Carroll Healthcare Center Inc

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

records to the basement. She threw away a wooden desk and old vases. She had spent the last one to two weeks looking for the lock box/brown box.Review of facility documentation revealed there was a Quality Assurance and Performance Improvement (QAPI) plan dated [DATE REDACTED] that included the previous social service designee did not inform new social service designee there was a lockbox with items in it. The new social service designee did not know there was a lockbox in the office with items inside to keep track of it.

Social Service office cleaned out by corporate office. No list/log kept of what was in the lock box. Box had not been used/needed in five months. The action plan was the new lock box was to be bolted down.

Computerized log kept of when items go in/out, whose items go in/out, whose items are in there, date of when items go in/out, and who is putting in/taking out the items. Two keys given to social services designee and Administrator. Monthly audits of lockbox to ensure items on log are in lockbox. The QAPI plan did not include a new policy for the handling of resident items to be placed in the facility lockbox. There were no in-services to educate staff on the new process. The QAPI plan did not include verifying what is contained

in a wallet or purse with the resident and witness before locking in the lock box. Further, there were no guidelines on completing a thorough investigation. Interview with [DATE REDACTED] at 3:22 P.M. with RN #51 revealed

she started in April (2025) cleaning out a social service office for a new hire. Social Service #52 was going to split her time between two buildings and was leaving the office she used to the new Social Service designee. There was a lot of old paperwork in the office. Registered Nurse #51 was going through the cabinets, drawers, room and removing things. She finished cleaning on the last Tuesday in May ([DATE REDACTED]).

She had housekeeping come and remove the trash and take boxes to medical records. Administration #53 indicated she is the one that put the wallet in the lockbox. She said she did not look in the wallet to see what was in there. She revealed there was a checkbook in the lock box and papers under the check book.

She did not know what the papers were. Social Service #52 revealed the papers were legal paperwork that belonged to Resident #43 who passed away and her family did not come to pick them up.Interview on [DATE REDACTED] at 4:42 P.M. with Housekeeping #53 revealed she wrote the statement that day. She revealed she took a clear tall kitchen trash can size bag out. She said she could see through it and did not notice a metal box. She also took the bathroom trash out, and a wooden desk. She said she was handed two vases that

she saved in a closet in case a resident would need them. She took about 10 boxes with lids to medical records. Interview on [DATE REDACTED] at 5:12 P.M. with RN #51 revealed the last day she was cleaning the office she found the lock box in the back of a cabinet. She asked other staff that were in the office what the box was and they said it was a lock box for resident items. She placed the lockbox in a box of medical records that was filled almost to the top on one side. She doesn't recall taking the lockbox out of the medical record box.

She doesn't recall moving it or putting a lid on the medical record box that contained the metal box. She verified she looked through the boxes in medical records. On [DATE REDACTED] at 5:12 P.M. during interview, the Administrator verified there were no witness statements obtained from other staff that were in the office when the lock box was found or from housekeeping until the facility was asked for an investigation. The police were not called by the facility but by a family. The facility did not obtain the police report until asked for the investigation. The Administrator verified there were no statements from all staff that were in the office. The Administrator verified there was no evidence of the lock box being thrown away. The Administrator verified the facility lost items belonging to three residents that were to be safeguarded by the facility in a lock box.This deficiency represents non-compliance investigated under Master Complaint Number 2594375.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carroll Healthcare Center Inc

648 Longhorn Street Carrollton, OH 44615

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)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview and policy review, the facility failed to ensure infection control protocols were maintained when performing incontinence care. This affected one resident (#28) of one resident observed for incontinence care The facility identified nine always incontinent residents.Findings Include:Observation on 09/10/25 at 11:02 A.M. of incontinence care for Resident #28 with Certified Nurse Aide (CNA) #50 revealed the CNA washed her hands, and put a barrier on the overbed table. The CNA placed a basin of warm water on the table with towels, washcloths, shampoo and body wash, barrier cream and plastic trash bags. The CNA provided privacy with the use of a bath blanket to cover the resident's pelvic area. The CNA released the incontinence brief, soaked a washcloth with water and applied a body wash. The CNA cleansed the resident from front to back appropriately, changing areas on the washcloth with each wipe and repeated the process with rinse water. The CNA dried the resident with a towel and the resident rolled to her right side and the process was repeated using the professionally accepted standard technique. Once completed, the CNA applied barrier cream, rolled the resident on to her back and fastened her clean incontinence brief. The CNA then pulled the resident's covers up to her chest, handed her the television remote control and used the bed control to lower the bed to the lowest level and elevate the bed all before removing the gloves which she had provided incontinence care with to the resident.Review of the undated facility policy for Incontinence/Perennial care included to rinse the area with warm water, pat dry, apply a small amount of lotion or prescribed ointment. Remove gloves and wash hands then return resident to clean, comfortable position. Clean the resident unit, provide clean linen as needed and return items to

the appropriate place. At 11:18 AM interview with CNA #50 verified she did not remove her gloves after providing incontinence care before touching the resident's bed covers television remote control, and bed control. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2564038.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet