applied, the POA and physician were notified, and the resident was sent to the ER. Hospital records documented brown substance coating the resident’s mouth and lips, rales in the right lung, and diagnoses of aspiration pneumonia, GI bleed, and severe sepsis, with the death certificate listing severe sepsis and bilateral aspiration pneumonia as the immediate cause of death. The facility’s own policies required detailed assessment, vital sign monitoring, and timely physician notification for acute condition changes, which were not followed in this case.
Failure to Notify Physician and Adequately Assess Resident With Repeated Dark Emesis
Penalty
Summary
The deficiency involves the facility’s failure to timely and thoroughly notify the physician of a resident’s acute change in condition, which prevented appropriate assessment and authorization of treatment. The resident was admitted with multiple significant diagnoses, including weakness, difficulty walking, oral phase dysphagia, muscle wasting, protein-calorie malnutrition, pneumonitis due to inhalation of food and vomit, asthma, and a history of viral meningitis, and had a DNRCC-A order. On admission, she was alert and oriented, with clear lungs, no cough, and stable vital signs, and required a mechanically altered diet due to swallowing difficulties and a history of coughing or choking during meals or when swallowing medications. Her care plans included monitoring for abnormal bleeding, vomiting, sudden changes in mental status, and respiratory distress, and reporting such changes to the physician. During the night in question, the resident experienced multiple episodes of dark, brown/black, mucus-like emesis. A nursing progress note at 1:40 A.M. documented an episode of dark watery emesis and that the daughter/POA was notified and did not want the resident sent to the ER at that time, but there was no documentation that the physician was notified. CNA interview later revealed the resident had approximately six episodes of emesis, including one large episode requiring a full bed change and placement of a towel by the resident’s mouth. LPN staff confirmed the emesis was dark brown and significant enough to require gown changes, and that there were three to four episodes during the night. Despite these repeated episodes and the resident’s risk factors, the nurse did not obtain additional vital signs after the initial set taken late the prior evening, did not perform or document further assessments, and did not contact the physician during the night. The nurse instead contacted the POA around 2:00 A.M., described the emesis as “spitting up a little bit,” and suggested waiting for the physician to see the resident later, which the POA agreed to based on that description. The nurse later administered the morning “RISE” medications between approximately 5:00 A.M. and 6:00 A.M. without documenting a reassessment of the resident’s condition or oral cavity. Around the end of the night shift, the nurse sent a text to the primary care physician about brown emesis, resulting in an order for a CBC, but there was still no documented comprehensive assessment or vital sign monitoring at that time. When the day-shift LPN assessed the resident for a lab draw, she found the resident unresponsive compared to baseline, with dark brown/black emesis, hypotension, tachycardia, tachypnea, and an oxygen saturation of 67% on room air. She applied oxygen, notified the physician and POA, and arranged transfer to the ER. Interviews with the DON and Medical Director confirmed that standard practice and facility policy required immediate vital sign monitoring and physician notification for acute changes such as multiple brown/black emesis episodes, and that three to four such episodes would be considered critical. The facility did not conduct an internal investigation at the time, and documentation of the night’s events, including frequency of emesis and contacts with the POA, was incomplete.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure that physician orders were followed for monitoring a resident's vital signs before administering medication. Resident #24, who had multiple diagnoses including hemiplegia, atherosclerotic heart disease, and congestive heart failure, was prescribed Carvedilol with specific instructions to withhold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was below 55 beats per minute. However, a review of the medication administration records for February and March 2025 showed no documentation of blood pressure or heart rate checks prior to administering the medication. On March 5, 2025, an observation revealed that RN #200 administered Carvedilol to Resident #24 without obtaining the required blood pressure or heart rate measurements. Interviews with RN #200 and the Director of Nursing confirmed that the staff did not check these vital signs before administering the medication, as ordered. The facility's policy on medication administration emphasized that medications should be administered as prescribed, but this was not adhered to in the case of Resident #24.
Inadequate Staffing Ratios in 4th Quarter 2023
Penalty
Summary
The facility failed to maintain adequate staffing ratios during the 4th quarter of 2023, which had the potential to affect all 93 residents. A review of the Payroll-Based Journal Staffing Data Report (PBJ) and staffing schedules revealed that the facility had excessively low weekend staffing during this period. Specific dates in October and December 2023 were identified where staffing levels were notably inadequate, with ratios falling below acceptable standards. Interviews with the Director of Nursing and the Administrator confirmed awareness of the staffing issues, although the Director of Nursing was initially doubtful about non-compliance. The deficiency was identified through a detailed review of staffing schedules for nurses and State tested Nurse Aides (STNA) for the months of October, November, and December 2023. The facility's staffing tool indicated inadequate staffing levels on several specific dates, highlighting a pattern of insufficient weekend staffing. This deficiency was recognized as an incident of past non-compliance that was subsequently corrected prior to the survey conducted in June 2024.
Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation, storage, and service areas, potentially affecting 89 residents. During a kitchen tour, several issues were observed, including dirt and debris on the floor of the walk-in freezer, unsealed and undated food items, and expired sour cream and cottage cheese. Additionally, a fan in the dish machine room was blowing visible black dust fibers, and various food items in the reach-in cooler were undated, contrary to the facility's food storage policies. The dishwashing process was also found to be inadequate. The dish machine's sanitizing rinse temperature was consistently below the recommended 180 degrees Fahrenheit, with readings as low as 162 degrees. A test strip confirmed that the machine was not reaching the necessary sanitizing temperature. Despite this, the dietary aide continued to use the machine without monitoring the temperature gauges, which is against the facility's policy that requires immediate cessation of use if temperatures are inadequate. Furthermore, improper sanitization practices were observed in the manual washing of kitchen equipment. A dietary aide washed parts of a commercial blender in a three-compartment sink but did not leave them in the sanitizing solution for the required 60 seconds, as per the chemical company's instructions. Additionally, a dietary staff member was seen handling baked potatoes with bare hands during meal preparation, which was confirmed to be against the facility's hygiene protocols.
Menu and Portion Size Deficiency for Mechanical Soft Diets
Penalty
Summary
The facility failed to ensure that the menu was followed and correct portion sizes were served for residents on a mechanical soft diet during lunch on June 4, 2024. This deficiency affected 13 out of 14 residents identified as being on a mechanical soft diet, with the potential to impact 89 residents who received meals from the kitchen. The planned menu for the lunch included pizza pasta casserole, Prince [NAME] vegetable medley, and lemon strawberry fluff dessert, with specific portion sizes outlined for different diet consistencies. During the observation of the tray line, it was noted that a dietary staff member used a green-handled scoop, which provided only three and one-fourth ounces of carrots, instead of the required four ounces for the mechanical soft diets. This discrepancy was confirmed through interviews with the dietary staff member and the dietary supervisor, who acknowledged that the portion served was less than the specified amount on the spread sheet. The mechanical soft diets were supposed to receive the same vegetable portion as the regular diets, but this was not initially followed.
Failure to Serve Food and Drink at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at appetizing temperatures and acceptable palatability, potentially affecting 89 residents who received meals. During an observation, the temperature of food items on the tray line was recorded, with the pizza pasta casserole at 185 degrees F, vegetables at 174 degrees F, milk at 38 degrees F, and dessert at 35 degrees F. However, when a test tray was prepared and served, the temperatures had significantly decreased. The pizza pasta casserole was 143 degrees F, and the vegetables were 142 degrees F, both tasting warm and having good flavor. However, the milk was 63 degrees F and tasted warm and unpalatable, while the dessert was 61 degrees F, also tasting warm and unpalatable. The Dietary Supervisor and Corporate Chef confirmed the milk and dessert were too warm and unpalatable. The Corporate Chef stated that no cold item should exceed 50 degrees F at the point of service, confirming the milk at 63 degrees F was too warm and unpalatable, and the dessert should have been below 50 degrees F. The facility's recipe for the dessert included ingredients such as cream cheese and whipped topping, which require cooler temperatures to maintain palatability. The deficiency was identified through observation, interview, and review of the facility's recipe, highlighting a failure in maintaining appropriate food service temperatures.
Resident's Right to Attend Activity Denied Due to Treatment
Penalty
Summary
The facility failed to honor a resident's right to attend an activity program, specifically affecting Resident #251. The resident, who had a history of nondisplaced intertrochanteric fracture of the left femur, difficulty in walking, acute kidney failure, type two diabetes, muscle wasting, essential hypertension, and weakness, expressed a desire to participate in activities such as bingo. Despite this, the resident was prevented from attending a bingo session because a Licensed Practical Nurse (LPN) insisted on completing a dressing change before allowing the resident to participate in the activity. The incident occurred when the resident was uncooperative with treatment and refused to lay down for a dressing change. The LPN informed the resident that she could not attend the bingo activity until the dressing was completed, which upset the resident. Interviews with the resident, activities staff, and the LPN confirmed that the resident was denied participation in the activity due to the insistence on completing the medical treatment first. The facility's policy states that residents have the right to participate in decisions affecting their lives, and the Corporate Infection Control Preventionist acknowledged that the resident had the right to refuse treatment and attend activities.
