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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Steubenville Country Club Manor during CMS and state inspections, most recent first.
A facility failed to ensure accurate recording of a resident's advanced directives. The resident's hard copy chart indicated a DNR-CCA directive, but this was not reflected in the EMR, where staff typically check for such information. Interviews with staff confirmed this inconsistency, which was against the facility's policy requiring directives to be in both the EMR and hard copy records.
A facility failed to accurately complete a PASRR for a resident upon admission. The resident's PASRR omitted diagnoses of bipolar disorder and PTSD, only indicating mood disorder and severe anxiety disorders. This was confirmed by an Admissions Coordinator interview.
A facility failed to monitor a resident's blood pressure before administering midodrine, an anti-hypotensive medication, as per the physician's order. The resident had a history of falls, subdural hematoma, craniotomy, cerebrovascular accident, hypotension, and hypertension. The medication was to be held if the systolic blood pressure was ≥150 mmHg, but the Medication Administration Record showed no evidence of monitoring. This was confirmed by the DON.
The facility failed to maintain complete and accurate documentation of showers for two residents, affecting their medical records. One resident, with multiple health conditions, had only one shower documented over a month despite a care plan for regular showers. Another resident, with mental health diagnoses, also had insufficient shower documentation. Interviews revealed that the transition to electronic records and staff forgetfulness contributed to the issue.
The facility failed to conduct assessments for proper antibiotic use for three residents, leading to the administration of antibiotics without documented justification. An LPN confirmed the absence of assessments, despite the facility's policy requiring the use of the McGeer Criteria for Infection Surveillance.
A facility failed to offer influenza and pneumococcal vaccines to a newly admitted resident with multiple diagnoses, as their policy only addressed annual vaccine offerings and not new admissions. An LPN confirmed the oversight, and the facility's vaccine policies lacked guidance for new admissions.
A facility failed to offer a COVID-19 vaccine to a newly admitted resident, who had no documented evidence of vaccination or declination. The resident's medical record lacked any vaccine information, and the facility's policy did not address offering vaccines to new admissions after the annual clinic. An LPN confirmed the oversight.
The facility failed to respond timely to residents' call lights, affecting four residents. Observations showed call lights left unanswered for extended periods, with residents reporting delays of up to an hour. Staff interviews revealed confusion over assignments and a lack of responsiveness, with an LPN noting that the issue was not due to staffing shortages but rather staff ignoring call lights. The DON acknowledged the problem, attributing it to staff congregating in one area.
The facility failed to honor the bathing preferences of three residents who were dependent on staff for assistance. A resident reported never receiving a shower since admission, despite her preference, and the DON confirmed the lack of documentation for her showers. Another resident's records did not specify the type of bath received, and the DON confirmed missing documentation for scheduled showers. Staff interviews revealed that bathing preferences were not honored due to time constraints.
The facility failed to ensure nursing assistants received required training before providing direct care, affecting all 46 residents. A nurse aide in training performed duties without formal training, and several nursing assistants were hired without being on the nurse aide registry or enrolled in training programs. The facility believed they had four months to enroll aides in classes, but some worked longer without enrollment.
The facility failed to maintain secure infection control records and did not investigate a resident's elopement incidents. The previous DON kept records on personal devices, leaving no retrievable data. Additionally, the facility did not follow up on elopement incidents, and the door alarm system was found to be non-functional.
The facility failed to maintain infection control logs and implement proper hand hygiene and PPE use, affecting two residents. An LPN used bare hands to handle medication, and another LPN did not follow hand hygiene or gown protocols during PEG tube care. Facility policies on hand hygiene and enhanced barrier precautions were not adhered to, leading to non-compliance with infection control standards.
The facility did not have a qualified Infection Preventionist (IP) after the Director of Nursing (DON), who was also the IP, left the facility. A Registered Nurse confirmed that no other staff member had the necessary training to fulfill the IP role, potentially affecting all 46 residents.
