Inspection·May 4, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #142 was admitted to the facility on [DATE]. Diagnoses included intracerebral hemorrhage, hemiplegia, peripheral vascular disease, and chronic pain syndrome. Residents Affected - Few Review of the Five-day Medicare Minimum Data Set assessment dated [DATE] revealed Resident #142 had severely impaired cognition. She required extensive assistance of two staff members for bed mobility, dressing, toilet use and personal hygiene. Observation on 05/01/23 at 9:33 A.M. revealed Resident #142 was in bed and her touch pad call light was hanging up clipped to the call light outlet on the wall. An interview at 9:35 A.M. with Licensed Practical Nurse #178 verified Resident #142's call light was hanging up on the wall outlet and she was unable to reach it while laying in her bed. Review of the undated facility policy titled, Call Light, Use of, revealed the purpose was to respond promptly to resident's call for assistance and to ensure call system was in proper working order. When providing care to a resident, be sure to position the call light conveniently for the resident to use. Tell the resident where the call light was and show them how to use the call light. Be sure all call lights were placed within the reach of each resident. Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure Resident #18, who was highly visibly impaired and dependent on staff, was able to locate call light, and Resident #142's call light was within reach. This affected two residents (#18 and #142) of 16 residents screened for call lights. The facility census was 40. Findings include: 1. Review of medical record for Resident #18 revealed an admission date of 12/29/22 and pertinent diagnoses included cerebral infarction (stroke) due to thrombosis (blood clot) of right posterior cerebral (brain) artery, major depressive disorder, restless and agitation, and repeated falls. Review of care plan dated 12/29/22 revealed Resident #18 required limited to extensive assistance, had a potential risk for falls related to poor safety awareness and repeated falls, was blind related to cataracts. Interventions included explaining use of call light and assess ability to use as needed. Review of optometrist exam on 02/27/23 revealed Resident #18 was evaluated for decreased vision in the left and right eye, had decreased vision which affected both near and far vision, and the condition was constant and significant. The exam revealed Resident #18 had changed in retinal vascular (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 4 Event ID: 365579 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 365579 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 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)