Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage Inn Of Steubenville during CMS and state inspections, most recent first.
Unsafe flooring in the TCU hallway remained unrepaired when staff observed a dip and cracked flooring with a hole starting in front of the nurses' station door. A CNA said the condition had been there for a while, and an RN reported maintenance knew about it and that PT staff were concerned because residents walking through the hallway during treatments had to go around the area. The MD said the flooring needed replacement and could not produce earlier records of the concern.
A resident with sepsis, bilateral venous ulcers, severe PVD, DM, HF, heart disease, and acute kidney failure was observed sitting in a wheelchair with the room door closed and the call light attached to a dresser behind him, out of reach. He required supervision and hands-on help with lower-body dressing and transfers, had no cognitive impairment, and told staff the nurse had left him, his foot dressings were falling off, and he could not reach the call light. RN verified the call light was not reachable.
Antipsychotic Used Without Timely Supporting Diagnosis: A resident with severe cognitive impairment and dementia received Risperdal 0.5 mg BID for agitation without an appropriate diagnosis documented to support its use. The MRR identified the missing diagnosis, but the physician did not address the irregularity in a timely manner, and the DON confirmed the delay.
Improper medication administration through a feeding tube occurred for a resident who was nonverbal, dependent for all care, and required enteral nutrition and meds. An RN crushed several meds, mixed them with water, and immediately drew up the mixture without allowing it to fully dissolve, leaving undissolved particles that clogged the stop cock and interrupted flow through the tube.
Delayed and Inadequate Post-Op Pain Control: A resident admitted after cardiac bypass surgery had only Tylenol ordered initially despite hospital orders for oxycodone, tramadol, and additional Tylenol PRN. The resident reported severe chest pain, requested stronger analgesia, and experienced a delay before Norco was prescribed and administered. MAR entries showed pain scores up to 9/10, with limited supporting nursing documentation for several recorded pain ratings.
Medication was not kept under direct observation when an RN left pills and a supplement on a resident’s breakfast tray instead of ensuring they were fully taken. The resident had multiple serious medical conditions and no cognitive impairment, and the RN confirmed she did not watch him take all of his meds. The DON stated staff are required to ensure meds are taken and not left in residents’ rooms, consistent with the facility’s med pass policy.
Surveyors observed that the facility did not follow its approved menus and diet spreadsheets for multiple residents on reduced concentrated sweets (RCS) and pureed diets. Several residents with type 2 DM, morbid obesity, CKD, severe protein-calorie malnutrition, dementia, Parkinson’s disease, COPD, and dysphagia, who were ordered RCS or RCS mechanical soft diets, were served white or chocolate cake with frosting or fruit shortcake instead of the chilled peaches specified for RCS diets. Residents on pureed diets, whose menu called for pureed fruit shortcake, were instead given vanilla pudding because the cook had not prepared the pureed dessert. A nurse supervisor acknowledged that menus were not always followed and that diabetic residents received desserts they should not have, while dietary staff and the RD confirmed that the RCS and puree spreadsheets should have been followed and that the desserts served were not appropriate for the ordered diets.
A resident with severe cognitive impairment and upper extremity weakness was not assessed for hot liquid safety and was given hot tea in a Styrofoam cup without a lid, resulting in second-degree burns when the beverage spilled on her lap. The hot water dispenser used was not temperature-monitored and dispensed water at 176°F. Additionally, a required fall prevention intervention (Dycem in the wheelchair) was not in place as ordered and care planned.
A resident with severe cognitive impairment and multiple health conditions, including chronic kidney disease and diuretic use, did not have water maintained at her bedside as required by her care plan. Observations revealed that water was either not present or placed out of the resident's reach, and staff confirmed the resident could not access drinks as needed.