The facility failed to consistently implement restorative nursing programs for four residents, impacting their range of motion maintenance. A resident with COPD and heart disease rarely received the prescribed ROM exercises, while another with heart disease and dementia experienced inconsistent shoulder exercises. Two other residents with various conditions also faced irregular program delivery. A restorative aide reported being frequently reassigned, affecting program implementation.
The facility failed to act on pharmacy recommendations for four residents, leading to unaddressed medication use issues. A resident was prescribed risperidone without a supporting diagnosis, while another lacked scheduled TSH levels for hypothyroidism. Two residents on insulin had no A1c levels scheduled, despite pharmacy recommendations. The RN could not locate pharmacy reviews for the past six months, resulting in unaddressed recommendations.
The facility failed to properly label and store medications, affecting multiple residents. Observations revealed opened insulin vials without dates, an earwax solution not discarded after use, an unlabeled inhaler, and topical creams stored with oral medications. Staff confirmed that creams should be stored separately, highlighting non-compliance with medication storage policies.
The facility failed to maintain accurate medical records, affecting several residents. A resident was found outside unsupervised, with no documentation of the incident. There were also inconsistencies in documenting bathing and bladder care. Additionally, medication administration records were incomplete, with reports of nurses signing off on medications they did not administer. Another resident's records lacked documentation for bathing and toileting assistance, despite orders for hourly checks. Staff interviews suggested these were documentation issues.
A facility failed to consistently implement a stop sign across a resident's room to deter wandering residents, despite it being part of the care plan for a resident with dementia. Observations showed the stop sign was not properly positioned, and staff, including an LPN, did not address its placement, even though another wandering resident was present.
A resident with dementia and a history of wandering was found outside the facility unaccompanied by staff. Despite being assessed as a high risk for elopement, the facility failed to notify the resident's family and physician, as required by policy. The incident was not documented in the nursing notes, and the responsible RN did not recall making the necessary notifications.
A resident with a history of falls and multiple medical conditions experienced several unwitnessed falls, and the facility failed to complete the required neurological checks. Despite the protocol for 72-hour monitoring, checks were either not initiated or not completed as required, indicating a lapse in providing appropriate care.
The facility failed to implement effective elopement interventions and ensure the proper functioning of safety devices, affecting two residents. One resident, at high risk for wandering, lacked a care plan until after multiple elopement incidents. Another resident, at high risk for falls, experienced multiple falls without new interventions. The facility's policies on elopement and fall prevention were not effectively implemented, contributing to these deficiencies.
A facility failed to ensure adequate indications for the use of risperidone in a resident with multiple diagnoses, including dementia. The RN confirmed that dementia was not an acceptable indication for risperidone, and there was no documentation justifying its continued use. A black box warning on risperidone highlighted increased risks for elderly residents with dementia-related psychosis.
Inconsistent Recording of Advanced Directives
Penalty
Summary
The facility failed to ensure that advanced directives were accurately and consistently recorded in the medical records for Resident #30. This resident, who was admitted with multiple diagnoses including Alzheimer's Disease, dementia, and malignant melanoma, had a documented advanced directive of Do Not Resuscitate Comfort Care - Arrest (DNR-CCA) in their hard copy chart, signed by a physician. However, this directive was not recorded in the Electronic Medical Record (EMR) in the demographic section, where staff typically look for such information. Interviews with facility staff, including an LPN and the Assistant Director of Nursing, confirmed that the standard procedure was to check the EMR for a resident's code status, and if not found there, to refer to the hard chart. The facility's policy on Advanced Directives, last reviewed in June 2024, stated that all advance directive documents should be located in both the EMR and the resident's medical record for easy retrieval by staff. The inconsistency between the hard copy chart and the EMR led to a deficiency in maintaining accurate and accessible records of the resident's advanced directives.
