The lockbox disappeared in late May when registered nurse #51 cleaned out a social service office for a new hire. She found the metal box in the back of a cabinet on her last day of cleaning and placed it inside a medical records box, but the lockbox vanished somewhere between the office and the basement storage area.
Nobody knew what was inside.
Administrator #53 had put a wallet in the lockbox without looking at its contents. She said there was also a checkbook and papers underneath it, but she didn't know what the papers were. Social Service #52 later revealed the documents were legal paperwork belonging to a deceased resident whose family never picked them up.
The facility's own quality assurance plan, written after the incident, acknowledged the fundamental problem: "The previous social service designee did not inform new social service designee there was a lockbox with items in it." The new social services worker "did not know there was a lockbox in the office with items inside to keep track of it."
No list existed of what was in the lockbox. No log tracked when items went in or out. The box hadn't been used in five months before it disappeared.
RN #51 spent one to two weeks looking for the missing lockbox, according to her interview with inspectors. She searched through boxes in the basement medical records area. She had thrown away a wooden desk and old vases during the cleanup. She had housekeeping remove trash and take about 10 boxes with lids to medical records.
Housekeeping #53 took out a clear kitchen-sized trash bag and said she could see through it but didn't notice a metal box inside. She also removed bathroom trash and saved two vases in a closet "in case a resident would need them."
The investigation revealed multiple failures in the cleanup process. RN #51 asked other staff in the office what the box was when she found it, and they told her it was for resident items. But she placed it in a medical records box that was "filled almost to the top on one side" and doesn't recall taking it out or putting a lid on the box.
The facility's response exposed more problems. The administrator verified that no witness statements were obtained from staff who were in the office when the lockbox was found. No statements were collected from housekeeping until inspectors demanded an investigation.
The police weren't called by the facility. Families called them.
The facility didn't obtain the police report until asked during the investigation. The administrator confirmed there were no statements from all staff who had been in the office, and there was no evidence the lockbox had been thrown away.
The facility's quality improvement plan, written after the loss, promised changes: a new lockbox would be bolted down, computerized logs would track all items going in and out, two keys would go to the social services designee and administrator, and monthly audits would verify items on the log matched what was in the box.
But the plan had gaps. It included no new policy for handling resident items. No training sessions were planned to educate staff on the new process. The plan didn't require verifying wallet or purse contents with residents and witnesses before locking items away. There were no guidelines for conducting thorough investigations when problems occurred.
The administrator verified the facility lost items belonging to three residents that were supposed to be safeguarded in the lockbox. The belongings included the wallet of unknown contents, a checkbook, and legal documents from a deceased resident.
Social Service #52 was splitting her time between two buildings and had left the office to a new social services designee. Corporate office had cleaned out the social service office, but no inventory was kept of the lockbox contents.
The box had sat unused for five months before the cleanup began. When it disappeared, staff spent weeks searching rather than immediately investigating how resident belongings could vanish from a secure storage system.
The families whose relatives' items were lost had to call police themselves. The facility that was entrusted with safeguarding their loved ones' possessions couldn't even document what had been lost, much less explain how it happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carroll Healthcare Center Inc from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Carroll Healthcare Center Inc
- Browse all OH nursing home inspections