Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Two residents with significant cognitive and physical impairments sustained thermal burns after spilling hot coffee on themselves. One resident with dementia and mobility limitations was handed two cups of hot coffee and tried to propel himself in a wheelchair, causing coffee to spill on his thighs and abdomen. Another resident with severe cognitive impairment and feeding assistance needs spilled coffee in the dining room and burned his arm, hip, and abdomen. Both incidents involved failure to provide adequate assistance and supervision during coffee service.
The facility failed to ensure residents receiving psychotropic meds were educated on the risks and benefits and failed to obtain informed consent before use. Four residents with diagnoses including dementia, anxiety, and depression had current orders for antipsychotic or antidepressant meds such as risperidone, venlafaxine, mirtazapine, trazodone, and sertraline, but the DON confirmed there was no documentation that the residents or their representatives were informed of the meds’ risks and side effects before administration.
Wet Blender Used for Pureed Food Preparation: During observation of pureed food prep, a dietary cook placed a robot coupe bowl with water droplets on the lid and inside the bowl onto the blender and began pouring roast beef into it for pureeing. The cook confirmed the equipment was still wet and stated it should be completely dry before use. Seven residents ordered pureed diets were identified as potentially affected.
Incomplete and missing baseline care plans were found for four residents. Two residents had only partial baseline documentation in the chart, with missing resident or representative signatures and missing care interventions, therapies, and advance discharge planning, while two other residents had no baseline care plan located in the record; staff stated only cover sheets or partial documents could be found, and the facility policy required the baseline care plan to be initiated on admission and kept accessible in the medical record.
A resident with epilepsy, severe cognitive impairment, and total dependence for care was sent to the ER for a change in condition, but the facility notified the secondary contact and his wife instead of the primary emergency contact and MPOA. The EMR stated both sons were to be called when the resident was sent out, and the primary contact reported he was not told about the breakthrough seizure or other updates, while staff records showed repeated communication with the secondary contact about care changes.
A resident received risperidone for dementia despite record review showing no hallucinations, delusions, or behavioral symptoms. The dose was increased, prior GDR attempts were noted, and the DON confirmed there was no signed consent and no documentation that the family had been educated on antipsychotic side effects.
Failure to Report Injury of Unknown Origin: A resident with vascular dementia, osteonecrosis, and prior patella fracture had ongoing L knee pain, bruising, effusion, and later a suspected patellar sleeve fracture with hemarthrosis. Staff and the DON assumed the findings were related to the resident’s chronic knee pain, but the cause was never definitively identified or investigated, and the injury was not reported to the State Survey Agency as an injury of unknown origin.
Failure to investigate unexplained bruising and a suspected patella fracture. A resident with dementia, osteonecrosis, and ongoing L knee pain developed purple bruising from the inner thigh to the knee and later was found by ortho to have a patellar sleeve fracture with hemarthrosis; the resident denied trauma or a fall. The DON said he spoke with the resident, an aide, and a nurse, but the facility did not document a formal investigation or fully determine whether the injuries were of unknown origin.
A resident with severe cognitive impairment, dependence for all personal care, and a colostomy had recurrent UTIs, including multiple E. coli-ESBL infections. During observed peri-care, CNAs used improper wiping technique, reused the same wipe on the front peri area, failed to perform hand hygiene after glove removal, and handled the resident and equipment before cleaning their hands. The DON acknowledged the colostomy bag position could contribute to stool contamination, while the IP stated she did not trend the resident’s repeated UTIs or provide recent staff education on hand hygiene or peri-care.
Expired stock meds were found in a medication cart and medication room, and one open bottle of ferrous sulfate had no visible expiration date. An LPN stated she did not know who was responsible for monitoring stock meds in the cabinet. One resident on the ortho hall had an order for ferrous sulfate, while no residents on the unit were identified as receiving the expired vitamin B complex, lanthanum carbonate, or bisacodyl tablets.
A facility failed to honor residents’ rights to manage their financial affairs by using facility-connected staff as witnesses on personal funds authorization forms. Multiple residents’ forms were witnessed by the BOM or a prior BOM, including a resident who initialed that she wanted to manage her own funds and several residents whose representatives signed the authorizations.
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.