Incomplete PASRR Assessment for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) was completed accurately for a resident upon admission. The resident, who was admitted with diagnoses including diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and post-traumatic stress disorder, had a PASRR completed that only indicated mood disorder and panic or other severe anxiety disorders. The PASRR did not reflect the resident's full mental health diagnoses, specifically omitting bipolar disorder and post-traumatic stress disorder. This discrepancy was confirmed during an interview with the Admissions Coordinator, who acknowledged that the PASRR did not include all current mental health diagnoses.
Failure to Monitor Blood Pressure Before Administering Hypotensive Medication
Penalty
Summary
The facility failed to ensure that a resident's blood pressure was monitored prior to the administration of hypotensive medication, as per the physician's order. The resident, who had a history of falls with subdural hematoma and craniotomy, cerebrovascular accident, hypotension, and hypertension, was prescribed midodrine, an anti-hypotensive medication, with specific parameters to hold the medication if the systolic blood pressure was greater than or equal to 150 mmHg. However, a review of the Medication Administration Record (MAR) showed that the medication was administered as ordered without evidence of the required blood pressure monitoring. This deficiency was confirmed during an interview with the Director of Nursing, who verified that the resident's blood pressure was not monitored prior to the administration of midodrine.
Incomplete Documentation of Resident Showers
Penalty
Summary
The facility failed to ensure that the medical records for two residents were complete and accurate, specifically regarding the documentation of showers provided. Resident #28, who has multiple diagnoses including malignant neoplasms and requires assistance with activities of daily living, had a care plan indicating showers were to be provided every Monday, Wednesday, and Friday night. However, the documentation from 01/12/25 to 02/12/25 showed only one shower was recorded as completed. Interviews with the Director of Nursing and CNAs revealed that showers were not consistently documented, and the transition from paper to electronic medical records contributed to this oversight. Similarly, Resident #8, who has diagnoses including diabetes mellitus and bipolar disorder, also required staff assistance with showers. The records indicated only one shower was documented in the prior 30 days, despite the resident expressing a preference for three showers a week. The Director of Nursing confirmed the lack of accurate documentation for showers provided to residents. The facility's shower policy requires documentation of each shower or refusal, but this was not adhered to, leading to incomplete records.
Failure to Conduct Antibiotic Use Assessments
Penalty
Summary
The facility failed to ensure that an assessment for proper indication of antibiotic use was completed prior to administering antibiotic medications to residents. This deficiency affected three residents out of five reviewed for medications, with a facility census of 42. The medical records of the affected residents revealed multiple instances of antibiotic use without documented assessments to determine the appropriate indication for their use. For example, Resident #7 was administered antibiotics such as doxycycline, Bactrim DS, cephalexin, and ciprofloxacin for various infections, but there was no evidence of any assessment completed to justify their use. Similarly, Resident #8 and Resident #10 were also given antibiotics for conditions like urinary tract infections, cellulitis, and pneumonia without documented assessments. The facility's infection preventionist, an LPN who started in December 2024, confirmed that no antibiotic assessments were completed for the affected residents during the specified dates. The facility's policy on the Antibiotic Stewardship Program, dated May 2024, required nurses to ensure that infections met the McGeer Guidelines by using the McGeer Criteria for Infection Surveillance Checklist. However, the previous infection preventionist and administrative nursing staff left no antibiotic assessments, leading to the deficiency. The LPN verified that the facility utilized the McGeer Criteria to determine appropriate use of antibiotics, but the required assessments were not conducted for the residents in question.
Failure to Offer Vaccines to New Admission
Penalty
Summary
The facility failed to ensure that a resident was offered influenza and pneumococcal vaccines after admission, affecting one of five residents reviewed for vaccines. The resident, who was admitted with diagnoses including diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and post-traumatic stress disorder, had no evidence of vaccines administered or any declination documented in their medical record. An interview with an LPN revealed that the facility's policy was to offer vaccines annually, but it did not address new admissions after the annual vaccine clinic. The facility's policies for influenza and pneumococcal vaccines, both dated March 2021, lacked instructions for offering vaccines to new admissions.
