Carriage Inn of Steubenville

Inspectors wroteBased on observation, maintenance ticket reviews, and staff interviews the facility failed to maintain safe flooring when it did not repair an area of flooring that was uneven and cracked on the transition care unit (TCU) utilized by residents. This affected nine mobile residents (#1, #9, #13, #25, #34, #42, #62, #95, and #105) of 20 residents residing on TCU. The facility census was 95.

Inspectors wroteBased on medical record review, resident interview and observation, and staff interview the facility failed to ensure a call light was accessible and within reach to meet resident needs. This affected one resident (#95) of 20 residents residing on the transitional care unit. The facility census was 95.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure an appropriate diagnosis was indicated for the use of an antipsychotic medication. This affected one resident (#2) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on review of medical records and facility policy, observation of medication administration, and staff interviews the facility failed to properly administer medications through a feeding tube for Resident #8. This affected one resident (#8) of one resident reviewed for tube feeding management and care. The facility census was 95.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to provide effective and timely pain control for Resident #104 upon admission. This affected one resident (#104) of one resident who was reviewed for pain management. The facility census was 95.

Inspectors wroteBased on medical record review, staff interview, and policy review the facility failed to ensure safe storage of medication when medications were left on the breakfast tray for Resident #95. This affected one resident (#95) of twenty residents receiving medication on the transitional care unit. The facility census was 95.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure the lunch menu and spreadsheets were followed as written. This affected 13 residents (#1, #5, #9, #10, #17, #33, #40, #59, #68, #73, #86, #98 and #100) of 88 residents receiving meals from the kitchen. The facility identified one resident (#83) who did not eat by mouth (NPO). The facility census was 102.

Inspectors wroteBased on observation, record review, manufacturer guideline review, facility policy review and interview, the facility failed to ensure Resident #7 was comprehensively assessed and appropriate interventions were in place to prevent a burn from a hot liquid. In addition, the facility failed to ensure care planned/physician ordered fall interventions were in place to decrease the resident's risk of falls. This affected one resident (#7) of four residents reviewed for accidents. The census was 78. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure an effective antibiotic stewardship program was implemented, when a resident returned from the hospital on an antibiotic for the treatment of a urinary tract infection, and the facility's infection preventionist failed to ensure an appropriate antibiotic was ordered to adequately treat the infection. This affected one (Resident #7) of three resident's reviewed.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to notify hospice of a resident refusal of respiratory treatments. This affected one (#83) of three residents sampled. The census was 84.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure fall interventions were implemented. This affected one (#83) of three residents sampled. The census was 84.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to provide appropriate care for oxygen and respiratory equipment. This affected one (#83) of three residents sampled. The census was 84.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to administer medications as ordered. This affected two (#50 and #58) of four residents observed for medication administration during 29 opportunities for error resulting in a 13.7% medication error rate. The census was 84.

Inspectors wroteBased on medical record review and interview, the facility failed to maintain a complete medical record. This affected one (Resident #85) of three residents sampled. The census was 84.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of the facility investigation, facility policy review, and interview, the facility failed to ensure residents were free from misappropriation of medications. This affected 13 (Resident #1, #3, #4, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22) of 13 residents reviewed for misappropriation. The facility census was 99.

Inspectors wroteBased on medical record review, interview, observation, and policy review the facility failed to trend and identify infections/organism. The facility also failed to use proper hand hygiene and glove use during suprapubic catheter care. This had the potential to affect all 102 residents residing in the building for infections and one resident (#78) of one observed for catheter care.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure Resident's #8, #43, and #197's insulin pens had a date they were first opened and used recorded on the pen. This affected three residents (Resident's #8, #43 and #197) who received insulin and resided on the second floor nursing unit.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to ensure residents met criteria for antibiotic treatment. This affected four residents (#29, #30, #78, and #82) of five reviewed for infections.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected three residents (#6, #28 and #32) of four residents reviewed for advanced directives. The facility census was 102. Findings Include: 1. Review of medical record revealed Resident #28 was admitted to the facility on [DATE]. Medical diagnoses included chronic obstructive pulmonary disease, unspecified asthma, respiratory failure, transient cerebral ischemic attack, abdominal aortic aneurysm, and heart failure. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #28 was cognitively intact. Review of Resident #28's physician order, dated 08/15/23 identified Resident #28 was a Do Not Resuscitate Comfort Care (DNR-CC). [...]

Inspectors wroteBased on record review, observation, review of an owner's manual/ technical specifications for a bed used for a resident, resident interview and staff interview, the facility failed to ensure a resident had an appropriate sized bed/ mattress to allow for proper positioning to accommodate his height and failed to identify and timely treat another resident who displayed signs of intense itching. This affected one (#65) of two residents reviewed for positioning and one (#198) of one resident reviewed for non-pressure skin conditions.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to monitor refrigerator temperatures on one of three resident units and failed to ensure refrigerators were maintained in a clean manner to prevent contamination and/or food borne illness. This had the potential to affect 19 residents (#33, #41, #49, #59, #76, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #233, #234 and #235) who resided on the Transitional Care unit (TCU) of 85 residents residing in the facility.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR's) were completed accurately on admission and/or failed to ensure a new PASARR was completed following a change in diagnoses. This affected three residents (#12, #45, and #56) of five residents reviewed for PASARR.

Inspectors wroteBased on closed record review, facility policy and procedure review and interview the facility failed to ensure the discharge summary completed for Resident #85 included a recapitulation of the resident's stay. This affected one resident (#85) of one resident reviewed for discharge.

Inspectors wroteBased on medical record review, facility policy and procedure review and interview the facility failed to ensure psychotropic medications were only administered when there were indications for use, failed to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medication ordered on an as necessary basis and/or failed to ensure orders for psychotropic medications were accurate and complete providing clear directions for use. This affected two residents (#8 and #48) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #2 was provided timely dental services to meet her needs. This affected one resident (#2) of three residents reviewed for dental care.