Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Laurels Of Steubenville The during CMS and state inspections, most recent first.
A hospice resident with chronic and terminal pain had multiple physician‑approved changes to Oxycodone dosing (scheduled and PRN) that were not timely implemented, and several scheduled doses were not given because the resident was sleeping, with no evidence of appropriate waste or alternative pain control. MAR entries and narcotic control sheets for Oxycodone 5 mg and 10 mg were inconsistent, with doses documented as administered but not signed out on narcotic logs, and the DON confirmed missing narcotic records and confusion between Oxycodone and Morphine orders. Hospice notes and assessments documented non‑verbal signs of pain and agitation, while the MDS showed staff‑observed indicators of pain in a severely cognitively impaired resident who could not self‑report. The resident’s family repeatedly reported that a nurse refused to administer pain medication per hospice orders, especially when the resident was sleeping, and staff interviews corroborated that a nurse did not believe in hospice and did not follow hospice pain orders. These actions and omissions led to uncontrolled end‑of‑life pain and necessitated escalation and changes in the resident’s opioid regimen to regain pain control.
A hospice resident with severe cognitive impairment and chronic pain had multiple discrepancies between the MAR and narcotic control sheets for Oxycodone, Ativan, and Morphine. Numerous controlled doses were signed out on narcotic logs but not documented on the MAR, while other doses were charted as given on the MAR without corresponding entries on the control sheets, leaving tablets and liquid doses unaccounted for and without evidence of proper wastage. The facility’s own medication administration policy requiring complete MAR documentation was not followed, staff reported that a nurse would not administer pain medication per hospice orders, and the resident’s family reported the resident did not receive pain medication as ordered.
Surveyors found that the facility did not maintain a clean and comfortable environment, with multiple rooms and common areas showing evidence of dust, debris, stained and discolored bathroom floors, overflowing trash cans, and dirty surfaces. Housekeeping staff confirmed that limited staffing made it difficult to clean every room daily, and some stains could not be removed with current cleaning methods. Facility leadership was aware of the issues but had no set plans for repairs or improvements at the time of the survey.
A resident with multiple fall risk factors, including muscle weakness and difficulty walking, did not have physician-ordered non-skid strips placed by the bed or brightly colored tape applied to the call bell. Observation confirmed these fall prevention interventions were not implemented as ordered.
An LPN failed to perform hand hygiene after disposing of a dropped medication and before administering additional medications and assisting with eye care for two residents. Additionally, a CNA used improper technique during perineal care by reusing the same area of a washcloth for multiple wipes and adjusting the bed before removing gloves and performing hand hygiene.
The facility failed to ensure over-the-counter medications had clearly labeled expiration dates, affecting 18 residents with aspirin orders. Nurses administered aspirin with illegible expiration dates, contrary to facility policy. Additionally, two residents had unsecured medications at their bedsides without orders to self-administer, violating the facility's medication security policy.
A resident with multiple medical conditions, including kidney failure, was found with an uncovered catheter bag, violating the facility's policy on dignity and privacy. The resident confirmed the absence of a cover, and a nurse acknowledged the oversight. The facility's policy required catheter bags to be concealed, but this was not adhered to, affecting the resident's dignity.
The facility failed to maintain consistent documentation of advanced directives for two residents. One resident's electronic medical record indicated a Full Code status, while a DNRCC form was also present. Another resident's record showed a Full Code status, but a DNRCC order was signed. Staff confirmed that updates to the electronic records and code status book were not made, leading to discrepancies in the residents' code status documentation.
A facility failed to ensure a clean environment for a resident with an abscess on the left gluteal fold. The resident, who required varying levels of assistance for toilet use, was on contact isolation. Bowel movement was observed on the toilet seat, and PPE was disposed of in the bathroom, where the handwashing sink was also located. This unsanitary condition was confirmed by an RN.
A resident with CHF and other health conditions experienced intense itching and significant weight gain, but the facility failed to address these issues timely. The resident's itching was attributed to arthritis and treated with a pain gel, leading to dry, flaking skin. Additionally, significant weight gain and edema were not promptly communicated to the NP, despite being documented in dietary notes and assessments. Confusion over reporting responsibilities contributed to the delay in addressing the resident's condition.