Failure to Offer COVID-19 Vaccine to New Admission
Penalty
Summary
The facility failed to ensure that a resident was offered COVID-19 vaccines after admission, affecting one of five residents reviewed for vaccines. The resident, who was admitted with diagnoses including diabetes mellitus, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, and post-traumatic stress disorder, had no evidence of any vaccines administered, including COVID-19, in their medical record. Additionally, there was no documentation of any declination of the vaccine. The facility's policy on COVID-19 vaccination did not include instructions for offering or reviewing vaccines for new admissions after the annual vaccine clinic. An interview with an LPN confirmed that the resident was not reviewed or offered the COVID-19 vaccine following their admission.
Failure to Respond Timely to Call Lights
Penalty
Summary
The facility failed to ensure the timely response to residents' call lights, affecting four residents out of 41. Observations revealed that call lights were left unanswered for extended periods, with one resident's call light remaining activated for eight minutes while staff walked by without responding. Another resident's call light was not answered for 21 minutes. Interviews with residents confirmed that call lights were often not answered promptly, with reports of waiting times ranging from 30 minutes to an hour. One resident, who suffers from chronic pain, expressed the need to activate her call light in advance to manage her pain medication schedule due to anticipated delays. Staff interviews indicated confusion over assignments and a lack of responsiveness to call lights. An STNA reported uncertainty about unit assignments due to a missing assignment sheet, leading to staff moving between units. An LPN confirmed that the issue was not due to staffing shortages but rather staff ignoring call lights or refusing to provide care to certain residents. The Director of Nursing acknowledged the ongoing issue of untimely responses to call lights, attributing it to staff congregating in one area rather than a lack of staff, as the facility had adequate staffing levels on the day of observation.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of three residents who were dependent on staff for assistance with activities of daily living. Resident #9, who was paraplegic and had multiple medical conditions, reported never having received a shower since her admission, despite her preference for one. The Director of Nursing (DON) confirmed the absence of documented evidence that Resident #9 received showers as per her preference. Similarly, Resident #22, who had hemiplegia and other significant health issues, was scheduled for showers on specific days, but the records did not specify the type of bath received, and the DON confirmed the lack of documentation for the scheduled showers. Resident #22's wife also expressed concerns about the care provided due to her husband's inappropriate behaviors. Resident #43, who had a history of cerebral infarctions and other health issues, was also dependent on staff for bathing. The records indicated that the resident received some form of bath on certain dates, but the type of bath was not specified, and the DON confirmed the lack of documentation for the resident's shower preferences. Interviews with State Tested Nurse's Aides (STNAs) and a Licensed Practical Nurse (LPN) revealed that resident bathing preferences were not being honored due to time constraints, with staff reporting insufficient time to complete scheduled showers. This deficiency was investigated under Complaint Number OH00157827.
Failure to Ensure Proper Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that nursing assistants received the required training before providing direct care to residents, potentially affecting all 46 residents. Employee #145, a nurse aide in training, had not started formal training classes but was performing duties equivalent to a state-tested nursing assistant, including helping with meals, providing showers, and incontinence care. Despite having previous experience in a group home, Employee #145 had not received dementia training or training on handling aggressive behaviors. The Human Resource employee confirmed that Employee #145 was not enrolled in classes and was functioning as a state-tested nursing assistant based on the Administrator's instructions. Additionally, the facility hired several nursing assistants who were not on the nurse aide registry at the time of hire and were not enrolled in nurse aide registry classes or nursing school. These employees, including STNA #155, STNA #120, and STNA #110, had their skills checked off on orientation checklists despite not being registered or enrolled in training programs. The Human Resource employee verified that the facility believed they had four months to enroll aides in classes, and some employees had worked longer than four months without being enrolled in the NATCEP program, as the Administrator decided the timing of enrollment.
