Carriage Inn Of Steubenville

F 0689 Level of Harm - Actual harm Residents Affected - Few

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

sitting up in her wheelchair. CNA #104 was asked to take the resident back to her room so she could be assisted into a standing position out of her wheelchair, to see if fall prevention interventions, including the use of Dycem to her wheelchair were in place. CNA #104 received assistance from the facility's Director of Nursing (DON) to stand the resident up from a seated position in her wheelchair. A gait belt and the assistance of the CNA and DON were used to have the resident stand from her wheelchair. The resident was observed to only have a cushion in the seat of her wheelchair with no evidence of Dycem being above or below her cushion. There was a piece of Dycem draped over the armrest of a stationary chair in her room. Findings were verified by the DON.On 10/14/25 at 2:40 P.M., an interview with CNA #104 revealed

the resident was assisted up into her wheelchair by the night shift staff, as the resident was already up when she came on duty at 6:00 A.M. She had not known the resident to fall in the month or so that she had been there, but did feel the resident was at risk for falls. She acknowledged the resident's plan of care for fall prevention included the use of Dycem when she was up in her wheelchair and was not sure why it was not in place. This deficiency demonstrates non-compliance investigated under Complaint Number 2630029.

Event ID:

Facility ID:

If continuation sheet

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

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carriage Inn of Steubenville

3102 St Charles Drive Steubenville, OH 43952

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 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, observation, and staff interview, the facility failed to ensure a resident at risk for dehydration had water maintained at her bedside. This affected one (Resident #7) of three residents reviewed for dehydration. Findings include: Review of Resident #7's medical record revealed she was admitted to the facility on [DATE REDACTED]. Her diagnoses included Alzheimer's disease with a late onset, unspecified dementia, adult onset diabetes mellitus, personal history of malignant neoplasm of the pancreas, malignant neoplasm of an unspecified part of an unspecified bronchus/ lung with metastasis to the brain, chronic kidney disease, unsteadiness on feet, and a history of falls. Review of Resident #7's annual Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed the resident did not have any communication issues and her cognition was severely impaired. She was not indicated to have displayed any behaviors and was not known to reject care. She required a partial to moderate assist with transfers and ambulation. The resident was coded as having received a diuretic medication during the seven day assessment period. Review of Resident #7's care plans revealed the resident had the potential for fluid imbalance related to kidney disease and diuretic use. The goal was for the resident to demonstrate adequate hydration as evidenced by laboratory values within normal range for the resident. The interventions included the need to maintain water at the resident's bedside.On 10/14/25 at 2:31 P.M., an observation of Resident #7 noted her to not have any water made available to her in her room as per her plan of care. There was no evidence of her being provided a Styrofoam cup, with a lid and straw, as was noted in other residents' rooms providing them with ice water. Her room was absent of any cups or other sources of a beverage for her to drink to help keep her hydrated per her plan of care. Findings were verified by Certified Nursing Assistant (CNA) #104.

On 10/14/25 at 2:40 P.M., an interview with CNA #104 revealed she had provided Resident #7 with ice water earlier that morning, when they were getting residents up for the day. She denied she had assisted Resident #7 with getting up that morning, as she was already up when she came on duty at 6:00 A.M. She reported night shift got Resident #7 up that morning. She was not able to locate a Styrofoam cup for the resident in her room or any other beverage for the resident to drink when she wanted. She suspected that maybe housekeeping had thrown it away when they were in the resident's room cleaning it earlier. She acknowledged housekeepers were in other residents' rooms cleaning their rooms without throwing their Styrofoam cups away. She further acknowledged Resident #7's plan of care indicated the staff were to maintain water at her bedside at all times. On 10/15/25 at 8:40 A.M., further observations of Resident #7 noted her to be lying in bed in her room. She was noted to have a Styrofoam cup dated 10/15/25 that had water in it, but the Styrofoam cup was sitting on the overbed table that was placed near the entry door to

the room and out of the resident's reach. On 10/15/25 at 8:43 A.M., an interview with CNA #26 confirmed Resident #7's water that was in a Styrofoam cup on her overbed table was not left in the resident's reach.

She further confirmed with the placement of the overbed table away from the resident's bed, the resident would not be able to reach her Styrofoam cup if she wanted or needed a drink. This deficiency demonstrates non-compliance investigated under Complaint Number 2630029.

Event ID:

Facility ID:

If continuation sheet

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

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carriage Inn of Steubenville

3102 St Charles Drive Steubenville, OH 43952

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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

labs to ensure an antibiotic was warranted. She claimed to have identified Resident #7 was started on an antibiotic for the treatment of a UTI, after the resident returned from the hospital on [DATE REDACTED]. She reported

she identified the organism causing the resident's UTI was not sensitive to the antibiotic that had been ordered at the hospital. She indicated she completed an antibiotic time-out and reached out to the resident's physician. She stated the physician wanted to continue the antibiotic as ordered even though it was not an effective treatment for the organism identified. She further indicated that particular physician, who was their prior medical director at the time, was one of the few physicians she dealt with that was not good about following the facility's ATB Stewardship program. He would often want antibiotics continued that had been ordered without supporting documentation confirming the resident had an active infection. He also did not always change the antibiotic that had been previously ordered when it was made know that antibiotic was not effective in treating the infection. She acknowledged the Antibiotic Time Out report improperly identified the organism that was causing the resident's UTI as being E. coli, which Keflex would have been an appropriate antibiotic to treat a UTI caused by that organism. She further acknowledged the physician's response to her Antibiotic Time Out was not received until 09/02/25, after the antibiotic therapy had already been completed. Review of the facility's Antibiotic Stewardship Program policy revised 05/30/23 revealed it was the policy of the facility to implement an Antibiotic Stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Medical Director and the facility's Director of Nursing (DON) was to serve as leaders of the Antibiotic Stewardship program. The Medical Director was to set the standards for antibiotic prescribing practices for all healthcare providers prescribing antibiotics, overseeing adherence to antibiotic prescribing practices, and was to

review antibiotic use data and ensure best practices were followed. The IP was to utilize expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections. Monitoring of the antibiotic was to include monitoring the response to antibiotics, and laboratory results, when available, to determine if the antibiotic was still indicated or adjustments should be made. Antibiotics orders obtained from emergency providers should be reviewed for appropriateness. This is an incidental finding discovered during the complaint investigation.

Event ID:

Facility ID:

If continuation sheet

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

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carriage Inn of Steubenville

3102 St Charles Drive Steubenville, OH 43952

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation, interview, and review of maintenance work orders the facility failed to maintain a safe and comfortable home like environment. This had the potential to affect one (Resident #07) of five residents rooms observed. the census was 78. Observation on 10/15/25 at 10:02 A.M. revealed a hole in

the wall behind the head of Resident #7's bed. The hole was observed to be located behind the head of the resident's bed, near the baseboard. The hole was approximately eight inches by eight inches.Review of facility maintenance work orders for the past six months revealed no documentation of an order to repair

the hole in the wall of Resident #7's room.Interview on 10/15/25 at 10:48 A.M. with Certified Nurses Assistant (CNA) #42 and Licensed Practical Nurse (LPN) #18 confirmed there was a larger hole in the wall of Resident #7's room. The hole was located behind the head board near the bottom of the wall. CNA #42 and LPN #18 stated they had not noticed the hole in the wall prior to it being pointed out. This deficiency demonstrates non-compliance investigated under Complaint Number 2630029.

Event ID:

Facility ID:

If continuation sheet