Failure to Implement Skin Protection Interventions
Penalty
Summary
The facility failed to implement interventions and orders to protect a resident's skin from injuries, specifically for a resident with Alzheimer's disease, stage three chronic kidney disease, and protein-calorie malnutrition. The resident had a care plan indicating a potential for skin integrity alteration due to decreased physical mobility, with interventions including the application of geri-sleeves to both upper extremities at all times except during bathing and hygiene. Despite a physician's order to apply geri-sleeves and check skin integrity every shift, the resident was observed multiple times without the sleeves on either arm. On one occasion, a registered nurse was observed changing the dressing on a skin tear on the resident's right arm and only partially covering the forearm with the sleeve, leaving the bottom third uncovered. Interviews with the registered nurse and a licensed practical nurse revealed a lack of awareness regarding the absence of the geri-sleeves and no reports of the resident refusing to wear them. The facility's protocol for nursing assistants included instructions to apply geri-gloves as ordered, but this was not adhered to, resulting in a deficiency in care.
Failure to Apply Splint for Resident's Hand Contracture
Penalty
Summary
The facility failed to assist a resident with applying her splint for her right-hand contracture, which was necessary to maintain or improve her range of motion. The resident, who is cognitively intact, has a history of Alzheimer's Disease, spastic hemiplegic cerebral palsy, and neuropathy, and is dependent on assistance for dressing. Her care plan included the application of a digit splint to her right hand from 8:00 A.M. to 12:00 P.M. daily, with monitoring for proper positioning and signs of inflammation. However, observations revealed that the resident did not have the splint on during the specified times, and interviews with staff confirmed that the splint had not been offered or applied as ordered. The resident reported that she no longer receives therapy services and has not been asked if she would like to apply the splint. Staff interviews revealed confusion about the responsibility for applying the splint, with the LPN stating it was the responsibility of the STNAs, who reported not offering the splint and being unable to locate it. The LPN later confirmed that the splint was found in the resident's closet, indicating a lapse in following the care plan and ensuring the resident's needs were met.
Failure to Document Tube Feeding Administration
Penalty
Summary
The facility failed to ensure proper documentation of the time and date when a tube feeding product was hung for a resident receiving enteral nutrition. This deficiency was identified during an observation of a resident who was dependent on tube feeding due to severe cognitive impairment and multiple medical conditions, including cerebral palsy and dysphagia. The resident's care plan required that all nutrition and hydration be provided via a feeding tube, with specific instructions to monitor the feeding process and equipment. During the observation, it was noted that the bag of Nutren 2.0 tube feeding product was three-fourths full but lacked documentation of the date and time it was hung, as required by the facility's policy. An LPN confirmed the absence of this documentation and acknowledged that the bag should have been labeled with the date and time. This oversight affected one resident directly and had the potential to impact four additional residents receiving continuous enteral feedings.
Failure in Communication and Weight Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication and documentation between the facility and the dialysis center for a resident receiving dialysis. The medical record review revealed that there was no proof of written communication between the two facilities on several dates, despite the requirement for communication after each dialysis treatment. This lack of documentation was confirmed by the Corporate Infection Preventionist, who stated that the facility should have received documentation from the dialysis center after each treatment and should have contacted the center if the documentation was not received. Additionally, the facility did not adhere to the physician's order for obtaining the resident's weight three times a week in conjunction with dialysis treatments. The medical record showed missing weights on multiple dates, and there was no documented reason for these omissions in the progress notes. The Registered Nurse confirmed the existence of the order for weights and acknowledged the missing entries. The facility's policy stated that all physician orders should be followed as prescribed, and any deviations should be recorded in the resident's medical record, which was not done in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Calcutta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Orchards Of East Liverpool, The | 2.5 mi | ★★★★★ | 9 | 0 |
| Valley Oaks Care Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Stone Pear Pavilion | 5 mi | ★★★★★ | 18 | 0 |
| Beaver Valley Rehabilitation And Healthcare Center | 10.1 mi | ★★★★★ | 34 | 1 |
| Vista Center, The | 11.8 mi | ★★★★★ | 4 | 0 |
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