Deficiencies in Record-Keeping and Elopement Investigation
Penalty
Summary
The facility failed to maintain secure and accessible records, specifically infection control surveillance logs, which were not available since February 2024. The previous Director of Nursing (DON) had kept these records on her personal devices, and upon her departure, the records were not retrievable. The current staff, including the Administrator and RN #100, were unable to locate any documentation or evaluations of infection data, indicating a lack of proper record-keeping and oversight. Additionally, the facility did not adequately investigate incidents of elopement involving a resident who left the facility on two occasions. The staff could not find any investigation or witness statements regarding these incidents. The Administrator believed the previous DON had handled the situation, but no follow-up was conducted. An inspection revealed that the door alarm system was not functioning properly, as no sound was heard when the door was opened, and the Administrator could not verify when the alarm was last checked or monitored.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control surveillance and implement appropriate hand hygiene and use of personal protective equipment (PPE) during care procedures, affecting two residents and potentially impacting all residents. During an entrance conference, the Administrator was unable to provide infection control surveillance logs for the past three months, as the previous infection control preventionist, RN #200, had left the facility and deleted records from her personal device. RN #100 attempted to gather information from other sources but could not find records beyond February 2024, and there was no evidence of trend evaluation or action taken based on infection data. During medication administration, an LPN dropped pills on a cart and used bare hands to pick up some of them before administering the medication to a resident. This action was acknowledged as inappropriate by the LPN. Additionally, another LPN failed to perform hand hygiene and did not don a gown while administering a water flush through a resident's PEG tube, despite the facility's policy requiring enhanced barrier precautions for such procedures. The LPN confirmed that her typical practice did not include wearing a gown for feeding tube care. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, as evidenced by the observations of staff not washing hands before direct resident care and not wearing gowns during high-contact activities. These deficiencies were identified during a survey and were part of a complaint investigation, highlighting non-compliance with infection control standards.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified individual was designated as the Infection Preventionist (IP) responsible for the infection prevention and control program. During the entrance conference, the Administrator reported that the Director of Nursing (DON), who was also assigned as the facility's IP, had their last day of employment on 05/15/24. Subsequently, on 05/21/24, a Registered Nurse (RN) confirmed that no other staff member had completed the specialized training required to serve as the IP. This deficiency had the potential to affect all 46 residents in the facility.
Inconsistent Implementation of Restorative Nursing Programs
Penalty
Summary
The facility failed to provide restorative nursing services as per program instructions to maintain the range of motion for four residents. Resident #10, diagnosed with conditions such as COPD, diabetes, and heart disease, was on a restorative nursing program for bilateral lower extremity active range of motion. However, the program was not consistently offered or documented, with records showing minimal engagement and no refusals documented. Resident #10 confirmed that staff rarely offered the ROM exercise program. Resident #9, with diagnoses including heart disease and dementia, was on an active range of motion program for the right shoulder. The program required cues and encouragement from staff, but records indicated inconsistent implementation, with only one day showing the program was conducted twice as required. Resident #9 expressed that STNAs did not consistently perform the exercise program, except during therapy sessions. Resident #2, diagnosed with COPD and osteoarthritis, was on a restorative program for both lower extremities and transfers. The program was not implemented as written, with records showing limited engagement. Similarly, Resident #42, with dementia and Alzheimer's, was on a passive range of motion and transfer program, which was also inconsistently provided. Restorative Aide #175 reported being frequently reassigned to floor duties, impacting her ability to perform restorative programs, and noted that other aides did not take responsibility for these programs.