A resident with dementia and chronic kidney disease returned from the hospital with a UTI diagnosis and was prescribed Keflex, despite urine culture results showing the infection was caused by Enterobacter Cloacae, which was not sensitive to that antibiotic. The acting IP identified the mismatch but incorrectly documented the organism and did not ensure the antibiotic was changed, resulting in the resident receiving a full course of an ineffective antibiotic, in violation of the facility's antibiotic stewardship policy.
A hole in the wall behind a resident's bed, measuring about eight inches by eight inches, was found during observation and confirmed by a CNA and an LPN, who had not previously noticed it. Review of maintenance records showed no work order for repair in the past six months.
A facility failed to notify hospice of a resident's refusal to use a CPAP machine, as prescribed. The resident, with a diagnosis including Parkinson's disease and receiving hospice services, refused the CPAP treatment on all but one day over a period of time without hospice or the physician being informed. Observations showed the resident's oxygen equipment was not in use as ordered, and staff confirmed the lack of current physician orders for oxygen administration.
A facility failed to implement fall interventions for a high-risk resident with Parkinson's disease, resulting in multiple falls. The resident's care plan was not updated after a fall, and necessary interventions like a grabber and proper footwear were not provided. Staff were unaware of the resident's fall history and interventions, leading to non-compliance under Complaint Number OH00159914.
A facility failed to provide proper care for a resident's respiratory equipment, including a CPAP machine and oxygen tubing. The resident, with multiple diagnoses including acute respiratory failure, had outdated oxygen tubing on the floor and a CPAP mask with black spots on a window sill. Staff interviews revealed a lack of current physician orders and specific CPAP settings, contrary to facility policy requiring physician orders and proper equipment maintenance.
The facility failed to administer medications as ordered, resulting in a 13.7% medication error rate. Two residents were affected: one with hypertension and other conditions did not receive Isosorbide or Lopressor despite blood pressure readings above the threshold for withholding, and another with cerebral infarction received ASA enteric-coated instead of the prescribed ASA. The facility's policy requires medications to be administered as prescribed.
A facility failed to maintain a complete medical record for a resident, as the Physician's Progress Notes lacked any resident-identifiable information. This issue was discovered during a complaint investigation, and the DON confirmed the incompleteness of the record due to the absence of identifying details.
An LTC facility failed to protect residents from medication misappropriation, affecting 13 residents. An LPN was observed accessing the narcotics drawer without proper documentation, leading to an investigation. Several residents did not receive their prescribed medications, and discrepancies were found in controlled drug records. The LPN was suspended and resigned, but the facility could not conclusively prove drug diversion.
Unsafe Flooring Left Unrepaired in TCU Hallway
Penalty
Summary
The facility failed to maintain safe flooring in the transition care unit (TCU) when it did not repair an area of flooring that was uneven and cracked in front of the nurses' station door. During the initial tour, a dip in the flooring and a cracked piece with a hole starting were observed in the hallway used by residents. A CNA confirmed the condition had been present for a while and stated she would submit a maintenance ticket. The issue was observed again on a return tour, with the same dip and crack still present. An RN reported that maintenance was aware of the flooring concern and that physical therapy staff had expressed concern because residents walk through that hallway during treatments and were having to walk around the area. The RN stated that non-emergent maintenance issues are placed on handwritten tickets at the nurses' station and that urgent issues are called immediately to the maintenance supervisor. The Maintenance Director reported receiving a ticket about the flooring issue and stated the flooring throughout the area needed replacement, but he could not produce records of earlier estimates or prior tickets related to the flooring concern. The Administrator stated she was only made aware of the concern on the day of the interview.