Inadequate Supervision During Coffee Service Resulted in Burn Injuries
Penalty
Summary
The facility failed to provide adequate assistance and supervision for two dependent residents during coffee service, resulting in preventable thermal burn injuries. One resident had diagnoses including Alzheimer's disease, dementia, chronic kidney disease, CHF, COPD, and edema, and was assessed to need physical assistance with ADLs, including meal set-up and wheelchair mobility. His care plan directed staff to assist him in his wheelchair, provide meal set-up, and have dietary staff deliver coffee to his room upon request, yet he was able to obtain and carry hot coffee himself. On 12/09/24, the resident spilled two cups of hot coffee while attempting to propel himself in his wheelchair, and the coffee burned his thighs and abdomen. The record documented red, blistered areas, later described as second degree burns, with wound care orders, pain medication, and ongoing treatment. The resident later stated that he had gone to the kitchen in his wheelchair and was handed two stacked 12-ounce Styrofoam cups of hot coffee, which collapsed as he tried to hold them and propel himself back to his room. A second resident had severe cognitive impairment, a stroke with right-sided impairment, aphasia, and required partial to moderate assistance with eating and was dependent for most other ADLs. On 02/06/25, while in the main dining room, he spilled coffee on himself and sustained burns to his right arm, right hip, and right abdomen. Nursing documented pain, redness, and blisters, and the physician ordered him to be a total feed with lids on all cups. The record also showed that he had been documented as dependent or requiring substantial assistance with eating around that time, yet he still had access to hot coffee that he spilled on himself.
Failure to Inform Residents and Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents receiving psychotropic medications were educated on the risks and benefits of those medications and failed to obtain informed consent from the resident and/or representative before use. This affected four residents reviewed for unnecessary medications, including residents with diagnoses such as Alzheimer’s disease, vascular dementia, generalized anxiety disorder, major depressive disorder, insomnia, and excoriation disorder. The record for one resident showed risperidone was increased from 0.25 mg twice daily to 0.5 mg twice daily for dementia, and the DON confirmed there was no documentation that the resident or responsible party was informed of the antipsychotic medication, including its risks and side effects, before administration. For another resident, the record showed venlafaxine HCL 75 mg daily for major depressive disorder, and the DON confirmed there was no documentation that the resident or responsible party was informed of the antidepressant medication and its risks and side effects before administration. Two additional residents had current orders for antidepressants, including mirtazapine, trazodone, and sertraline, and there was no evidence of education related to the risks of antidepressant use. The DON verified there was no documentation that these residents or their responsible parties were informed of the risks of antidepressant use prior to administration, and also confirmed the facility did not have a policy in place regarding consents or authorizations for psychotropic medication use.
Wet Blender Used for Pureed Food Preparation
Penalty
Summary
The facility failed to ensure the robot coupe blender was clean and dry before it was used to prepare pureed food for meal service. During observation of pureed food preparation, dietary cook #145 placed the robot coupe bowl onto the blender and water droplets were noted on the lid and inside the bowl. The cook then began pouring roast beef into the bowl to puree it and was stopped by the surveyor to verify the presence of water droplets in the bowl and on the lid. Dietary cook #145 confirmed there was still water in the bowl and on the lid and stated she was unsure who had put the bowl away while it was wet. She stated the bowl would have been washed after breakfast. The cook also verified that equipment should be completely dry prior to use and then removed the bowl to be run through the high temperature dishwasher. The report identified seven residents ordered pureed diets who could have been affected: Residents #5, #16, #21, #75, #81, #88, and #96.
Incomplete and Missing Baseline Care Plans
Penalty
Summary
The facility failed to ensure comprehensive baseline care plans were completed and maintained in the medical record for four residents reviewed. For Resident #51, admitted with diagnoses including a left femur fracture, osteoporosis, a lumbar vertebra fracture, seizures, a right heel pressure ulcer, urinary retention, and muscle wasting, the baseline care plan contained only a scanned face sheet and active physician orders, with no resident or representative signature and no documented care interventions, therapies, or advance discharge plan. For Resident #90, admitted with diagnoses including an artificial opening of the digestive tract, malignant neoplasm of the tongue, dysphagia, nausea and vomiting, and a history of cerebral infarction, the baseline care plan contained only a scanned face sheet, active physician orders, and PASRR, with no resident or representative signature and no documented care interventions or advance discharge plan. For Resident #4, admitted with diagnoses including metabolic encephalopathy, dysphagia, dementia, osteoporosis, protein-calorie malnutrition, atrial fibrillation, anemia, cardiomegaly, atherosclerosis of the aorta, insomnia, adult failure to thrive, thrombocytopenia, and lymphocytopenia, no baseline care plan could be located in the medical record. RN #196 later found only a cover sheet dated on admission with checkmarks for admitting plan of care orders, advance discharge plan, and PASRR, along with a statement that the baseline care plan was reviewed with the resident/family/representative; the form was signed by a nurse and the resident's representative, but the full baseline care plan was not available. For Resident #12, admitted with COPD, mild intermittent asthma, generalized anxiety disorder, schizoaffective disorder, intellectual disabilities, urinary retention, protein-calorie malnutrition, and allergic rhinitis, no baseline care plan could be located, and RN #118 stated only a cover sheet showing review of the baseline care plan was found. The facility policy stated the baseline care plan must be initiated for every resident upon admission and be accessible in the medical record or electronic health record.
