Federal inspectors found the violation during an October complaint investigation at Carriage Inn of Steubenville. The resident, identified as Resident 7, suffers from late-onset Alzheimer's disease, diabetes, chronic kidney disease, and metastatic lung cancer that has spread to her brain. She takes diuretic medications and has severely impaired cognition.
Her care plan explicitly stated she had "the potential for fluid imbalance related to kidney disease and diuretic use." The goal was for her to "demonstrate adequate hydration as evidenced by laboratory values within normal range." Staff interventions included "the need to maintain water at the resident's bedside."
On October 14 at 2:31 PM, inspectors found the resident's room completely absent of any water source. There was no Styrofoam cup with lid and straw like those provided to other residents for ice water. Her room contained no cups or other beverages.
Certified Nursing Assistant 104 confirmed the violation when interviewed nine minutes later. She said she had given the resident ice water that morning when getting residents up for the day, but then contradicted herself by saying she hadn't helped the resident get up because "she was already up when she came on duty at 6:00 A.M."
The assistant couldn't locate any cup or beverage for the resident. She speculated that "maybe housekeeping had thrown it away when they were in the resident's room cleaning it earlier."
But housekeepers had cleaned other residents' rooms without discarding their water cups.
The assistant acknowledged that the resident's care plan required staff to maintain water at her bedside at all times.
The next morning brought a different violation of the same requirement. At 8:40 AM on October 15, inspectors found the resident lying in bed with a dated Styrofoam cup containing water sitting on her overbed table near the room's entry door, completely out of reach.
Certified Nursing Assistant 26 confirmed three minutes later that the resident's water "was not left in the resident's reach." With the overbed table positioned away from the bed, "the resident would not be able to reach her Styrofoam cup if she wanted or needed a drink."
The resident's medical complexity makes the hydration failures particularly concerning. Beyond her Alzheimer's disease and chronic kidney disease, she has diabetes and a history of pancreatic cancer. Her lung cancer has metastasized to her brain, and she has unsteadiness on her feet with a history of falls.
Her cognitive impairment is severe, though she has no communication issues and doesn't reject care. She requires partial to moderate assistance with transfers and walking.
The facility's own assessment noted she received diuretic medication during the seven-day assessment period, medications that increase fluid loss and make consistent hydration access even more critical.
Despite these documented medical needs and the specific care plan interventions, staff failed twice in two days to ensure the resident could access water when needed.
The violation demonstrates a breakdown in basic care coordination. On the first day, staff couldn't explain how a resident's water disappeared entirely from her room. On the second day, staff provided water but placed it where the resident couldn't reach it, rendering the gesture meaningless for someone with severe cognitive impairment and mobility limitations.
The inspection was conducted in response to a complaint filed under number 2630029. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
For a resident whose kidneys are already compromised and who takes medications that promote fluid loss, being left without accessible water represents more than simple neglect. It's a failure to provide the most basic requirement for human survival, particularly dangerous for someone who may not be able to advocate for herself or remember to request assistance.
The resident's cancer has already spread from her pancreas to her lungs and brain. Her diabetes and kidney disease require careful medical management. Her Alzheimer's disease has progressed to severe cognitive impairment.
None of these conditions improve when basic hydration needs go unmet.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carriage Inn of Steubenville from 2025-10-23 including all violations, facility responses, and corrective action plans.