Call light not within reach of resident needing assistance
Penalty
Summary
The facility failed to ensure a call light was accessible and within reach for a resident who needed assistance with care and mobility. Resident #95 was admitted with diagnoses including sepsis, venous ulcers to both lower legs, severe peripheral vascular disease, diabetes, heart failure, heart disease, and acute kidney failure. The resident’s MDS assessment showed he required supervision and hands-on assistance with lower-body dressing, supervision with transfers from bed to wheelchair, and dependence on staff for wheelchair mobility, while also indicating no cognitive impairment with a brief interview score of 15/15. During observation, Resident #95 was found sitting in a wheelchair in the middle of his room with the door closed. The call light was attached to the bedside dresser behind him and was not within reach, and there was not enough space to move the wheelchair into the area to retrieve it. The resident stated that the nurse had left him while getting something for his bed, that his dressings were falling off his foot, and that he could not reach his call light with the door shut. RN #255 verified that the resident could not reach the call light and said someone would be gotten to change the resident’s foot dressing. The facility policy stated that staff will ensure call lights are within reach of residents and secured as needed.
Antipsychotic Used Without Timely Supporting Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis was documented to support the use of an antipsychotic medication for one resident reviewed for unnecessary medications. Resident #2 was admitted with diagnoses including Alzheimer's disease, non-Alzheimer's disease, unspecified fracture of the right lower leg, osteomyelitis of the right ankle and foot, diabetes mellitus, cirrhosis of the liver, chronic obstructive pulmonary disease, and muscle wasting. The MDS assessment dated 10/01/25 showed severe cognitive impairment, a diagnosis of non-Alzheimer's dementia, and use of an antipsychotic medication. A physician order dated 10/02/25 prescribed Risperdal 0.5 mg by mouth twice daily for agitation. The monthly regimen review dated 10/08/25 identified that an appropriate diagnosis was needed to support the use of Risperdal. The physician did not address this recommendation until 11/20/25, when the diagnosis was changed to dementia with mood disturbance. The DON confirmed in interview that the October 2025 MRR was not addressed timely and that the resident received Risperdal 0.5 mg twice per day without an appropriate diagnosis.
Improper Medication Administration Through Feeding Tube
Penalty
Summary
Improper administration of medications through a feeding tube occurred for Resident #8, who was admitted with diagnoses including high blood pressure, paraplegia, aphasia, seizure disorder, depression, gastrotomy tube use for nutrition and medications, and anoxic brain damage. The resident’s MDS indicated the resident was unable to speak or communicate needs, was dependent for all cares and mobility, and required a feeding tube for nutrition and medication administration. During observed medication administration, RN #466 crushed Baclofen 20 mg, lisinopril 10 mg, Vitamin D 25 mg, and a multivitamin tablet, then placed the crushed medications into approximately 180 ml of water and immediately drew up the mixture for administration through the feeding tube without allowing the medications to fully dissolve. A residual layer of medication remained in the cup, and when a second syringe of the mixture was administered, the fluid stopped flowing because undissolved medication particles were blocking the three-way stop cock. RN #466 removed the blockage, continued administering the remaining mixture, added more water to rinse the cup, and then flushed the tube with 30 ml of water. The facility policy titled Medication Administration via Enteral Tube stated medications should be crushed and mixed with water and dilute the solid or liquid medications as appropriate.
Delayed and Inadequate Post-Operative Pain Control
Penalty
Summary
The facility failed to provide effective and timely pain control for a resident admitted after triple vessel cardiac bypass surgery. The resident had multiple diagnoses including heart disease, anemia, depression, hypertension, spinal stenosis, bilateral hip replacements, a left knee replacement, and uterine cancer with radiation. The hospital medication list sent to the facility showed active orders for oxycodone 5 mg every 4 hours as needed for post-operative pain, tramadol 50 mg every 6 hours as needed, and Tylenol 500 mg three times daily plus Tylenol 650 mg every 4 hours as needed, but on admission the resident only had Tylenol 500 mg three times daily ordered for pain management. On admission, the resident rated pain as 3/10 and described it as achy and infrequent. During the first night, nursing contacted the on-call physician and obtained an order to increase Tylenol to 1000 mg three times daily instead of the hospital discharge order of 500 mg three times daily. The next day, the resident reported that she had been receiving oxycodone in the hospital and requested that medication for pain control. The RN notified the PCP, who declined to prescribe it and no rationale was documented. Later that day, the NP saw the resident, discussed pain medications with the PCP, and recommended Norco for severe pain and Tylenol for mild to moderate pain. A Norco 5-325 mg order every 8 hours as needed was then sent to the pharmacy. The resident did not receive the requested pain medication until several hours later, after reporting severe pain rated 9/10. The MAR documented pain ratings ranging from 6/10 to 9/10 over the next several days, with relief after Norco administration, but there were no nursing progress notes or comprehensive assessments to support several of the recorded pain scores. During observation, the resident was noted sitting in a chair breathing heavily with facial grimacing and guarded posture, and she reported chest pain rated 8/10 from recent bypass surgery while waiting for pain medication. She stated Tylenol was not effective, that it took a whole day to get pain medications figured out, and that her pain had been poorly controlled during the first 24 hours after admission until Norco was started.