The facility failed to implement appropriate interventions and physician orders for pressure ulcer care for two residents. One resident did not receive the prescribed CMC fiber dressing for a wound, while another resident with a stage four sacral ulcer was not provided with timely interventions to address bed immobility and pressure, including the delayed provision of a low air loss mattress.
A resident with a Foley catheter and bowel incontinence did not receive appropriate care, leading to multiple UTIs and unmanaged constipation. The facility failed to document catheter care and did not activate the necessary tasks in the electronic medical record. Additionally, the resident experienced extended periods without bowel movements, with no interventions or physician notifications documented.
The facility failed to administer oxygen as ordered for two residents, with one resident receiving an incorrect oxygen flow rate and both having undated oxygen tubing. A resident with congestive heart failure had their oxygen set at three liters per minute instead of the ordered two liters, and another resident with heart disease had undated tubing. Staff confirmed the discrepancies, which affected two of three residents reviewed for oxygen use.
A facility failed to consistently complete pre and post dialysis assessments for a resident requiring hemodialysis due to end-stage kidney disease. The care plan required dialysis on specific days and included monitoring for medication side effects and access site conditions. However, documentation from February to March 2025 showed inconsistencies in recording weights, access site conditions, mental status, and medication changes. An LPN confirmed the assessments were not thoroughly completed, contrary to facility policy.
The facility failed to properly manage medications for two residents, leading to deficiencies in pain and insulin administration. A resident with cognitive impairment received narcotic pain medication without documented nonpharmacological interventions or physician contact. Another resident with diabetes received insulin outside prescribed parameters, with no interventions documented for low blood sugar levels. The facility did not adhere to its policies on pain and diabetic management, affecting the quality of care.
A facility failed to document a physician's order for STAT laboratory tests and delayed obtaining these tests for a resident with multiple health issues, including a urinary tract infection. The resident showed signs of lethargy, prompting the NP to order immediate tests, but the laboratory specimens were not collected until the next morning. The DON confirmed the delay and the absence of a written order, and the facility lacked a laboratory services policy.
A facility failed to ensure a resident's pneumonia vaccination was up to date. The resident, with multiple health conditions, had received the PPSV23 vaccine but was not administered the recommended PCV or PCV20 vaccine after one year, as per the facility's policy and the PneumoRecs Vax Advisor application. The DON confirmed the lapse in vaccination.
Failure to Implement and Follow Hospice Opioid Orders Resulting in Uncontrolled End‑of‑Life Pain
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective pain management program for a hospice resident with chronic and end‑of‑life pain, including failure to timely implement and consistently administer ordered opioid medications. The resident had extensive diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, prior shoulder replacement, cerebral infarction, and was receiving hospice services for terminal care. The care plan identified the resident as at risk for pain and chronic pain, with interventions to administer pain medications as ordered, monitor for effectiveness and side effects, observe for non‑verbal signs of pain, and notify the physician or hospice for breakthrough pain. The resident’s hospice plan of care included multiple analgesics (Lidocaine patch, Gabapentin, Ibuprofen, Tylenol, and Oxycodone) and recognized that the resident grimaced with movement and had constant pain despite scheduled medications. Hospice recommended increasing Oxycodone to every eight hours scheduled and every four hours as needed, with Zofran as needed, and the physician approved these changes. However, the new Oxycodone and Zofran orders dated one day were not implemented in the facility’s record until three days later at 7:43 p.m., despite narcotic control documentation showing the Oxycodone order had been received earlier. During this period, there was no evidence in the medical record that the new dosing regimen was in place. Additionally, the MAR showed that scheduled Oxycodone doses at 10:00 p.m. and 6:00 a.m. on two consecutive days were not administered because the resident was sleeping, even though the narcotic control sheet showed a 10:00 p.m. dose signed out without documentation of waste. There was also no evidence that as‑needed Oxycodone was administered over several days, despite the resident’s known chronic and hospice‑related pain and staff‑documented non‑verbal indicators of pain on the MDS. Further documentation showed ongoing inconsistencies and omissions in opioid administration and order management. Progress notes indicated that the resident’s pain had been well controlled when all scheduled Oxycodone