Failure to Act on Pharmacy Recommendations for Medication Use
Penalty
Summary
The facility failed to ensure timely action on pharmacy recommendations for medication use, affecting four residents. Resident #13's medical record lacked a diagnosis to justify the use of risperidone, an antipsychotic medication, despite being prescribed for behaviors. The pharmacy review indicated the need for a diagnosis, but no physician response was documented. Resident #13 was under psychiatric care, but there was no documentation supporting the use of risperidone or its benefits outweighing the risks. Resident #40 was prescribed synthroid for hypothyroidism, but no Thyroid Stimulating Hormone (TSH) level was scheduled or obtained since the pharmacy recommendation. Resident #34, with diabetes and severe dementia, was receiving insulin without an A1c level scheduled, as noted in the pharmacy review. Similarly, Resident #10, also on insulin, had no A1c level scheduled since the pharmacy recommendation. The facility's RN was unable to locate pharmacy reviews for the past six months, leading to unaddressed recommendations and missing lab orders.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, affecting five residents. During an observation of the medication cart, it was found that a resident had two bottles of opened Humalog insulin without a date indicating when they were opened. The nurse stated that the insulin vials were transferred with the resident from another facility, and she was unaware of how long they had been opened. According to Medscape, open vials of Humalog insulin can be used for up to 28 days. Another resident had an earwax removal solution that was opened and labeled for a limited time, but it was not discarded after the order was fulfilled. Additionally, an inhaler was found in the medication cart with only the last name of a resident and no label, as the box with the label was sent with the resident upon discharge. Furthermore, during another observation, it was verified that several residents' topical creams were stored with oral medications, contrary to the facility's policy. The nurse confirmed that creams should be stored in the treatment cart, not with medications. This deficiency was investigated under a specific complaint number.
Inaccurate Medical Records and Documentation Issues
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records, affecting three known residents and potentially impacting all residents. For Resident #18, there was a lack of documentation regarding an incident where the resident was found outside without supervision, despite having a wander guard. Additionally, there were inconsistencies in documenting bathing and bladder care, with several days lacking entries. Interviews with staff suggested these were documentation issues rather than failures in care. The report also highlighted issues with medication administration documentation. An LPN mentioned hearing about day shift nurses administering night shift medications, which was corroborated by an RN who admitted to signing off on medications she did not administer. This practice was against the facility's Medication Administration policy, which requires nurses to sign the Medication Administration Record (MAR) only after administering medications. For Resident #47, there was a lack of documentation for bathing and toileting assistance during the last 30 days of their stay. Despite having orders for hourly incontinence checks, records were incomplete, and there was no documentation of bathing for extended periods. Interviews with staff indicated these were believed to be documentation issues, but the records did not specify the type of care provided. This deficiency was part of a broader investigation under specific complaint numbers.
Failure to Implement Stop Sign for Resident's Room
Penalty
Summary
The facility failed to implement a stop sign across a resident's room to deter wandering residents from entering, affecting a resident with dementia and cognitive communication deficit. The care plan for this resident, initiated in January 2014, included the use of a stop sign to prevent wandering residents from entering her room. Despite the care plan's directive, observations on multiple occasions revealed that the stop sign was not properly positioned across the door. The resident was assessed as severely cognitively impaired but was able to make herself understood and understand others. On several occasions, the stop sign was observed not being used as intended. Staff members, including a State Tested Nursing Assistant and a Licensed Practical Nurse, acknowledged the purpose of the stop sign but did not ensure it was in place. The stop sign was initially implemented to prevent another resident, who no longer resided at the facility, from entering the room. However, another wandering resident was present in the facility, yet the stop sign was still not consistently used. Staff members, including three unidentified staff and an LPN, passed by the room without addressing the stop sign's placement.
Failure to Notify Family and Physician of Resident Elopement
Penalty
Summary
The facility failed to notify the family and physician of Resident #18 when she was found outside the facility unaccompanied by staff. Resident #18, who had a history of wandering and was assessed as a high risk for elopement, was discovered outside the building by housekeeping staff. Despite being found without injuries, there was no documentation of notification to the resident's family or physician, as required by the facility's elopement policy. Resident #18 had multiple diagnoses, including dementia with agitation and major depressive disorder, and was assessed as severely cognitively impaired. The incident report from the night of the event indicated that the resident was confused about place and time, yet ambulatory without assistance. The responsible RN on duty did not recall notifying the physician or family, although the administrator was informed via text. The lack of documentation and notification represents a deficiency in the facility's adherence to its policies.