Medication Left on Resident’s Tray During Administration
Penalty
Summary
Safe storage of medication was not ensured when medications were left on a resident’s breakfast tray during administration. Resident #95 was admitted with diagnoses including sepsis, venous ulcers to both lower legs, severe peripheral vascular disease, diabetes, heart failure, heart disease, and acute kidney failure. The resident’s MDS showed he required supervision and hands-on assistance with lower-body dressing, supervision with transfers, and dependence on staff for wheelchair mobility, while also having no cognitive impairment with a brief interview score of 15/15. During observation, Resident #95 was sitting on the side of his bed with his breakfast tray on the bedside table, and a medicine cup containing 30 milliliters of brownish liquid and another cup containing four pills were found on the tray. The resident stated he had been working on taking the medications and that there had been 15 pills, but he could only take 3-4 at a time. The RN confirmed she had not visualized the resident take all of his medications and acknowledged that four pills remained in the cup and that the liquid was his ProSource supplement. The RN stated she should have observed the resident taking all medications and should not have left them with him. The DON confirmed nursing staff are to ensure medications are taken when administered and that medications are not to be left in residents’ rooms. The facility policy stated medications during a pass must be under direct observation of the person administering them or locked in the medication storage area/cart.
Failure to Follow Therapeutic Diet Menus and Spreadsheets for RCS and Pureed Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and the approved menu/spreadsheet for residents, particularly those on reduced concentrated sweets (RCS) and pureed diets. Surveyors observed the lunch tray line and found that multiple residents with orders for RCS diets, including those with morbid obesity, type 2 diabetes mellitus, chronic kidney disease, and severe protein-calorie malnutrition, were served high-sugar desserts that were inconsistent with their diet orders and the facility’s RCS policy. For several cognitively intact or moderately impaired residents who required setup or cleanup assistance and were care planned as being at nutritional risk, tray tickets specified chilled peaches as the dessert for RCS diets, yet staff placed large portions of white cake with cherry topping and whipped topping on their trays. Fruit was available and had been placed on other residents’ trays, but was not used for these RCS diet trays. Additional observations showed that residents on RCS mechanical soft diets were also served inappropriate desserts. Residents with diagnoses including type 2 diabetes with neuropathy, dementia, Parkinson’s disease, COPD, and dysphagia, and who were ordered RCS, no salt packet, mechanical soft diets, received chocolate cake with white frosting or fruit shortcake. The tray tickets for these residents indicated RCS mechanical soft diets, and in at least one case specified fruit shortcake, but the facility’s RCS spreadsheet indicated that RCS diets should receive chilled peaches instead of fruit shortcake. The registered dietitian and dietary technician later confirmed that chocolate cake with icing and fruit shortcake were not appropriate dessert choices for residents on RCS mechanical soft diets and that a glitch in the tray card system meant there was no spreadsheet breakdown for combination diets such as RCS mechanical soft. Surveyors also identified that the facility did not follow the puree diet spreadsheet for residents ordered pureed texture diets. The facility’s fall and winter menu and corresponding spreadsheet specified that residents on pureed diets were to receive pureed fish of the day, pureed vegetables, pureed dinner roll with margarine, and pureed fruit shortcake for lunch. However, during observation of the tray line, no pureed fruit shortcake was present, and residents on pureed diets were instead given small plastic bowls of vanilla pudding. The dietary director confirmed that the cook had not prepared the pureed fruit shortcake and that these residents were therefore receiving vanilla pudding in place of the menu-specified dessert. A registered dietitian and dietary technician confirmed that the