doses were given, and that missed 2:00 a.m. doses (charted as not given because the resident was sleeping) and changes in the pain regimen were associated with increased pain noted by hospice. There was confusion between Oxycodone and Morphine orders, including a hospice order for Morphine solution as needed without clear discontinuation of Oxycodone, and later notes indicating that Oxycodone should have been continued until Morphine was started, resulting in missed Oxycodone doses. MARs and narcotic control sheets did not match for Oxycodone 5 mg and 10 mg, with doses documented as given on the MAR but not signed out on narcotic logs, and the DON confirmed there were no narcotic control records to support certain documented administrations. Hospice notes and interviews described the resident exhibiting non‑verbal signs of pain and distress (anxiety, crying, moaning, fidgeting, yelling, smacking, kicking, and tense posture), and staff and family reported that at least one nurse did not administer pain medication per hospice orders, sometimes stating the resident did not need it or was fine because she was sleeping. The surveyors concluded that these failures resulted in uncontrolled pain at end of life and required escalation and changes in the resident’s pain regimen to regain control. Additional information in the record showed that the resident’s daughter repeatedly voiced concerns that pain medications were not being administered when the resident was sleeping and that she wanted her mother awakened to receive ordered pain medication. A guest satisfaction concern form documented the daughter’s complaint that a nurse was not giving pain medication when the resident was sleeping, and anonymous staff interviews confirmed that the daughter was upset because a nurse did not administer medications per hospice orders and did not believe in hospice. The facility’s own soft file and corporate review acknowledged family concerns about pain management, and hospice documentation noted that a previous Oxycodone order had not been placed in the resident’s orders, resulting in the resident not receiving it until hospice intervened to have it added back. The DON and Administrator confirmed delays in implementing hospice orders, missed scheduled Oxycodone doses due to the resident sleeping, confusion over concurrent Oxycodone and Morphine orders, and lack of narcotic control documentation to support certain MAR entries. The surveyors determined that these actions and inactions constituted a failure to provide safe, appropriate pain management for a resident requiring such services, resulting in actual harm in the form of uncontrolled end‑of‑life pain. The record also referenced another resident who had concerns that pain medication was not provided upon request in a timely manner, though this concern was not incorporated into the facility’s investigation of pain management issues. The facility’s pain management policy stated that residents’ pain would be evaluated and identified, including in residents with dementia who cannot verbalize pain, and that behaviors such as calling out, facial expressions, refusing to eat, striking out when moved, or increased confusion could indicate pain. Despite this policy, the documentation for this hospice resident showed repeated non‑verbal signs of pain and family reports of suffering, alongside missed or delayed implementation of opioid orders, inconsistent documentation between MARs and narcotic logs, and staff decisions not to administer ordered opioids when the resident was sleeping. These documented events formed the basis of the cited deficiency for failure to provide safe, appropriate pain management.
Unaccounted and Undocumented Controlled Medications for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and account for a hospice resident’s controlled pain and anxiety medications, resulting in misappropriation concerns and undocumented administration. The resident had multiple diagnoses including chronic pain syndrome, Parkinsonism, osteoarthritis, neuropathy, cerebral infarction, and severe cognitive impairment, and was non-verbal with staff-assessed indicators of pain such as non-verbal sounds and facial expressions. The resident’s care plans called for consistent pain assessment, administration of ordered pain medications (including Oxycodone, Tylenol, Ibuprofen, Gabapentin, and later Morphine and Ativan), observation for side effects, and close collaboration with hospice to provide maximum comfort. Record review showed significant discrepancies between the MARs and narcotic control sheets for Oxycodone, Ativan, and Morphine. For Oxycodone 5 mg, the narcotic control sheet indicated 60 tablets received, with 27 remaining on one date and only one tablet documented as disposed of later, but there was no narcotic control sheet documentation for 16 doses that were recorded as administered on the MAR over several days. Reconciliation indicated there should have been 11 tablets remaining if the MAR entries were accurate, and the Administrator and DON confirmed there was no control sheet to account for the 27 tablets previously remaining. For Ativan 0.5 mg, multiple doses were signed out on the narcotic control sheet on several dates but were not documented on the MAR, and several refused doses were signed out on the control sheet without any evidence of wastage. Later, when the Ativan dose was changed to 1 mg scheduled and PRN, two tablets were removed per the control sheet but not documented on the MAR. For Morphine Sulfate, the resident had PRN orders that were later increased in dose and frequency, yet the narcotic control sheet showed multiple administrations on different dates that were not signed off on the MAR, and on another date several 0.5 ml doses were removed without the nurse signing the control sheet. The facility’s medication administration policy required recording dose, route, and time on the MAR, which was not followed in these instances. Anonymous staff interviews indicated the resident’s daughter was upset because a nurse would not administer pain medication per hospice orders, and the DON and Administrator confirmed the reconciliation findings, including that a nurse did not sign off Morphine on the control sheets on a specific date. The resident’s daughter also reported that her mother did not receive pain medication as ordered by hospice.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, and comfortable environment for residents, as evidenced by observations in 10 out of 13 rooms, one of two resident shower/bathing rooms, and common areas. Surveyors, accompanied by the Housekeeping Supervisor and Administrator, observed dusty and debris-laden handrails, dirt around baseboards, stained and discolored bathroom floors, overflowing trash cans, and dirty over-bed tables. In several rooms, there were additional issues such as bags with briefs and tissues on the floor, splatter on bathroom walls, and urine collection containers left behind toilets. The Housekeeping Supervisor verified these findings and acknowledged that some stains and discolorations could not be removed with current cleaning efforts. Further observations revealed holes in bathroom floor linoleum, rust spots, and overflowing trash cans with wet paper towels on the floor. The spa area had thick yellow and black discoloration on the tiles and walls, attributed to soap build-up. The Housekeeping Supervisor reported that only two housekeepers were scheduled daily, making it difficult to clean every room each day, with the goal being to clean each room at least every other day. The Administrator confirmed awareness of the stained bathroom floors and stated that discussions with corporate had occurred, but no definitive plans or timelines for repairs or material purchases were in place at the time of the survey.
Failure to Implement Physician-Ordered Fall Interventions
Penalty
Summary
The facility failed to implement physician-ordered fall interventions for one resident identified as being at risk for falls. The resident had multiple diagnoses, including generalized muscle weakness, difficulty walking, hypertensive heart disease, and affective mood disorder. The admission nursing assessment indicated the resident was alert and oriented, required one-person assistance for toileting and ambulation with a device, and had several fall risk factors such as muscle weakness, balance deficit, and medication use. Interventions listed in the care plan included encouraging appropriate footwear, maintaining a safe environment, PT/OT evaluation and treatment, providing diversionary activities, and ensuring the call light was within reach. Despite these interventions, a review of the resident's physician orders revealed specific directives for non-skid strips to be placed on the left side of the bed and for brightly colored tape to be applied to the call bell. During an observation with a registered nurse, it was verified that neither the non-skid strips nor the brightly colored tape had been implemented as ordered. This failure to follow physician orders for fall prevention measures constituted the identified deficiency.
Failure to Follow Infection Control Practices During Medication Administration and Incontinence Care
Penalty
Summary
The facility failed to implement appropriate infection control practices during both medication administration and incontinence care. During medication administration, an LPN was observed dropping a famotidine tablet on the floor, disposing of it, and then continuing to prepare and administer other medications to a resident without performing hand hygiene. The LPN also touched items in the resident's environment and assisted the resident to a seated position without hand hygiene. After leaving the room to obtain a replacement medication, the LPN returned and administered it to the resident, and then proceeded to assist another resident with eye care, again without performing hand hygiene. The facility's policy required hand hygiene after direct resident contact, which was not followed in these instances. During incontinence care, a CNA was observed providing perineal care to a resident using improper technique. The CNA used the same area of a washcloth to make multiple wipes in the same area of the pelvic region and then used the same area of the washcloth to clean the buttocks, moving from the coccygeal area downward. After completing care, the CNA adjusted the bed using the bed control prior to removing gloves and performing hand hygiene. The CNA later confirmed the improper technique and sequence of care. These actions were not in accordance with infection control practices outlined in the facility's policies.
Medication Labeling and Security Deficiencies
Penalty
Summary
The facility failed to ensure that over-the-counter medications had clearly labeled expiration dates, as observed in two of four medication carts. This deficiency had the potential to affect 18 residents who had orders for aspirin 81 mg. During medication administration, a nurse was unable to find an expiration date on an aspirin bottle but proceeded to administer the medication. Another nurse found the expiration date on a different aspirin bottle to be illegible and had to retrieve a new bottle. The facility's policy required the destruction and reordering of medications with illegible labels, which was not followed in these instances. Additionally, the facility failed to secure medications for two residents. One resident was found with Bengay cream at their bedside without an order to self-administer, and the facility policy required all medications to be securely locked. Another resident was observed self-administering allergy eye drops and had saline nasal spray at their bedside, which was brought in by a family member. The facility policy stated that all medications should be administered by staff and stored securely, which was not adhered to in these cases.
Failure to Ensure Privacy for Resident with Catheter
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident by not covering the catheter bag as required. Resident #289, who was cognitively intact and had multiple medical conditions including sepsis, congestive heart failure, and kidney failure, was observed in bed with an uncovered catheter urinary drainage bag. The resident confirmed that he had never seen a cover on the catheter bag, and the Registered Nurse acknowledged that all catheter bags should have a privacy cover, which was missing in this case. The facility's policy on Indwelling Urinary Catheter Care and Management, dated February 28, 2025, clearly stated that urinary drainage bags should be concealed with a dignity bag. Despite this policy, the observation on March 17, 2025, revealed non-compliance, as the catheter bag was not covered, compromising the resident's right to dignity. This deficiency was identified during a review of three residents for dignity, affecting one resident directly, with the facility having a total of five residents using catheters.
Inconsistent Advanced Directives Documentation
Penalty
Summary
The facility failed to ensure that advanced directives were consistent within the medical records of two residents. Resident #138, who had severe cognitive impairment, was documented as a Full Code in the electronic medical record, indicating that CPR should be performed if necessary. However, a Do Not Resuscitate Comfort Care (DNRCC) form was also present, indicating that no resuscitation should occur. This inconsistency was confirmed by Regional Nurse #1098, who acknowledged that the order and banner were not updated when the DNRCC form was signed. Licensed Practical Nurse (LPN) #1017 stated that she would rely on the computer banner or orders to determine a resident's code status. Similarly, Resident #139's medical record showed discrepancies in code status documentation. The face sheet and electronic health record indicated a Full Code status, while a signed DNRCC order was also present. Regional Nurse #1098 later provided a form indicating a change to Full Code, which had not yet been scanned into the system. The Director of Nursing (DON) and Regional Nurse #1098 confirmed that the code status book at the nursing station was not updated to reflect the change. This inconsistency was further verified by LPN #197 and Registered Nurse (RN) #1100, who indicated they would check the electronic health record or code book for code status information.
Failure to Maintain Sanitary Environment for Resident with Wound
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for a resident with a wound, specifically affecting a resident with an abscess on the left gluteal fold. The resident's medical record indicated diagnoses of depression, emphysema, anemia, and thrombocytopenia, with varying levels of assistance required for toilet use. An order was in place to cleanse the abscess with normal saline and apply Aquacel AG with border gauze daily. However, on one occasion, bowel movement was observed on both sides of the resident's toilet seat, and the resident was on contact isolation with personal protective equipment disposed of in the bathroom. The sink for handwashing was also located inside the bathroom, necessitating staff to enter the bathroom to dispose of PPE and perform hand hygiene. This unsanitary condition was verified by a registered nurse the following day.
Failure to Address Itching and CHF Indicators
Penalty
Summary
The facility failed to timely address reports of intense itching and skin impairment for a resident with multiple health conditions, including congestive heart failure (CHF) and chronic kidney disease. On several occasions, the resident reported itching on her right shoulder, which was attributed to arthritis and treated with a pain-relieving gel. However, observations revealed dry, flaking skin with scratches, indicating a possible adverse reaction to the gel. Despite the resident's complaints and visible skin issues, there was a delay in consulting with the nurse practitioner to address the itching and flaking skin. Additionally, the facility did not make timely notifications regarding indicators of CHF for the same resident. The resident experienced significant weight gain over several months, which was documented in dietary notes and nursing assessments. Despite the weight gain and the presence of edema in the lower extremities, there was a lack of timely communication with the nurse practitioner or physician to address these changes. The resident's weight was monitored, but the significant weight gain was not consistently reported as a potential sign of worsening CHF. The facility's weight management policy required the dietary manager, unit manager, or registered dietitian to communicate weight changes to the interdisciplinary team and the attending physician. However, there was confusion about the responsibility for reporting significant weight changes, leading to delays in addressing the resident's condition. The registered dietitian acknowledged the importance of timely notifications for residents with heart problems but noted that the responsibility for reporting had shifted without clear communication, contributing to the deficiency.
Failure to Implement Pressure Ulcer Care Interventions
Penalty
Summary
The facility failed to implement appropriate interventions and physician orders for pressure ulcer care for two residents. Resident #49, who has a history of type two diabetes mellitus, quadriplegia, anemia, and peripheral vascular disease, had a physician's order to cleanse a wound on the right lateral malleolus with normal saline, apply a CMC fiber dressing, and cover it with a foam patch daily. However, on 03/18/25, RN #1212 was observed applying only a dry dressing, omitting the CMC fiber dressing, which was later confirmed by the nurse. Resident #139, with multiple diagnoses including acute and chronic respiratory failure, morbid obesity, and chronic lymphedema, was readmitted with a stage four sacral ulcer and other skin issues. The baseline care plan included interventions for skin integrity, but observations revealed that Resident #139 was often lying on her back, adding pressure to the sacrum, and refused to reposition. The facility had not implemented specific interventions to address the risk factors of bed immobility and pressure, and the resident was using a regular bariatric mattress instead of a low air loss mattress, which was only ordered on 03/18/25. The Director of Nursing acknowledged the delay in obtaining the appropriate mattress and stated that it was the responsibility of the marketing director to review referral information for equipment needs. The facility's interdisciplinary team was expected to discuss Resident #139's care after her readmission, but the necessary interventions to prevent further skin breakdown were not timely implemented, contributing to the deficiency in care.
Deficiencies in Catheter and Bowel Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder and bowel, leading to deficiencies in preventing urinary tract infections (UTIs) and managing bowel function. The resident, who was cognitively intact, required substantial assistance with toileting and was frequently incontinent of urine and always incontinent of bowel. Despite having a Foley catheter, there was no documentation of catheter care being completed, and the catheter drainage bag was observed lying on the floor, contrary to facility policy. The resident's medical records revealed multiple instances of UTIs with bacteria such as Klebsiella and Escherichia coli. Interviews with staff indicated a lack of awareness regarding the documentation and care procedures for the Foley catheter. The catheter care task was not activated in the resident's electronic medical record, leading to a lack of documented evidence of care since the catheter's placement. Additionally, the resident experienced prolonged periods without bowel movements, with no documented interventions or physician notifications. The care plan indicated a risk for constipation, yet there was no evidence of actions taken to address this issue. Staff interviews revealed a lack of consistent procedures for monitoring and managing bowel movements, contributing to the deficiency in care.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper administration of oxygen as ordered by the physician for two residents. Resident #289, who had multiple diagnoses including congestive heart failure and pulmonary fibrosis, was observed with his oxygen set at three liters per minute, contrary to the physician's order of two liters per minute. Additionally, the oxygen tubing was not dated, and the resident was unsure of the correct oxygen setting or when the tubing was last changed. A registered nurse confirmed the incorrect oxygen setting and the absence of a date on the tubing. Similarly, Resident #292, who had diagnoses including kidney failure and heart disease, was observed with undated oxygen tubing. The resident could not verify when the tubing was last changed. A licensed practical nurse confirmed that all tubing should have been dated 03/12/25, as per facility policy, which mandates weekly changes and dating of oxygen masks and tubing. These deficiencies affected two of the three residents reviewed for oxygen administration, with the facility identifying 18 residents utilizing oxygen.
Inconsistent Dialysis Assessments for Resident
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were consistently completed for Resident #66, who required hemodialysis services due to end-stage kidney disease. The resident's care plan indicated the need for dialysis on specific days, and interventions included monitoring for medication side effects, checking the access site, and using a communication form to coordinate with the dialysis center. However, a review of the pre and post dialysis assessment forms from early February to mid-March 2025 revealed inconsistencies in documenting weights, the condition of the access site, mental status, and medication changes. An interview with LPN #1003 confirmed that the nurse on duty was responsible for completing the pre-dialysis form before the resident's departure and ensuring the dialysis center completed their portion upon the resident's return. The LPN acknowledged that the assessments had not been thoroughly completed and lacked documented evidence to verify that these assessments were conducted for Resident #66. The facility's policy required daily evaluations of dialysis access sites and potential complications, but this was not consistently adhered to, leading to the deficiency.
Medication Management Deficiencies in Pain and Insulin Administration
Penalty
Summary
The facility failed to ensure proper administration of pain medication and insulin for two residents, leading to deficiencies in medication management. For Resident #3, who was severely cognitively impaired and dependent on staff for most activities, the facility did not have clear parameters for administering narcotic pain medication. The resident received Tramadol for varying pain levels without documented evidence of nonpharmacological interventions being attempted first or the physician being contacted for alternative pain management strategies. The Director of Nursing confirmed the lack of documentation and the absence of a clear scale for assessing when to administer pain medication. For Resident #21, who was cognitively intact and had multiple diagnoses including diabetes mellitus, the facility failed to administer insulin according to the physician's orders. Despite having specific instructions to hold insulin if blood sugar levels were below 150, insulin was administered on several occasions when the resident's blood sugar was below this threshold. Additionally, there was no documented evidence of interventions being implemented when the resident's blood sugar dropped to 61, as per the facility's policy. The Director of Nursing confirmed that insulin was given outside of the prescribed parameters and that the physician should have been notified. The facility's policies on pain management and diabetic management were not adhered to, resulting in the improper administration of medications. The lack of documentation and failure to follow physician orders and facility policies contributed to the deficiencies identified during the survey. These actions and inactions affected the quality of care provided to the residents involved.
Failure to Obtain STAT Laboratory Tests and Document Orders
Penalty
Summary
The facility failed to ensure that a physician's order was written for laboratory tests and that these tests were obtained immediately (STAT) as ordered by the physician for a resident. The resident, who was admitted with multiple diagnoses including urinary tract infection, diabetes, and kidney failure, exhibited lethargy and minimal verbal interaction, prompting the Nurse Practitioner (NP) to order STAT laboratory tests, including a urine test, complete blood count (CBC), and complete metabolic panel (CMP). However, these orders were not documented in the medical record, and the laboratory specimens were not collected until the following morning, indicating a delay in obtaining the STAT tests. Interviews with the Director of Nursing (DON) revealed that the laboratory took up to four hours to pick up the STAT lab, and there was no written order for the laboratory work to be done on the day the NP ordered the tests. The DON confirmed the delay in the laboratory's pickup of the STAT urine culture and acknowledged the absence of a written order for the laboratory tests. Additionally, the facility lacked a laboratory services policy, which may have contributed to the oversight and delay in obtaining the necessary laboratory tests for the resident.
Failure to Update Pneumonia Vaccination for Resident
Penalty
Summary
The facility failed to ensure that a resident's pneumonia vaccination was up to date, affecting one of the five residents reviewed for vaccination status. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, epilepsy, chronic kidney disease, and shortness of breath, had received the pneumococcal polysaccharide vaccine 23 (PPSV23) on 11/19/23. According to the PneumoRecs Vax Advisor application and the facility's policy, residents over a certain age who have received the PPSV23 should be administered the Pneumonia conjugate vaccine 15 (PCV) or PCV20 one year after the PPSV23. However, the Director of Nursing confirmed that the resident was not up to date with her pneumonia vaccines, indicating a lapse in following the recommended vaccination schedule as per the facility's policy.
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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.
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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) |
|---|---|---|---|---|
| Carriage Inn Of Steubenville | 1.1 mi | ★★★★★ | 18 | 0 |
| Catherine's Care Center, Inc | 1.3 mi | — | 0 | 0 |
| Villa Vista Royale Llc | 1.7 mi | ★★★★★ | 3 | 0 |
| Steubenville Country Club Manor | 2 mi | ★★★★★ | 0 | 0 |
| Sienna Skilled Nursing & Rehabilitation | 3.6 mi | ★★★★★ | 24 | 0 |
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