Failure to Notify Primary Contact of Change in Condition
Penalty
Summary
The facility failed to notify the designated medical power of attorney and primary emergency contact of a change in condition for a resident with epilepsy, anoxic brain damage, hypertension, a stage three pressure injury, dementia with anxiety, colostomy status, and a history of UTIs. The resident’s most recent MDS showed a BIMS score of 3/15, indicating severe cognitive impairment, and dependence on staff for all personal care, toileting hygiene, dressing, bathing, transfers, and mobility in a wheelchair. The resident’s demographic record identified the eldest son as the primary emergency contact, responsible party, care conference person, and billing contact, while the EMR special instructions stated that both sons were to be called when the resident was sent to the hospital. A Change in Condition Evaluation form documented that an LPN notified the secondary contact, the younger son, and his wife when the resident was sent to the ER for a change in condition, but there was no evidence that the primary emergency contact was notified. Nursing progress notes also showed the secondary contact and his wife were notified of plan-of-care updates, including new PT orders for a tilt-in-space wheelchair and later use of a mechanical lift for all transfers. The primary emergency contact stated he was not notified of the resident’s recent ER transfer for a breakthrough seizure and said he was the resident’s medical power of attorney and should be notified first of changes or updates in her condition.
Inappropriate Antipsychotic Diagnosis and Missing Consent Documentation
Penalty
Summary
The facility failed to provide an appropriate diagnosis for Resident #11, who was receiving the antipsychotic medication risperidone. The resident was admitted with diagnoses including Alzheimer's disease, dementia, generalized anxiety, major depressive disorder, excoriation disorder, and localized edema. The MDS assessment showed a BIMS score of 11, indicating moderately impaired cognition, and documented no hallucinations, delusions, physical or verbal behaviors, or rejection of care. The assessment also indicated dementia and that the resident was receiving an antipsychotic medication. Review of the record showed risperidone was ordered for dementia, with the dose increased from 0.25 mg twice daily to 0.5 mg twice daily, and the MAR showed the higher dose was administered beginning on 06/09/26. The care plan noted the resident received antidepressant, antianxiety, and antipsychotic medications and referenced prior GDR attempts, including one that led to discontinuation of the medication and increased anxiety. A psychiatric progress note stated the resident was calm and cooperative with coherent baseline dementia and no hallucinations. The DON confirmed the resident was receiving risperidone and had a diagnosis of dementia, and also confirmed there was no signed consent and no documentation that the family had been educated on the side effects of the antipsychotic medication.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to identify and report injuries of unknown origin to the State Survey Agency for one resident who had vascular dementia, osteonecrosis, and a history of left patella fracture. The resident had repeated complaints of left knee pain, swelling, and later bruising from the left mid inner thigh to the knee. A left knee x-ray showed no acute fracture or dislocation but did show moderately severe DJD, and the resident was later sent to the hospital for uncontrolled left leg pain and returned after receiving a steroid injection. An elastic brace was ordered for left knee support, and the resident was later lowered to the floor during a transfer with no injuries noted. The resident continued to have left knee problems, including an orthopedic appointment for left knee OA and effusion with increased pain, a cortisone injection, and a later ER visit for edema and pain. The resident returned with a diagnosis of suspected left patella fracture with joint effusion and was seen by orthopedics, where she denied any injury or fall. The orthopedic evaluation found a patellar sleeve fracture of the left knee and a large joint effusion with hemarthrosis, and the knee was aspirated for dark acute blood. The resident was moderately cognitively impaired with a BIMS score of 11 but was able to make herself understood and usually understand others. The DON stated he had not identified the bruising or fracture as an injury of unknown origin because the resident had been complaining of left knee pain and he assumed it was all related. The cause of the injuries was never definitively identified or investigated, and the injuries were not reported to the State Survey Agency. The facility policy defined an injury of unknown source as one whose source was not observed or could not be explained by the resident and was suspicious because of the extent, location, number, or timing of injuries, and required such injuries to be reported immediately to the Administrator or designee and then to the State Survey Agency.