spreadsheets needed to be followed and that residents on pureed diets should have received pureed fruit shortcake. The facility’s own policies on RCS diets and on menus and adequate nutrition required that meals be prepared consistent with RCS guidelines and that menus be followed, but these were not adhered to during the observed meal service. A registered nurse supervisor acknowledged during interview that menus were not always followed and stated that diabetic residents were receiving desserts they should not be getting, noting that everybody got cake for lunch that day. Across the cited examples, residents’ medical records consistently showed therapeutic diet orders, MDS assessments documenting therapeutic or mechanically altered diets, and care plans identifying nutritional risk with interventions to provide diet and fluids as ordered and to honor preferences as able. Despite this, the lunch service on the observed day did not follow the written menus, diet spreadsheets, or physician orders for RCS and pureed diets, resulting in desserts being served that were inconsistent with the residents’ prescribed diets and the facility’s written policies.
Failure to Assess and Implement Safety Measures for Hot Liquids and Fall Prevention
Penalty
Summary
A resident with severe cognitive impairment, upper extremity weakness, and a history of falls was not comprehensively assessed for safety with hot liquids, nor were appropriate interventions implemented to prevent burns. The resident required staff assistance with activities of daily living and had an occupational therapy plan indicating upper extremity weakness and a need for set-up or clean-up help for eating. Despite these needs, there was no assessment or care plan addressing the resident's ability to safely consume hot liquids, and no interventions were in place to reduce the risk of burns from hot beverages. On the day of the incident, the resident was provided hot tea in a Styrofoam cup without a lid by therapy staff, using water from a hot water dispenser that was not temperature-monitored and dispensed water at 176 degrees Fahrenheit. The resident attempted to balance the cup on her lap, resulting in the hot liquid spilling onto her left thigh and causing large second-degree burns. Immediate first aid was provided, and the resident required ongoing pain management and wound care. Interviews confirmed that the facility's policy required evaluation of residents for hot liquid safety and the use of lids on hot beverages, but these measures were not followed in this case. Additionally, the resident had a care plan and physician's order for the use of Dycem in her wheelchair as a fall prevention intervention, but this intervention was not in place at the time of observation. Staff interviews and observations confirmed that the Dycem was not present in the resident's wheelchair, despite being ordered and care planned. The lack of adherence to both hot liquid safety protocols and fall prevention interventions contributed to the resident experiencing actual harm.
Failure to Maintain Accessible Hydration for At-Risk Resident
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, diabetes, chronic kidney disease, and a history of falls, was identified as being at risk for dehydration. Her care plan specifically required that water be maintained at her bedside at all times to support adequate hydration, especially given her use of diuretic medication and potential for fluid imbalance. During an observation, it was noted that the resident did not have any water or beverage available in her room, and there was no evidence of a Styrofoam cup or other drinking vessel as provided to other residents. A CNA confirmed that she had not provided water to the resident that morning and could not locate a cup in the room, suggesting it may have been discarded by housekeeping, although this was not the case in other rooms. On a subsequent observation, the resident was found to have a Styrofoam cup with water, but it was placed on an overbed table near the entry door, out of the resident's reach. Another CNA confirmed that the placement of the table and cup made it inaccessible to the resident, preventing her from obtaining a drink when needed. These findings demonstrate that the facility failed to ensure the resident had water maintained at her bedside and within reach, as required by her care plan.
