Carriage Inn of Steubenville: Fall Prevention Failure - OH
Federal inspectors documented the finding on October 14, 2025, during a complaint investigation at the facility on St. Charles Drive. The resident was identified as a fall risk. Her plan of care called for Dycem, a thin non-slip material, to be placed in her wheelchair seat whenever she was up. It was not there.
Dycem works by creating friction between a cushion and a surface, or between a resident and a cushion, reducing the chance a person slides or shifts in ways that lead to falls. For a resident already flagged as a fall risk, its absence is not a minor oversight.
When inspectors arrived and observed the resident seated in her wheelchair, they asked CNA #104 to bring the resident back to her room so they could check whether the fall prevention measures were actually in place. The facility's Director of Nursing came to help. Together, the CNA and the DON used a gait belt to assist the resident to a standing position. What they found when they looked at the wheelchair seat was a cushion, nothing more. No Dycem above it. No Dycem below it. The DON confirmed what inspectors saw.
CNA #104 told inspectors she had come on duty at 6:00 a.m. that morning and the resident was already up in her wheelchair when she arrived, placed there by the overnight staff. She said she had not known the resident to fall during the month or so she had been working there. She also said she did know the resident was a fall risk, and she knew the care plan called for Dycem when the resident was in her wheelchair. She said she was not sure why it was not in place.
The Dycem was in the room. It was within sight. It had simply not been put where it was supposed to be, at some point during the night, when the resident was transferred into her chair, and then again at 6:00 a.m., when the day shift began and a new set of eyes came into the room.
CMS rated the deficiency as causing actual harm. The inspection was conducted as a complaint investigation, complaint number 2630029.
The resident sat in her wheelchair, at risk, for an unknown number of hours before inspectors walked in and asked someone to check.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
CARRIAGE INN OF STEUBENVILLE in STEUBENVILLE, OH was cited for violations during a health inspection on October 23, 2025.
Federal inspectors documented the finding on October 14, 2025, during a complaint investigation at the facility on St.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.