Carriage Inn Of Steubenville
CARRIAGE INN OF STEUBENVILLE in STEUBENVILLE, OH — inspection on October 23, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation on 10/15/25 at 10:57 A.M. of Licensed Practical Nurse (LPN) #18 changing Resident #7 dressing to the burn on the left thigh. LPN #18 cleansed the area with normal saline, applied Silver sulfadiazine External Cream 1%, applied telfa, secured the dressing with Medi pore tape.
Observation of Resident #7 wound revealed a red area to the left lateral thigh, two open areas that were moist and beefy red.
There were intact, reddened skin areas spread from lateral to medial thigh.
Observation on 10/15/25 at 11:06 A.M. with Registered Nurse #107 revealed hot water temperature from the Hydroz machine into a Styrofoam cup was verified with a thermometer from the facility's kitchen. RN #107 confirmed the temperature of the water from the machine was 176 degrees Fahrenheit Review of Hydroz H20-2500 manufacturer guide revealed heating of the hot water tank was up to 180 degrees Fahrenheit.
Review of facility policy titled Safety of Hot Liquids implemented 10/2014 revealed residents would be evaluated for safety concerns and potential injury from hot liquids upon admission, readmission and on change of condition.
Appropriate precautions would be implemented to maximize choice of beverages while minimizing the potential for injury.
The potential for burns from hot liquids was considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions.
Interventions include serving hot beverages in a cup with a lid, maintaining a hot liquid serving temperature of no more than 180 degrees, encouraging residents to sit at a table while drinking or eating hot liquids and staff supervision or assistance with hot beverages.
Food service staff would monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. In addition, review of Resident #7's active care plans revealed the resident had a care plan in place for the potential for falls related to a history of falls, medication use, and requiring assistance with transfers.
The goal was for the resident to remain free of falls.
Interventions included the use of Dycem (a tacky piece of material placed in a chair to prevent sliding out of the chair) to her wheelchair.
Review of Resident #7's physician's orders revealed the resident had an order (originated 05/24/24) for the use of Dycem to the resident's wheelchair. On 10/14/25 at 2:31 P.M., an observation of Resident #7 revealed the resident was 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.
365271 10/23/2025
Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952
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.
365271 10/23/2025
Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952
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.
365271 10/23/2025
Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952
and the public.
a safe and comfortable home like environment.
This had the potential to affect one (Resident #07) of
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.