Failure to Implement Effective Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program when a resident returned from the hospital with a new order for Keflex to treat a urinary tract infection (UTI). The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and chronic kidney disease, was sent to the emergency room for chest pain and returned with a UTI diagnosis and an order for Keflex. Hospital records showed that a urine culture identified Enterobacter Cloacae as the causative organism, which was not sensitive to Keflex. Despite this, the resident received the full seven-day course of Keflex as ordered. The acting Infection Preventionist (IP) at the facility was responsible for reviewing antibiotic use for residents returning from the hospital. The IP identified that the organism causing the UTI was not sensitive to the prescribed antibiotic and completed an antibiotic time-out, reaching out to the resident's physician. However, the Antibiotic Time Out report incorrectly documented the organism as E. coli, for which Keflex would have been appropriate, rather than Enterobacter Cloacae. The physician was informed of the incorrect organism and did not respond until the antibiotic course was nearly complete, instructing to finish the course despite its ineffectiveness against the identified organism. Facility policy required the IP to monitor antibiotic use, review laboratory results, and ensure antibiotics were appropriate for the identified infection. The policy also stated that the Medical Director was responsible for setting standards for antibiotic prescribing and overseeing adherence. In this case, there was no evidence that the antibiotic was changed to one effective against the organism identified in the culture, and the resident received an ineffective antibiotic regimen, contrary to the facility's antibiotic stewardship policy.
Failure to Repair Wall Damage in Resident Room
Penalty
Summary
A hole measuring approximately eight inches by eight inches was observed in the wall behind the head of a resident's bed, near the baseboard. This issue was identified during an observation and was confirmed by interviews with a CNA and an LPN, both of whom stated they had not previously noticed the hole. Review of the facility's maintenance work orders for the past six months showed no documentation of a request to repair the hole in the resident's room. The deficiency was identified as part of a complaint investigation and had the potential to affect one of five resident rooms observed, with a facility census of 78 at the time.
Failure to Notify Hospice of Respiratory Treatment Refusal
Penalty
Summary
The facility failed to notify hospice of a resident's refusal of respiratory treatments, specifically the use of a CPAP machine. Resident #83, who was admitted with a diagnosis including Parkinson's disease, was receiving hospice services and had a history of falls. The resident was prescribed a CPAP machine to be worn at bedtime, but the order did not include the required settings. The resident refused the CPAP treatment on all but one day between November 1 and December 18, 2024, without hospice or the physician being notified of these refusals. Observations revealed that the resident was lying in bed with an oxygen concentrator present, but the nasal cannula was on the floor, and the oxygen tubing was dated from November 9, 2024. Interviews with facility staff, including a CNA and an LPN, confirmed that there were no current physician orders for the resident's oxygen administration, and the resident did not wear the oxygen continuously. The LPN verified the lack of notification to hospice or the physician regarding the CPAP refusals. This deficiency was identified during a complaint investigation.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with Parkinson's disease who was severely impaired in daily decision-making and receiving hospice services. The resident had a history of falls, some resulting in injuries. Despite being identified as a high fall risk, the care plan interventions, such as keeping the call light within reach, assisting with proper footwear, and ensuring the resident wore glasses, were not consistently implemented. Observations revealed the resident was often without gripper socks, glasses, and the call light was not within reach, increasing the risk of falls. After a fall on 12/16/24, the resident's care plan was not updated to include new interventions, such as the use of a grabber or ensuring the resident was in a geri-chair when out of bed. Staff interviews confirmed a lack of awareness and education regarding the resident's fall and the necessary interventions. Additionally, the facility did not have the ordered grabber available for the resident's use, and no alternative interventions were implemented to prevent further falls. The deficiency was noted under Complaint Number OH00159914.
Inadequate Respiratory Equipment Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for oxygen and respiratory equipment for a resident diagnosed with Parkinson's disease, generalized anxiety disorder, pneumonia, and acute respiratory failure with hypoxia. The resident was admitted with orders for a CPAP machine to be worn at bedtime and to continue home settings, as well as hospice orders for oxygen via nasal cannula at two to five liters per minute continuously. Observations revealed that the oxygen tubing was lying on the floor and dated over a month old, while the CPAP mask was resting on a window sill with visible black spots and without a protective barrier. Interviews with facility staff, including a CNA and an LPN, confirmed that the oxygen and CPAP equipment should be stored in a bag and changed regularly. The LPN acknowledged the lack of current physician orders for the resident's oxygen and the absence of specific settings for the CPAP machine, indicating a need to contact the physician for clarification. The facility's policy on oxygen administration requires that oxygen be administered under physician orders and that equipment be cleaned and maintained according to facility policies. This deficiency was identified during a complaint investigation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 13.7%. This deficiency was observed during the medication administration for two residents. Resident #50, who was admitted with diagnoses including hypertension, congestive heart failure, coronary artery disease, and anxiety, had specific physician orders for medications such as chewable aspirin, Isosorbide Dinitrate, and Lopressor, with parameters to hold the latter two if the systolic blood pressure (SBP) was less than 100 mmHg. On December 17, 2024, RN #209 assessed Resident #50's blood pressure at 108/72 mmHg, which was above the threshold to withhold the medications. However, RN #209 decided not to administer Isosorbide or Lopressor, despite the blood pressure reading exceeding the parameters for withholding the medications. Resident #58, admitted with a diagnosis of cerebral infarction, had an order for ASA 81 mg. During the same observation period, RN #209 administered ASA enteric-coated 81 mg instead of the prescribed ASA 81 mg. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered as prescribed. The failure to adhere to these orders and policies resulted in the identified medication errors, which were investigated under Complaint Number OH00159914.
Incomplete Medical Record Due to Lack of Resident Identification
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, which was identified during a complaint investigation. A review of the closed medical record for a resident revealed that the Physician's Progress Notes, dated 10/25/24 and 10/31/24, were not labeled with any resident-identifiable information such as a name, identification number, or room number. This lack of identifying information made it impossible to verify which resident the notes pertained to. An interview with the Director of Nursing confirmed that the progress notes were part of the closed record for the resident, but without the necessary identifying information, the medical record was deemed incomplete.
Medication Misappropriation Incident
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, affecting 13 residents. The incident was discovered when the Administrator observed suspicious activity by an LPN on the facility's video cameras. The LPN was seen accessing the narcotics drawer without documenting on the medication administration record or narcotic count sheets. An immediate investigation was launched, revealing that medications were unaccounted for, and some routine medications were found discarded in the trash. The investigation into the incident revealed that several residents did not receive their prescribed medications. For instance, one resident was not administered risperidone and buspirone as ordered, while another resident was missing doses of prednisone and sertraline. Additionally, discrepancies were found in the controlled drug records, with pills missing and not documented as administered. These findings were consistent across multiple residents, indicating a pattern of misappropriation. The facility's investigation could not conclusively prove that the LPN had committed drug diversion, but the evidence of discarded medications and discrepancies in narcotic counts substantiated the misappropriation allegations. The LPN was suspended and subsequently resigned. The facility's policy on abuse, neglect, and exploitation defines misappropriation as the wrongful use of a resident's belongings, which was evident in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Steubenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Vista Royale Llc | 0.7 mi | ★★★★★ | 3 | 0 |
| Steubenville Country Club Manor | 0.9 mi | ★★★★★ | 0 | 0 |
| Laurels Of Steubenville The | 1.1 mi | ★★★★★ | 2 | 0 |
| Catherine's Care Center, Inc | 2.4 mi | — | 0 | 0 |
| Sienna Skilled Nursing & Rehabilitation | 2.5 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.