Failure to Investigate Unexplained Bruising and Knee Fracture
Penalty
Summary
The facility failed to complete a thorough investigation after a resident with vascular dementia, osteonecrosis, and left knee pain was identified with scattered purple bruising from the left mid inner thigh to the knee and later with a suspected left patella fracture. The resident had complained of left knee pain for weeks, had multiple x-rays and hospital visits for worsening pain and swelling, and was later found to have a patellar sleeve fracture with a large joint effusion and hemarthrosis. The resident denied any fall or injury when seen by orthopedics and stated she had not had trauma to the left knee or leg. When the bruising was noted, the resident stated it was caused by staff not properly applying her knee brace. The DON later stated he spoke with the resident, who denied abuse, and had an aide demonstrate brace application, but this was not documented as part of a formal investigation. The DON also stated he spoke with the nurse who documented the bruising, but he did not document those interviews or expand the review to determine whether other staff had applied the brace incorrectly or whether any unrecorded accidents had occurred. The facility’s abuse policy defined an injury of unknown source as one that could not be explained by the resident or was suspicious based on the extent, location, number, or timing of injuries, and required immediate reporting and investigation. The Administrator stated he was not aware of the concern, and no completed investigation was provided for the bruising or the fracture as injuries of unknown origin.
Failure to Prevent Recurrent UTIs and Follow Hand Hygiene During Peri-Care
Penalty
Summary
The facility failed to prevent the recurrence of urinary tract infections for a resident with a history of recurrent UTIs, severe cognitive impairment, dependence on staff for all personal care, and diagnoses including dementia, anoxic brain damage, epilepsy, a stage three pressure injury, and a colostomy. The resident’s care plan identified a UTI/cystitis related to E. coli and ESBL and included monitoring for signs and symptoms of infection, encouraging fluids, and notifying the provider of changes. The medical record and infection control logs showed nine facility-acquired UTIs requiring antibiotics over the review period, including five cultures positive for E. coli-ESBL. During observation of incontinence care, two CNAs provided peri-care and changed the resident’s brief. One CNA used a single disposable wipe to cleanse the front peri area and continued using the same wipe in an upward motion, while the other CNA cleaned the back peri area and applied barrier cream. After care was completed, both CNAs removed their gloves but did not perform hand hygiene. One CNA then combed the resident’s hair and transported the resident out of the room in a wheelchair before hand hygiene was completed. The resident’s colostomy bag was also positioned over the pubic area under the brief, and the DON acknowledged that if the bag opening was laying over the pubic area and not thoroughly cleaned after emptying, it could increase the risk of cross contamination of stool into the peri-area. The infection preventionist and DON confirmed the resident had several UTIs in the past year and that a urology consult had been arranged for recurrent UTIs. The infection preventionist stated she reviewed monthly infection reports for trends by organism and location but did not trend individual residents for recurrence or frequency of infections and had not specifically reviewed this resident for frequent UTIs. She also stated she had not provided recent staff education in the past six months related to hand hygiene or peri-care. Facility policy required hand hygiene before and after personal care and after removing gloves and gown, and required female perineal care to be washed downward and front to back without reusing the same washcloth or water.
Expired and Unlabeled Stock Medications in Medication Storage
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles because the facility failed to ensure stock medication expiration dates were clearly legible and failed to remove expired stock medications. During observation of the ortho wing medication cart and medication room with an LPN, one open bottle of ferrous sulfate in the medication cart had no expiration date visible, and a cabinet contained one unopened bottle of vitamin B complex expired in March 2026, one unopened bottle of lanthanum carbonate expired in May 2026, and one unopened bottle of bisacodyl tablets expired in May 2026. The facility identified one resident on the ortho wing who had orders for ferrous sulfate and resided on the ortho hall, while no residents on the ortho wing were identified as receiving the expired vitamin B complex, lanthanum carbonate, or bisacodyl tablets. The LPN stated she did not know who was responsible for monitoring stock medications in the cabinet to ensure they were not expired.
Improper Witnessing of Resident Personal Funds Authorizations
Penalty
Summary
The facility failed to honor residents’ rights to manage their financial affairs by using a witness associated with the facility when obtaining authorization to handle residents’ personal funds. Review of personal funds accounts showed the facility used an authorization form that required a witness who was not connected with the facility or the Administrator, yet the witness on multiple residents’ forms was the Business Office Manager or a prior Business Office Manager. This affected six of seven residents whose accounts were reviewed, out of 44 residents identified as having personal funds accounts managed by the facility. Resident #13’s authorization, signed by the resident’s guardian, was witnessed by a prior Business Office Manager. Resident #44’s authorization, signed by the resident, showed the resident initialed that she wanted to manage her own funds, but the witness was a prior Business Office Manager; the Business Office Manager later acknowledged the form had been witnessed by facility staff and stated the resident had opened the account before her employment. Resident #110’s, #69’s, #93’s, and #38’s authorizations were each witnessed by the Business Office Manager, and the Business Office Manager verified she had witnessed those authorizations.
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 | ★★★★★ | 10 | 0 |
| Stone Pear Pavilion | 5 mi | ★★★★★ | 18 | 0 |
| Beaver Valley Rehabilitation And Healthcare Center | 10.1 mi | ★★★★★ | 27 | 0 |
| Vista Center, The | 11.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.