Failure to Complete Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed after unwitnessed falls for a resident with a history of falling and multiple medical conditions, including right-sided paralysis and hypertension. The resident experienced several falls, and the facility's protocol required neurological checks to be conducted following such incidents. However, the documentation revealed that these checks were either not initiated or not completed as required. For instance, after a fall on January 19, 2024, neurological checks were only documented between 6:00 P.M. and 7:00 P.M., failing to meet the 72-hour monitoring requirement. Further incidents on February 19, 2024, and May 2, 2024, also showed deficiencies in the completion of neurological checks. On February 19, checks were initiated but not continued for the full 72 hours, and on May 2, there was no record of checks being initiated at all. These lapses in following the facility's post-fall monitoring protocol indicate a failure to provide appropriate treatment and care according to the resident's needs and the physician's orders.
Failure to Implement Elopement and Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective elopement interventions and ensure the proper functioning of wanderguards and exit doors, affecting two residents. Resident #18, diagnosed with dementia and other conditions, was assessed as a high risk for wandering but lacked a care plan or interventions until after multiple elopement incidents. Despite being identified as a high risk in December 2023, no documented actions were taken until March 2024, when Resident #18 was found outside the facility twice. The facility's failure to monitor the wanderguard's functionality and the exit doors' alarms contributed to these incidents. Additionally, the facility did not maintain a comprehensive fall prevention program for Resident #13, who had a history of falls and was at high risk. Despite physician orders for the bed to remain in the lowest position, observations revealed the bed was often raised, increasing the risk of falls. Multiple falls occurred without post-fall evaluations or new interventions being implemented. The facility's lack of consistent monitoring and intervention for Resident #13's fall risk was evident in repeated incidents, including a fall in the bathroom where the resident was left unattended. The facility's policies on elopement and fall prevention were not effectively implemented, as evidenced by the lack of documentation, investigation, and monitoring of interventions for both residents. The absence of a coordinated response to the identified risks and the failure to ensure the functionality of safety devices contributed to the deficiencies noted in the report.
Inadequate Indication for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident had adequate indications for the use of a psychotropic medication, specifically risperidone. The medical record review revealed that the resident had multiple diagnoses, including hemiplegia, rhabdomyolysis, heart failure, and dementia, among others. A physician had ordered risperidone for the resident, but the Registered Nurse (RN) confirmed that dementia was not an acceptable indication for its use. The RN also noted that a gradual dose reduction had been attempted unsuccessfully, but there was no documentation to justify the continued use of risperidone, indicating that the benefits outweighed the risks. Further review of risperidone information on Medscape highlighted a black box warning against its use in elderly residents with dementia-related psychosis due to an increased risk of death, primarily from cardiovascular or infectious causes. Additionally, the risk of orthostatic hypotension was noted to be higher in the elderly with the use of risperidone. This deficiency affected one resident out of five whose medications were reviewed, in a facility with a census of 46.
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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) |
|---|---|---|---|---|
| Villa Vista Royale Llc | 0.2 mi | ★★★★★ | 3 | 0 |
| Carriage Inn Of Steubenville | 0.9 mi | ★★★★★ | 5 | 0 |
| Sienna Skilled Nursing & Rehabilitation | 1.9 mi | ★★★★★ | 28 | 0 |
| Laurels Of Steubenville The | 2 mi | ★★★★★ | 5 | 0 |
| Dixon Healthcare Center | 2.7 mi | ★★★★★ | 13 | 1 |
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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 June 2026) and official state health department websites.