Health inspection·August 5, 2019

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to ensure resident's rooms were maintained in a clean, sanitary, and safe condition. This affected five (Residents #3, #16, #20, #34, and #62) of 43 residents residing on 300 halls. Findings included: 1. Observation of Resident #62's room on 07/08/19 at 3:57 P.M. and 07/10/19 at 1:59 P.M., revealed the resident's entry door was cracked. The findings were verified with the Maintenance Director (MD) on 07/10/19 at 1:59 P.M. 2. Observation of Resident #34's room on 07/08/19 at 4:20 P.M. and 07/10/19 at 2:05 P.M., revealed the metal baseboard heating shield that ran along the bottom of wall was bent outward exposing the heating coils. The wall next to both beds had dried water lines running down the wall. The findings were confirmed with the MD on 07/10/19 at 2:05 P.M. 3. Observation of Resident #16's room on 07/08/19 at 3:45 P.M. and 07/10/19 at 2:02 P.M., revealed the bathroom wall had a large four foot by four foot square area under the sink that was missing tile, and the plywood was exposed. The findings were confirmed with the MD on 07/10/19 at 2:02 P.M. 4. Observation of Resident #20's room on 07/08/19 at 3:18 P.M. and 07/10/19 at 1:58 P.M., revealed there was dry tube feeding drippings on the resident's night stand, floor beside the resident's bed, and on the wall. The baseboard heating shield that ran along the bottom of the wall was not attached to the metal base exposing the heating coils. The findings were confirmed with the MD on 07/10/19 at 1:58 P.M. 5. Observation of Resident #3's room on 07/08/19 at 4:06 P.M. and 07/10/19 at 2:18 P.M., revealed the resident's bedside tables in her room were chipped, and the one by the window had a dried white substance on it. The privacy curtain was stained with a red/brown substance. There was a patched area on the wall by the clock that had not been sanded or painted. The findings were confirmed with the MD on 07/10/19 at 2:18 P.M. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 2 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on review of personnel files, new hire list, staff interview and review of the facility abuse policy, the facility failed to ensure all staff were checked against the Nurse Aide Registry prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all residents residing in the facility. Residents Affected - Many Findings include: Review of the new hire list dated 06/01/18 to 07/03/19 and personnel files revealed Housekeeper #8, Dietary Aide (DA) #13, DA #18, DA #25, DA #23, Hospitality Aide (HA) #29, DA #28, Director #32, [NAME] #41, HA #48, HA #50, Nurse Aide Training (NAT) #44, Laundry #66, HA #67, [NAME] #68, Maintenance Assistant (MA) #81, DA #89, DA #91, Maintenance Director (MD) #93, HA #94, HA #97, HA #104, HA #105, and NAT #110 had not been checked against the Nurse Aide Registry (NAR) prior to hire. Interview on 07/09/19 at 11:53 A.M., with Human Resource Director (HRD) #102 verified she had no documented evidence the above non-licensed staff were checked against the NAR to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. Review of the facility Abuse, Neglect, Misappropriation, and Exploitation policy originated dated 11/2016 revealed the facility would undertake background checks of all employees and to retain on file applicable record of current employees regarding such checks. The facility would do the following prior to hiring a new employee: 1a. Check with the Ohio NAR and any other nurse assistant registries that the facility had reason to believe contain information on an individual, prior to using the individual as a nursing assistant. b. Check with all applicable licensing and certification authorities to ensure that employees hold the requisite license and/or certification status to perform their job function and do not have a disciplinary action in effect against his or her professional license by state licensure agency because of a finding of abuse, neglect, exploitation or misappropriation of resident property; c. Conduct a criminal background check d. Verify that the applicant was not excluded from any Federally-funded health care programs. 2. All potential employees certify as part of the employment application process that they had not been convicted of an offense or otherwise have been found guilty of an offense that would preclude employment in a nursing facility. 3. It is the ongoing obligation of all employees to alert the facility of any convictions or findings that would disqualify them form continued employment with the facility under Ohio or Federal law, or the facilities policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 3 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure residents and/or resident representatives were notified, in writing, of a transfer to the hospital. This affected one resident (Resident #103) of one resident reviewed for hospitalization. Findings include: Record review revealed Resident #103 was admitted to the facility on [DATE] with diagnoses including pneumonia, heart disease, metabolic encephalopathy, anemia, sepsis, rheumatoid arthritis, chronic pain, acute and chronic respiratory failure, and dysphagia. The resident was discharged to the hospital on [DATE]. Review of Resident #103's discharge Minimum Data Set (MDS) dated [DATE] revealed the resident was discharged to an acute care hospital on [DATE]. Review of Resident #103's nurse progress notes dated 04/25/19 revealed the resident was directly admitted to the hospital with re-occurring pneumonia. The progress notes did not indicate the resident or family was notified of the transfer in writing. Interview on 07/10/19 at 2:57 P.M., with the Administrator verified there was no evidence written notification was provided to Resident #103 or her family after her transfer to the hospital on [DATE]. Interview on 07/11/19 at 8:39 A.M., with the Administrator, reported the facility did not have a policy that included notifying the resident/resident representative in writing upon transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 4 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident #13's Pre-admission Screening and Resident Review (PASRR) extension was completed. This affected one of one resident in the facility with a limited PASRR approval for skilled therapy. Residents Affected - Few Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses which included Developmental Delay with a recent fracture requiring short term rehabilitation. Review of the care plan initiated [DATE] revealed to follow the PASRR recommendations. Review of the admission Minimum Data Set (MDS) 3.0 dated [DATE] revealed the resident was cognitively intact, no level II PASRR was needed and active discharge planning was occurring. Review of the PASRR determination revealed the resident was approved for 60 days for skilled services. This determination expired on [DATE], and if an extension would be requested it must be done by [DATE]. Further review of the medical record revealed there was no evidence of a request for an extension yet the resident remained in the facility. On [DATE] at 12:30 P.M., interview with the resident revealed she was still not able to walk up steps, and the group home where she lived prior had steps. Her goal was to go back to the group home. No one had discussed her PASRR with her. On [DATE] at 9:10 A.M., interview with Social Service Designee (SSD) #16 revealed she had been in the position for about one month and was not aware of the residents 60 day PASRR that expired on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 5 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure a resident's comprehensive care plans included a care plan that identified him as having bilateral lower extremity contractures and reflected his non-compliance with restorative nursing for passive range of motion. This affected one (Resident #54) of 29 residents reviewed for comprehensive care plans. Findings include: A review of Resident #54's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included muscle wasting and atrophy, muscle weakness, difficulty in walking and contractures of an unspecified joint. A review of Resident #54's range of motion (ROM) assessment dated [DATE] revealed the resident was noted to have moderate limitations in range of motion in his hips, ankles, feet and toes when passive range of motion (PROM) was provided. The resident had severe limitations in ROM of his bilateral knees when PROM was provided. A review of Resident #54's Minimum Data Set (MDS) assessment, an assessment tool used by the facility to identify a resident's level of care for reimbursement purposes, dated 05/26/19 revealed the resident did not have any communication issues. His cognition was intact with no impairment noted. He was not identified on the MDS as having displayed any behaviors nor was he known to reject care. He required extensive assistance of two staff for bed mobility and was totally dependent on two staff for transfers. Ambulation did not occur. He was indicated on the MDS as having a functional limitation in his range of motion on both sides of his lower extremities. A review of Resident #54's active care plans revealed he did not have a care plan in place to address his contractures to his bilateral lower extremities. None of the existing care plans addressed him having contractures or included interventions that addressed them. On 07/09/19 at 8:19 A.M., an observation of Resident #54 noted him to have contractures of his bilateral lower extremities. He had his legs bent at the knees with his legs drawn up to where his heels were near his upper posterior legs. None of the observations made of the resident in bed or in his specialty chair noted him to have his legs extended out away in a normal anatomical position. On 07/11/19 at 3:57 P.M., an interview with Registered Nurse (RN) #45 confirmed Resident #54 had contractures of his bilateral lower extremities. She reported she was the facility's restorative nurse, and the resident had refused to participate in a restorative nursing program for passive range of motion. She also confirmed the resident's active care plans did not address his contractures nor did they indicate he was non-compliant with the restorative nursing program for passive range of motion that had been recommended by therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 6 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #45, a dependent resident, received assistance with showers as indicated on the Plan of Care. This affected one (Resident #45) of five residents reviewed for activities of daily living (ADL). Residents Affected - Few Findings include: Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, adult failure to thrive, and diabetes mellitus. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19, revealed a Brief Interview for Mental Status (BIM) score of 15, which indicated Resident #45 was cognitively intact. The MDS further revealed Resident #45 was totally dependent and required physical assistance of one person during bathing. Review of the Care Plan, initiated on 11/28/18, revealed the resident will have ADL needs met with staff assistance. During observations, between 07/08/19 and 07/10/19, the resident was wearing a blue hospital gown, which was not tied securely and was hanging loosely, exposing his chest. Resident #45's hair was uncombed and disheveled. During interview on 07/10/19 at 8:59 A.M., Resident #45 revealed that he never received a shower, and he only received a bed bath. He revealed that he would like to have a shower and would like to be out more often. Review of Resident #45's Shower Task Log revealed the resident did not receive a shower on 06/29/19, 07/03/19, and 07/06/19. Review of Resident #45's nursing progress notes and Shower Task Log did not reveal that he refused a shower. During interview on 07/10/19 at 9:10 A.M., State-Tested Nursing Assistant (STNA) #121 confirmed the resident had not received a shower since 06/28/19, as indicated on the Shower Task Log. During interview on 07/10/19 at 10:15 A.M., the Director of Nursing (DON) confirmed Resident #45's Shower Task Log indicated a shower schedule of Wednesdays and Saturdays, and that the resident did not receive a shower, per the plan of care, on 06/29/19, 07/03/19, and 07/06/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 7 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one to one activities were provided as planned for Resident's #11 and #22. This affected two of four residents reviewed for activities. Residents Affected - Few Findings include: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses which included dementia and Parkinson's disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable. Review of the 03/07/19 progress note revealed the resident had a change in condition and needed one to one activities at this time for socialization because the resident spend the majority of his time in his room. The residents likes included music and entertainment. Review of the residents current activities care plan initiated 03/12/19 revealed the resident would receive one to one visits two to three times a week for socialization. Interventions included to provide favorite activities such as television (TV), music, spiritual support and invite to sit in the lounge with other residents. Review of the May 2019 calendar revealed one to one visits were scheduled on 05/01/19, 05/06/19, 05/11/19, 05/19/19, 05/21/19, 05/24/19 and 05/28/19. Further review of the participation record revealed the resident received one to one visits on 05/01/19, 05/06/19, 05/11/19, 05/19/19, 05/21/19, 05/24/19 and 05/28/19 of reading. Review of the June 2019 calendar revealed one to one visits were scheduled on 06/01/19, 06/03/19, 06/09/19, 06/10/19, 06/11/19, 06/18/19, 06/22/19 and 06/27/19. Further review of the participation record revealed the resident received one to one visits on 06/01/19 of reading and TV, 06/03/19 and 06/09/19 of reading, 06/10/19 and 06/11/19 of reading and TV, 06/18/19 and 06/22/19 of reading, and 06/27/19 of reading and TV. Review of the July 2019 calendar revealed one to one visits were scheduled on 07/01/19, 07/07/19 and 07/13/19. Further review of the participation record revealed the resident receive one to one visits on 07/01/19 of reading and TV and 07/07/19 of reading. On 07/08/19 at 11:22 A.M., 12:42 P.M., 3:10 P.M., 4:25 P.M., 5:56 P.M. and 6:30 P.M., the resident was observed sleeping or not engaged in any activities. On 07/09/19 at 9:20 A.M., 2:10 P.M. and 3:16 P.M., the resident was observed sleeping or not engaged in any activities. On 07/10/19 at 10:12 A.M., 1:00 P.M. and 4:59 P.M., the resident was observed sleeping or not engaged in any activities. On 07/11/19 at 8:40 A.M., 10:19 A.M. and 11:16 A.M., the resident was observed sleeping or not engaged in any activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 8 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm On 07/11/19 at 10:35 A.M., interview with Activities Assistant (AA) #5 stated she provided one on one activities to residents on the days they were listed on the monthly calendars. She verified the one on one activities consisted of reading or watching TV with the resident despite other activities that could be done. She stated the visits were to be completed two to three times a week for about 20 minutes but were not always scheduled for two to three times a week and therefore not completed two to three times a week. Residents Affected - Few On 07/11/19 at 3:00 P.M., interview with Activities Director (AD) # 15 verified the resident did not receive one to one activities as planned nor were the one to one's provided individualized to the resident. 2. Resident #22 was admitted to the facility on [DATE] with diagnoses which included dementia. Review of the activity initial review dated 10/10/18 revealed the residents interests included crossword puzzles, music, religious services, visits and bingo. Review of the quarterly MDS 3.0 dated 04/18/19 revealed the resident was severely cognitively impaired. Review of the 04/18/19 activities progress note revealed the resident had continued to decline and no longer did self directed activities. The resident would be placed on one to one activities two to three times a week for socialization. Review of the residents current activities care plan initiated 04/19/19 revealed the resident would receive one to one visits two to three times a week. Interventions included to escort the resident off unit for programs of interest and provide items needed for self directed activities. The care plan was not updated to include individualized one to one activities according to the residents interests. Review of the May 2019 calendar revealed one to one visits were scheduled on 05/01/19, 05/06/19, 05/11/19, 05/19/19, 05/21/19, 05/24/19 and 05/28/19. Further review of the participation record revealed the resident received one to one visits on 05/01/19 of reading, on 05/06/19 and 05/19/19 of reading and TV, and on 05/21/19 and 05/24/19 of reading. Review of the June 2019 calendar revealed one to one visits were scheduled on 06/01/19, 06/03/19, 06/09/19, 06/10/19, 06/11/19, 06/18/19, 06/22/19 and 06/27/19. Further review of the participation record revealed the resident received one to one visits on 06/01/19, 06/09/19, 06/10/19, 06/11/19 of reading and TV, 06/18/19 and 06/22/19 of reading, and 06/27/19 of reading and TV. Review of the July 2019 calendar revealed one to one visits were scheduled on 07/01/19, 07/07/19 and 07/13/19. Further review of the participation record revealed the resident receive one to one visits on 07/01/19 and 07/07/19 or reading. Review of the 07/09/19 group activity participation log indicated the resident attended bingo at 2:15 P.M. despite the resident not getting out of bed and being observed in bed at 2:18 P.M. On 07/08/19 at 9:00 A.M., 2:50 P.M., 4:15 P.m., 5:46 P.M. and 6:37 P.M., the resident was observed in bed sleeping without the TV on and no activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 9 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm On 07/09/19 at 9:19 A.M., 10:48 A.M., 1:16 P.M., 2:18 P.M., and 3:00 P.M., the resident was observed in bed without the TV on and no activities. On 07/10/19 at 10:21 A.M., 11:13 A.M., and 5:32 P.m., the resident was observed in bed without the TV on and no activities. Residents Affected - Few On 07/11/19 at 8:45 A.M., 10:20 A.M. and 11:17 A.M., the resident was observed in bed without the TV on and no activities. On 07/11/19 at 10:35 A.M., interview with AA #5 stated she provided one on one activities to residents on the days they were listed on the monthly calendars. She verified the resident liked checkers, reading the paper and religious activities. She stated the visits were to be completed two to three times a week for about 20 minutes but were not always scheduled for two to three times a week and consisted of reading or watching TV with the resident. On 07/11/19 at 3:00 P.M., interview with AD # 15 verified the resident did not receive one to one activities as planned. AD #15 verified the resident had not been out of bed in months and verified the group activity of bingo on 07/09/19 at 2:15 P.M., participation log indicated the resident attended was inaccurate. On 07/11/19 at 3:45 P.M., interview with AD #15 verified the residents one to one activities were reading and watching TV and they were no individualized to the residents likes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 10 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #22 was admitted to the facility on [DATE] with diagnoses which included chronic embolism and deep vein thrombosis of left lower extremity and dementia. Residents Affected - Few Review of the physician's order dated 10/17/18 revealed for the resident was to wear compression stocking in the A.M. and remove them in the P.M. Further review of the skin integrity care plan initiated 10/11/18 revealed it was updated on 04/30/19 to have the resident wear compression stockings in the A.M. and remove them in the P.M. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed the resident was severely confused and required extensive assistance of one person for dressing. On 07/08/19 at 2:50 P.M. and 5:46 P.M., the resident was observed without her compression stockings on. On 07/08/19 at 6:36 P.M., the resident was observed without her compression stockings on. On 07/08/19 at 6:37 P.M., interview with STNA #7 verified the resident did not have on her compression stockings as ordered. On 07/09/19 at 9:19 A.M., 10:48 A.M., 1:16 P.M., 2:18 P.M. and 2:59 P.M., the resident was observed without her compression stockings on. On 07/09/19 at 3:00 P.M., interview with STNA #35 verified the resident did not have on her compression stockings as ordered. She stated there was no documentation to say what each resident needed for the aides to use as a guide. Information was passed on by verbal report or asking the nurse. On 07/10/19 at 10:50 A.M., interview with the Assistant Director of Nursing (ADON) #45 indicated the aides had a device list they could review. After obtaining the device list, which she verified had not been updated since 06/15/19, it revealed there was no indication the resident was to wear compression stockings. This is an example of continued noncompliance from the survey completed on 06/25/19. Based on record review, observation and interview, the facility failed to ensure Resident #17 was properly positioned in her wheelchair and failed to ensure Resident #22's compression stockings were worn per physician's order. This affected one (Resident #17) of two residents reviewed for positioning and one (Resident #22) of one resident reviewed for compression stockings. Findings include: 1. Medical record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including dementia, abnormal posture, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 04/10/19, revealed Resident #17 was totally dependent and required the assistance of two persons for transfers and mobility and had a limitation in range of motion of both lower extremities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 11 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm During observation on 07/09/19 at 9:02 A.M., the resident was sitting in her reclining wheelchair with both feet unsupported and dangling behind the footrests. During observation on 07/10/19 at 10:04 A.M., the resident was sitting in her wheelchair with both feet unsupported and dangling behind the footrests. The left footrest was placed in a vertical position. Residents Affected - Few During interview on 07/10/19 at 10:10 A.M., State-Tested Nursing Assistant (STNA) #92 verified Resident #17's feet were unsupported, dangling and not properly positioned on the footrests of the wheelchair. During interview on 07/10/19 at 10:15 A.M., Licensed Practical Nurse (LPN) #21 verified Resident #17's feet were dangling and not properly supported on the footrests of the wheelchair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 12 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to adequately assess resident's hearing loss and provide timely audiology services to assess hearing loss and repair of hearing aids to ensure the resident-maintained hearing abilities. This affected one (Resident #46) of one resident reviewed for hearing. Residents Affected - Few Findings included: Record review revealed Resident #46 was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses including communication deficit and diabetes. Review of Resident #46's 360 Care audiology visit dated 04/03/19 revealed the resident was seen by a nurse practitioner and reported chronic hearing loss and tinnitus (ringing or buzzing noise) in both ears. The resident reported her hearing aids were not working well or have been broken for almost four years. The left hearing aid was broken, and the right hearing aid didn't fit properly in her ear. The resident would like audiology to consult to get new hearing aids. An audiology referral recommendation was made on 12/03/18. An audiology referral recommendation was being made as the resident would benefit from a hearing test by an audiologist in the next one to six months for hearing loss based upon additional information from the facility, resident, and doctor. The resident needed a new pair of hearing aids. Review of Resident #46's communication deficit plan of care revealed the resident reported chronic hearing loss and chronic tinnitus. The resident's goal included the resident would retain/improve conversation. The resident's intervention included to arrange for a hearing consult as needed, and arrange for follow-up as ordered. There was no evidence the resident had hearing aids. Review of Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had adequate hearing and no hearing devices. Review of the MDS Resident Assessment Instrument (RAI) manual revealed to interview the resident and ask about hearing function in different situations, review the medical record, and prior to beginning the hearing assessment, ask the resident if he or she had own hearing aids or other hearing appliance and, if so, whether they were at the nursing home. Interview on 07/09/19 at 8:37 A.M., with Resident #46 revealed she had hearing aids that were in disrepair. She reported her hearing had changed due to her diabetes. She had been waiting four months to have a hearing test done so she could get new hearing aids. Interview on 07/10/19 at 10:41 A.M., the Administrator verified the resident had not seen the audiologist for hearing testing at this time. The audiologist would not be back until 08/07/19. Interview and observation on 07/10/19 at 1:02 P.M., of Resident #46 with Registered Nurse (RN) #84 revealed the resident had two hearing aids in a box in her dresser. One hearing aid was broken. The resident reported she had stepped on it. She has had the hearing aids for five to six years and had brought them to the facility upon admission. She reported she would like to hear again and would like new hearing aids. She reported she had voiced concerns to staff, however she still had not seen the audiologist for her hearing test. The television was playing at normal volume during observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 13 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The resident reported the voices on the television were muffled. RN #84 reported she was not aware the resident had hearing aids. Interview on 07/10/19 at 1:34 P.M., RN #84 (MDS nurse) verified she was not aware the resident had hearing aids, nor did she ask the resident during the last MDS assessment. She confirmed the RAI manual indicated to interview the resident and ask about hearing function in different situations, review the medical record, and prior to beginning the hearing assessment, ask the resident if he or she had own hearing aids or other hearing appliance and, if so, whether they were at the nursing home. RN #84 confirmed the current plan of care did not indicate the resident had hearing aids. She indicated she coded the MDS indicating the resident had adequate hearing based on her observation that the resident was able to hear her when speaking at normal tone and her television was at a normal volume. Event ID: Facility ID: 365271 If continuation sheet Page 14 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #38, who was at risk for developing pressure ulcers, had interventions in place to prevent the development of pressure ulcers. This affected one of one resident reviewed for pressure ulcers. Residents Affected - Few Findings include: Resident #38 was admitted to the facility on [DATE] with diagnoses which included cerebral vascular accident with right sided hemiparesis, muscle wasting, weakness and edema. The resident did not sleep in her bed but preferred to sleep in her wheelchair. Review of the impaired skin integrity care plan, initiated 10/17/18, revealed interventions included to encourage the resident to elevate her legs and include the resident and/or responsible party in the treatment plan. Review of the current physician's order initiated 04/07/19 revealed to encourage and assist the resident with elevating her heels while in bed, and assist with repositioning in bed at least every two hours and as needed. Review of the most recent Braden assessment, an assessment to determine the risk for developing pressure ulcers, dated 04/30/19 and completed by the wound Licensed Practical Nurse (LPN) #106, revealed the resident scored a 16 which indicated the resident was at risk for developing pressure ulcers. Review of the 05/13/19 Minimum Data Set (MDS) 3.0 assessment revealed the resident was not able to be interviewed. The resident required assistance from staff with activities of daily living (ADL) including dressing. The resident did not have any pressure ulcers. Review of the physician's order dated 05/01/19 revealed to apply Unna boot to the right lower extremity, a compression dressing made by wrapping layers of gauze around your leg and foot up to the base of the toes. It is often used to protect an ulcer or open wound. The Unna boot was covered with Co-Ban which was used to secure and protect the Unna boot. It also helped immobilize injuries and provide compression. The dressing was changed weekly on Wednesdays (Wednesdays in May 2019 were 05/01/19, 05/08/19, 05/15/19, 05/22/19 and 05/29/19). Review of the weekly skin rounds assessments dated 05/04/19 (Saturday), 05/12/19 (Sunday) and 05/25/19 (Saturday) revealed bony prominence's were assessed which included the right and left heel, and they were intact despite the heels not able to be observed due to the above dressing which could not be removed. The only pressure relieving device in place was a pressure relieving mattress. (Staff indicated the resident did not sleep in bed). Review of the May 2019 Treatment Administrator Record (TAR) revealed the documentation was not consistent to accurately reflect when the Unna boot was changed. Also the TAR indicated the resident legs were elevated daily while in bed despite the resident not sleeping in bed. Further review of the May 2019 Medication Administrator Record (MAR) revealed the resident was monitored for behaviors including resisting care and being non-complaint with treatment and there were no behaviors noted for the month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 15 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the weekly skin rounds assessments for June 2019 revealed the only assessment completed was on 06/01/19 which indicated the right heel was intact. This assessment was completed on Saturday. Review of the physician's order dated 06/06/19 revealed to cleanse the right heel with wound cleanser, apply opritcell, an alginate based gel fiber product (best used on wounds that have a large amount of exudate or fluid based inflammation) and used to provide an optimal moist wound healing environment and was indicated for use on partial and full thickness wounds. Then apply a foam dressing and change with the weekly (Wednesday) Unna boot dressing. Review of the 06/06/19 wound observation evaluation indicated the resident was admitted with a right heel stasis ulcer with a small amount of serosanguineous drainage measuring 2.0 centimeters (cm) in length by 1.0 cm in width by 0.3 cm in depth with pink peri-wound tissue and well-defined shape and edges which was found during the weekly removal of the Unna boot. No new pressure relieving interventions were initiated for the heels. Further review of the 06/19/19 wound observation evaluation indicated the wound was unchanged yet slough tissue was present in the center and the width grew to 2.0 cm's. Further review of the 06/26/19 wound observation evaluation indicated the wound was unchanged yet 40 percent of necrosis and/or slough comprised the wound bed and the width measured 3.0 cm's. Review of the June 2019 TAR revealed the documentation was not consistent to accurately reflect when the Unna boot and dressing to the right heel were changed. Also the TAR indicated the residents legs were elevated daily while in bed. Further review of the June 2019 MAR revealed the resident only had behaviors on two days for the month 06/14/19 and 06/23/19. Review of the revised skin integrity care plan, dated 07/01/19 revealed the resident had a venous stasis pressure ulcer to the right heel. There were no added interventions for the development of the wounds. Review of the 07/03/19 wound observation evaluation indicated the wound was unchanged yet the length measured 3.0 cm's. The wound was moist with yellow slough and slightly macerated. No interventions were put into place. Review of the July 2019 TAR revealed the residents legs were elevated daily while in bed. Further review of the July 2019 MAR revealed the resident resisted care one time on 07/02/19. On 07/08/19 at 9:10 A.M. and 11:19 A.M., the resident was observed in her wheelchair with Unna boots and socks, and her feet were on the floor. On 07/08/19 at 11:20 A.M., interview with the resident revealed when asked about any sores or open areas she pointed to her legs but was not able to give any additional information. On 07/08/19 at 4:20 P.M., 5:47 P.M. and 6:35 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor. On 07/09/19 at 9:19 A.M., 10:46 A.M., 12:30 P.M. and 1:15 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor. On 07/09/19 at 1:16 P.M., interview with Licensed Practical nurse (LPN) #19 revealed the resident did not sleep in bed. The family bought her a recliner so she could elevated her legs, but she did not like that either and preferred to sleep in her wheelchair. LPN #19 verified the resident had not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 16 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 worn any protective boots on her feet but usually just wore socks. Level of Harm - Minimal harm or potential for actual harm On 07/09/19 at 3:20 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor. Residents Affected - Few On 07/10/19 at 11:12 A.M. and 12:58 P.M., the resident was observed in her wheelchair with Unna boots and socks and her feet on the floor. On 07/10/19 at 5:00 P.M., interview with the wound nurse, LPN #106, revealed the right heel wound currently measured 3.5 cm by 2.0 cm by 0.2 cm with 90 percent granulation and slough. LPN #106 verified she coded the heel as a stasis ulcer but could have been developed from the Unna boot. She verified there were no appropriate interventions in place prior to the development of the wound to the heel nor were any additional interventions implemented after development of the wound except for the treatment of the wound. On 07/10/19 at 5:15 P.M., observation of the wound with LPN #106 and the wound physician #300 revealed a large area over the bony prominence of the right heel with pink tissue around the wound, but the wound was covered with a white area and had depth to it with drainage. During the observation the resident was very anxious and moving around while laying in bed repeatedly saying hurry I have to get up I have things to do. On 07/10/19 at 5:25 P.M., interview with wound physician #300 verified the right heel was on the bony prominence of the right heel and was in fact a pressure ulcer and not a stasis ulcer. The physician indicated the wound had not gotten better and was going to change the treatment but decided to wait another week. The physician was aware the resident did not sleep in bed nor did she like to elevate her legs, and she liked to stay in her wheelchair. On 07/11/19 at 5:40 P.M., interview with LPN #106 verified the TAR was inconsistent and could not accurately reflect when the weekly dressing changes of the Unna boot were completed, verified there were no interventions prior to or after the development of the heel pressure ulcer to alleviate pressure off the heels, verified the resident did not sleep in bed despite the TAR indicating she did daily and verified she coded the pressure ulcer as a stasis ulcer and inadvertently coded the wound as developed on admission when the wound was actually acquired while the resident was in the facility. She verified the right heel wound was originally found as a blister but had a depth of 0.3 cm and was not able to provide any addition descriptions of the wound when found on 06/06/19. LPN #106 verified the size of the wound had gotten bigger and there had been no improvement in the wound since found on 06/06/19. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 17 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #38 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident with right sided hemiparesis, muscle wasting and weakness. Review of the 02/05/19 MDS 3.0 assessment revealed the resident was not able to be interviewed. The resident required assistance from staff with activities of daily living (ADL) including bed mobility, transfers and toileting. The resident was unsteady without the assistance of staff. Review of the nurse's note dated 04/14/2019 at 1:45 A.M. indicated the resident was heard shouting out from her room, Help. The resident was found sitting upward on floor. The resident had missed her wheelchair to use the bathroom and was sitting on the floor. The resident was educated to use her call light for assistance when she wanted to use the restroom. Further review of the IDT note dated 04/15/19 revealed a dycem, a sticky pad used to reduce sliding potential, was placed in the seat of the wheelchair. There was no further documentation of the fall in the medical record. It was unclear were the resident was prior to the fall and there was no evidence the call light was within reach or what if any other fall interventions were in place. Review of the fall risk assessment dated [DATE] indicated the resident did not have any falls in the last 90 days. Review of the nurse's note dated 06/18/2019 at 1:45 A.M., revealed the resident was observed on the floor on her back on the left side of the bed. No injuries were noted. Review of a nurse's note dated 06/20/19, revealed the resident was trying to get to her chair and indicated the resident was currently in skilled therapy for function decline in ADL. The IDT note indicated to ensure the bed was locked and in the lowest position. On 07/08/19 at 11:20 A.M., interview with the resident revealed she had fallen and had gotten hurt but she was not able to describe her injuries. On 07/08/19 at 4:20 P.M., 5:47 P.M. and 6:35 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. On 07/09/19 at 9:19 A.M., 10:46 A.M., 12:30 P.M. and 1:15 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. On 07/09/19 at 1:16 P.M., interview with LPN #16 verified the resident did not have on non-skid socks. On 07/09/19 at 3:20 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. 7/10/19 at 11:12 A.M. and 12:58 P.M., the resident was observed in her wheelchair with socks on that were not non-skid. On 07/11/19 at 11:20 A.M., interview with the DON verified the fall investigations were available and located in the computer system but none were completed for the 04/14/19, 06/18/19 or 06/20/19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 18 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few falls. The DON verified there was no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the fall, if appropriate interventions were in place after the fall and no monitoring to ensure planned interventions were put into place. Based on medical record review, policy review, observation and interview, the facility failed to ensure fall interventions were in place for four residents (Resident #73, #38, #92 and #153) and failed to complete fall investigations for three (Resident #73, #38, and #153) of five residents reviewed for falls. Actual Harm occurred on 05/15/19 when Resident #73, who was determined to be at a high risk for falls, attempted to transfer himself, resulting in an acute, closed head injury, hematoma to the back of his head, and skin tears requiring emergency care and on 05/12/19 and when Resident #153, who was confused and determined to be at risk for falls, attempted to toilet himself resulting in a hip fracture requiring surgical intervention. There was no evidence planned interventions were in place prior to the fall. Findings include: 1. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle wasting and atrophy, and difficulty walking. Review of a nursing progress note, dated 02/17/19, revealed the resident was found lying on the floor of his room. A skin tear was noted to his left elbow, and he stated that he bumped his head. A new intervention for visual reminders, to ask for assistance when getting out of bed was initiated. A fall investigation was not completed by the facility. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/07/19, revealed the resident required extensive, one-person assistance for mobility, transfers, and dressing. Review of a nursing progress note, dated 05/15/19, revealed the resident was found in his room, lying on his back on the floor, with his head near the foot of the bed. The resident stated that he was trying to get up and didn't make it to the chair. The resident received skin tears to the right and left forearms, and a hematoma to the back of his head. Review of a nursing progress note, dated 05/15/19, revealed the resident was sent to the emergency room and diagnosed with an acute closed head injury related to the fall. A fall investigation was not completed by the facility. Review of Resident #73's physician order, dated 05/15/19, revealed an order for non-skid socks, to be worn at all times. Review of the Plan of Care, dated 05/15/19, revealed a fall intervention for non-skid socks to be worn at all times. Review of a nursing progress note, dated 05/22/19, revealed the resident was found sitting on the floor, leaning against his bed. The resident was wearing plain, cotton socks with no shoes. Bruising was noted to the resident's neck. The physician ordered an x-ray of the right shoulder and clavicle due to the resident complaining of pain in that area and cervical x-rays of the spine. Review of the cervical spine x-ray findings, dated 05/22/19 revealed no acute findings. A fall investigation was not completed by the facility. There were no fall investigations following the falls on 02/17/19, 05/15/19 and 05/22/19. During interview on 07/11/19 at 11:40 A.M., the Director of Nursing (DON) reviewed the progress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 19 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few notes and confirmed the fall intervention for non-skid socks was not in place at the time of the fall on 05/22/19. The DON further confirmed there was no fall investigation following the falls on 02/17/19, 05/15/19 and 05/22/19, resulting in no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the falls, if appropriate interventions were in place after the fall, and there was no monitoring to ensure planned interventions were put into place. The DON stated that fall investigations were not completed for every fall, prior to three weeks ago, when she assumed the role of DON. Review of the facility's policy titled, Managing Falls and Fall Risk, revised May 2019, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 2. Resident #153 was admitted to the facility on [DATE] with diagnoses which included abnormal gait and mobility and muscle weakness. The resident was mobile in a wheelchair. Review of the baseline care plan dated 05/08/19 revealed the goal was for the resident to be free from fall related injury, provide side rails, assist the resident with mobility as needed, ensure proper footwear, assist with toileting needs and incontinence care on routine rounds and as needed, keep bed in the lowest position, ensure call light was within reach, keep fluids and frequently used items within easy reach, observe medication use for side effects that may increase fall risk, and provide verbal reminders to not transfer or ambulate without assistance. There was no evidence the resident and/or family participated in the plan. Review of the 05/08/19 nurse's note revealed the resident was only oriented to person and place. Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of the 05/09/19 nurse's note revealed the resident was oriented to person and place with confusion. Review of the five-day MDS 3.0 assessment dated [DATE] revealed the resident's cognition was not assessed but he required extensive assistance of two or more staff for bed mobility, transfers and toileting. The resident did not walk. The resident was not steady, only able to stabilize with staff assistance for surface to surface transfers. Review of the nurse note dated 05/12/19 at 12:00 P.M., revealed the staff was notified by a visitor the resident had fallen. Upon entering the resident's room the resident was found laying on the floor outside of the bedroom door in the common area on his left side with his back facing the door. The resident had on slipper socks. The resident stated he was going to the bathroom and complained of left hip pain. The resident presented with severe pain and decreased range of motion to the left leg. The resident was sent to the hospital. Review of the hospital x-ray dated 05/12/19 revealed the resident had a left femoral neck fracture with impaction. Further review of the hospital consultation note dated 05/12/19 revealed the resident would be scheduled for surgery to perform a left bipolar hemiarthroplasty. The resident was discharged back to the facility after recovering from the surgery on 05/16/19. Review of the interdisciplinary team meeting (IDT) note dated 05/13/19 revealed the intervention was going to be to move the residents room for easier access to the restroom and closer to the nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 20 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few The resident would also be placed on every two hour toileting. Further review of the medical record revealed there were no further documentation related to the fall, interventions, causes or evidence interventions were in place prior to the fall. There was no investigation completed for the fall. Review of the census indicated prior to the fall the resident was in room [ROOM NUMBER] and after the fall, when the resident returned from the hospital on [DATE] the resident was placed in room [ROOM NUMBER] which did not follow the above intervention. Review of the fall risk care plan initiated 05/17/19 revealed on 05/12/19 the resident was to be toileted every two hours per order. Further review revealed there were no further interventions initiated until 05/17/19 which included to assist the resident with mobility as needed, assist the resident with wearing proper footwear, assist with toileting needs and incontinence care on routine rounds and as needed, include the resident and/or family in the treatment plan, keep call light in reach, keep fluids and frequently used items within easy reach, observe medications use for side effects that may increase fall risk, remind resident and assist with use of mobility devices as needed and therapy screens as needed. Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of the nurse's note dated 06/20/19 at 2:30 A.M., revealed the resident was found on the floor in the bathroom. Further review of the IDT note revealed the resident was educated on safety awareness when transferring. No interventions were put into place nor was it determined if prior interventions were in place at the time of the fall. There was no investigation completed for the fall nor any additional information available in the medical record. There was no order for or evidence the resident was toileted every two hours as planned. On 07/08/19 at 4:04 P.M., the resident was observed being pushed back to his room in his wheelchair by staff, he had socks on his feet. On 07/08/19 at 5:35 P.M., the resident was observed in bed which was not in the lowest position and he was bare foot. On 07/08/19 at 5:36 P.M., attempted interview with the resident revealed he had no recollection of either of the above falls. On 07/09/19 at 9:11 A.M., the resident was observed in his recliner in the room without a call button available if he needed assistance. On 07/09/19 at 2:50 P.M., the resident was observed in bed which was not in the lowest position and the resident was bare foot. On 07/11/19 at 11:20 A.M., interview with the Director of Nursing (DON) verified the fall investigations were to be completed in the computer system but none were completed for the 05/12/19 or 06/20/19 falls. The DON verified there was no investigation to attempt to determine the root cause of the falls, if planned interventions were in place at the time of the fall, if appropriate interventions were in place after the fall and no monitoring to ensure planned interventions were put into place. On 07/11/19 at 11:35 A.M., interview with the MDS and care plan Licensed Practical Nurse (LPN) #56 revealed the admitting nurse completed the baseline care plan and it was not discussed as a team and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 21 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few then she completed the subsequent care plans based on the data from the MDS. She verified the two hour toileting was initiated prior to the development of the 05/17/19 falls care plan because it was a fall intervention. 3. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and difficulty walking. Review of the MDS 3.0 assessment, dated 06/30/19, revealed the resident required limited, one-person assistance for mobility and transfers and supervision, one-person assistance for dressing. Review of a Fall Incident Audit Report, dated 09/05/18, revealed Resident #92 was found lying face-down on the floor, beside her bed on 08/27/18. A hematoma and abrasion were noted to the right, upper arm, and a skin tear was noted to the right and left forearms. No further injuries were observed. The resident stated she was reaching to get a drink of water when she lost her balance and fell on the floor. A new intervention to ask for assistance when getting out of bed was initiated. Review of a Fall Incident Audit Report, dated 07/10/19, revealed a fall occurred on 07/07/19 when the resident was overheard yelling help and found in her room, lying face down on the floor in front of her wheelchair. The resident stated that she was trying to wheel to the bathroom when her foot got stuck. The resident was observed wearing slide sandals with slick soles. The resident received an abrasion and two superficial lacerations to the forehead. The new intervention initiated was for the resident to wear non-skid socks, when not wearing non-skid shoes. An x-ray was ordered of the left ankle on 07/08/19, which revealed no fracture or dislocation. Review of Resident #92's Plan of Care, dated 08/28/18, revealed a new fall intervention to assist the resident with ensuring she was wearing proper footwear. During interview on 07/11/19 at 11:40 A.M., the Director of Nursing (DON) reviewed Resident #92's progress notes and confirmed the fall intervention for appropriate, non-skid footwear was not in place at the time of the fall on 07/07/19. Review of the facility's policy titled, Managing Falls and Fall Risk, revised May 2019, revealed if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 22 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Resident #45's urinal was located at his bedside, as indicated on the Plan of Care. This affected one (Resident #45) of one resident reviewed for bowel and bladder incontinence. Findings include: Medical record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, adult failure to thrive, and diabetes mellitus. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #45 was cognitively intact. The MDS further revealed Resident #45 required extensive, physical assistance by two-persons during toileting and was frequently incontinent of urine and bowel. Review of the Care Plan, initiated on 11/28/18, revealed the resident will have activities of daily living (ADL) needs met with staff assistance, and the resident preferred to leave his urinal nearby, located on his bedside table and/or side rail. During observation on 07/08/19 at 11:51 A.M., there was no urinal located in the resident's room. During interview on 07/08/19 at 11:52 A.M., the resident revealed that he did not know the location of his urinal. During observation on 07/08/19 at 2:52 P.M., the urinal was not located in the resident's room. State-Tested Nursing Assistant (STNA) #110 entered the room and checked Resident #45's incontinence brief for wetness. STNA #110 revealed the resident sometimes uses his urinal and is checked for incontinence every two hours. During interview on 07/08/19 at 2:53 P.M., STNA #110 verified there was no urinal in the room, and she would go and get a urinal for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 23 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #11, who sustained significant weight loss, had a comprehensive interdisciplinary plan of care in place including nutritional assessments to monitor the residents weights and provide adequate interventions in an attempt to decrease the weight loss and ensure the resident maintained optimal intake. This affected one of two residents reviewed for nutrition. Residents Affected - Few Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses which included dementia and Parkinson's disease. Review of the nutrition care plan initiated on 11/22/17 revealed the resident would be free of unavoidable weight fluctuations. The intervention was to encourage the resident to eat, observe the ability for the resident to feed himself, and provide assistance with meals as needed. The care plan was not revised until 02/26/19. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was not interviewable. Review of the physician's order dated 11/15/17 revealed the resident had been on 40 milligrams of Lasix, a diuretic, which was continued until 02/16/19 when the resident went to the hospital. Review of the December 2018 meal intake record revealed intake was sparatic with zero to 75 percent intakes and 22 meals not documented, with many intakes less than 50 percent. Review of the Occupational Therapy (OT) evaluation dated 12/19/18 revealed the resident was having increased difficulty feeding himself. Upon assessment he required maximum assistance to complete self-feed with the use of built-up utensils. The resident presented with decreased coordination that impacted his feeding performance. Review of the January 2019 meal intake record revealed the resident consumed less than 50 percent of at least half of the meals for the month. Review of the 01/07/19 weights revealed the resident was 236 pounds which was stable for the resident. Review of the physician's progress note dated 01/07/19 revealed there was no indication the physician was made aware of the residents decline in being able to feed himself. Review of the 01/10/19 quarterly nutrition assessment revealed no changes in weight. The resident was on Lasix which could contribute to weight fluctuation and no edema was noted. There were no current interventions. The resident was confused and was consuming an average of 60 percent of his meals. Staff were to encourage meals were greater than 50 percent each day. There was no mention of the residents decreased ability to feed himself requiring skilled therapy. Review of the OT Discharge summary dated [DATE] revealed the staff were educated the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 24 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few required cues during meals to maintain his attention for eating. The staff were to have the resident out of bed for all meals. The resident was referred to the restorative dining program. Review of the restorative program note dated 01/24/19 revealed the resident was referred to restorative dining for all meals after completing skilled therapy. Further review of the restorative grids for January 2019 revealed the resident did not participate in any of the dinner meals. Review of the February 2019 meal intake record revealed the resident refused or took in minimal amounts of food with 11 meals not documented until 02/12/19 when the resident went to the hospital. Review of the restorative grids for February 2019 revealed the resident did not participate in any of the dinner meals, and there were 11 meals without any documentation prior to 02/12/19 when the resident was sent to the hospital. Review of the 02/04/19 weight revealed the residents current weight was 199 pounds, which was a 37 pound weight loss in one month. Further review of the re-weight on 02/04/19 revealed the weight was 197 pounds or a 39 pound weight loss in one month. Review of the nutrition progress note dated 02/04/19 revealed the resident lost 37 pounds in one month and was a significant weight loss for one, three and six months. The note stated the resident continued on Lasix which could cause weight fluctuation, and the resident had bilateral lower extremity edema. The note indicated the physician did not feel the weight loss occurred in the last 30 days and gradual weight loss was desired. The resident had edema to the bilateral lower extremities at this time. The resident was being fed at meals by staff when he stayed in bed. There were no interventions put into place. Review of the psychiatrist order dated 02/08/19 revealed to initiate Remeron (an antidepressant also used for behavioral disturbances and an appetite stimulant) at night for behavioral disturbances. Further review of the note revealed staff reported the resident was mean and had an increase in combativeness at times but he was more so verbally aggressive towards them. Review of the nutrition progress note dated 02/12/19 revealed the residents weight on 02/11/19 was 193 pounds which was a six pound weight loss in seven days. There were no interventions put into place by the Registered Dietetic Technician (DTR) #118. Review of the hospital discharge note dated 02/16/19 revealed the resident had diagnoses included acute encephalopathy, urinary tract infection requiring antibiotics and atrioventricular block. The resident failed a swallowing study and was ordered nothing by mouth. On 07/10/19 at 12:50 P.M., interview with DTR #118 verified she was the one who completed the progress notes. DTR #118 verified the nutritional care plan had not been updated to indicate the resident was having difficulty feeding himself requiring skilled therapy starting in December 2018, to indicated the resident was in restorative therapy in January 2019 nor addressing the recent significant weight loss. DTR #118 verified the notes indicated to ensure the resident ate at least 50 percent of his meals and when he did not she did not address the concern. On 07/08/19 at 5:46 P.M., the resident was observed reclined in a Broda chair receiving his nutrition through a feeding tube. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 25 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 On 07/10/19 at 1:35 P.M., interview with the Administrator reviewed and verified the above concerns. Level of Harm - Minimal harm or potential for actual harm On 07/10/19 at 2:35 P.M., interview with Occupational Therapist (OT) #108 revealed therapy was asked to pick up the resident in December 2018 because he was having a decline in feeding himself and not eating as much. OT #108 verified upon discharge from skilled therapy the resident was referred to restorative dining in January 2019 because he needed cueing and at times fed meals. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 26 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to timely administer Resident #18's narcotic pain medication. This affected one (Resident #18) of four residents reviewed for pain management. Residents Affected - Few Findings include: Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including low back pain, displaced fracture of the neck, and muscle weakness. Review of the Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #18 was cognitively intact. The MDS further revealed the resident had frequent pain and the administration of opioid pain medication. Review of the Care Plan, dated [DATE], revealed the intervention to administer pain medication as ordered, observe for effectiveness and/or side effects, and to update the physician, as needed, regarding effectiveness or need for order change. During interview on [DATE] at 11:50 A.M., Resident #18 revealed that she did not receive her 9:00 A.M. dose of Percocet, and her current pain level was a seven, on a one to ten pain level scale. The resident further revealed the facility ran out of her pain medication and the nurse was trying to contact her physician for a pain medication prescription. Review of a physician order, dated [DATE], revealed an order for Percocet 5-325 milligrams (mg), an opioid pain medication, one tablet by mouth every 12 hours as needed for pain. Review of Resident #18's Medication Administration Record (MAR), dated [DATE], revealed the last dose of Percocet 5-325 mg was given on [DATE] at 9:00 P.M. During interview on [DATE] at 11:55 A.M., Licensed Practical Nurse (LPN) #60 verified that Percocet 5-325 mg was not administered on [DATE] at 9:00 A.M. because the facility had been unable to reach the pain medicine physician for a new prescription. During interview on [DATE] at 5:10 P.M., the Director of Nursing (DON) confirmed the Percocet prescription was not available timely and the nursing staff should have obtained a prescription five days before the prescription expired. The DON further revealed that she would educate the staff to timely obtain medication prescriptions at least five days prior to the expiration date. Review of the facility's policy titled Administering Medications, dated [DATE], revealed medications must be administered in accordance with the orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 27 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure pharmacy recommendations were addressed by the physician. This affected two (Resident #4 and #36) of five reviewed for unnecessary medications. Findings included: 1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, pseudobulbar affect, major depression, pain, symbolic dysfunction, peripheral vascular disease, psychosis, heart disease, anxiety, dementia, anemia, and osteoarthritis. The resident was receiving Seroquel 25 milligrams (mg), an antipsychotic medication, daily for psychosis and Celexa 10 mg, an antidepressant medication, daily for depression. Review of Resident #4's monthly pharmacy medication regimen review flow sheet revealed the pharmacist made recommendation to the prescriber on 01/14/19, 02/07/19, and 04/08/19. Further review revealed on 03/08/19 the pharmacist reviewed the residents record, however did not indicate if there were irregularities or recommendations. Review of Resident #4's pharmacy recommendations revealed no evidence the pharmacy recommendations were addressed for 01/14/19, 02/07/19, 03/08/19, or 04/08/19. Interview on 07/11/19 at 1:44 P.M. with Registered Nurse (RN) #45 verified there was no documented evidence the pharmacy recommendations were addressed by the physician on 01/14/19, 02/07/19, or 04/08/19. She found the blank recommendation for 01/14/19 that requested a stop date for Cephalexin, an antibiotic medication, which there was no order; however, it was completed on 01/19/19. The 02/07/19 recommendation requested diagnoses on the two Seroquel orders, and she was not able to find the recommendation for 03/08/19 or 04/08/19. 2. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, chronic kidney disease, urinary incontinence, hypertension, anxiety, dementia, major depressive disorder, dysphagia, and psychosis. Review of Resident #36's monthly pharmacy medication regimen review flow sheet revealed the pharmacist made recommendations to the prescriber on 07/31/18, 11/19/18, and 02/18/19. Review of Resident #36's pharmacy recommendations revealed no evidence of pharmacy recommendations were addressed for 07/31/18, 11/19/18, and 02/18/19. Interview on 07/11/19 at 1:44 P.M., with RN #45 verified she was unable to locate the pharmacy recommendations for 07/31/18, 11/19/18, and 02/18/19. She was able to find blank copies of the pharmacy recommendation for 11/19/18 and 02/18/19. The 11/19/18 recommendation was to change Metoprolol (beta-blocker) 100 mg daily to 50 mg twice daily and 02/18/19 was for gradual dose reductions for Lexapro (antidepressant) and Risperdal (antipsychotic). She was not able to find the recommendation for 07/31/18. She confirmed there was no evidence the pharmacy recommendations mentioned above had been addressed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 28 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #77 admitted to the facility on [DATE] with diagnoses which included femur fracture and osteoarthritis. Residents Affected - Few Review of the physicians order dated 05/18/19 revealed to give two tablets of 325 milligrams (mg) of Acetaminophen (Tylenol), an analgesic, every four hours as needed for pain. Review of the physicians order dated 05/20/19 revealed to give one tablet of 5-325 mg of Hydrocodone-Acetaminophen (Vicodin), a narcotic pain medication, every eight hours as needed for moderate to severe pain. Review of the potential for pain care plan initiated 05/20/19 revealed the residents pain would be controlled. Interventions included assess the resident for location, onset, origin, intensity of and precipitating factors of pain utilizing a scale from zero to ten (mild, moderate and severe). Attempt to increase comfort through non-pharmacological interventions and include the resident in the treatment plan. Review of the May 2019 Medication Administrator Record (MAR) revealed Tylenol was given on 05/19/19 twice for a pain score of five and seven which was effective. Vicodin was given on 05/20/19, 05/21/19, 05/22/19, 05/24/19 and 05/25/19 without assessing the residents pain level and no Tylenol was attempted prior. Also, for the doses of Vicodin given on 05/20/19, 05/21/19 and 05/25/19 there was no evidence of attempting non-pharmalogical interventions prior to the administration of the Vicodin. Review of the MDS 3.0 dated 05/25/19 revealed the resident had mild cognitive impairment, was on scheduled and as needed pain medications and had occasional pain of intensity of a three from a scale of zero to ten. No pain assessment was completed. Review of the June 2019 MAR revealed no Tylenol was given for pain. Vicodin was given on 06/05/19 (twice), 06/06/19, 06/10/19, 06/11/19 (twice), 06/12/19 (twice), 06/13/19, 06/14/19, 06/15/19, 06/18/19, 06/19/19, 06/20/19 (twice), 06/21/19 (twice), 06/24/19, 06/25/19, 06/26/19 (twice), 06/27/19 twice and 06/29/19. The range of the pain scale was between three and eight. Also for doses of Vicodin given on 06/05/19, 0606/19, 06/11/19, 06/12/19, 06/13/19, 06/14/19, 06/15/19, 06/20/19, 06/25/19, 06/26/19 and 06/27/19 there was no evidence of attempting non-pharmalogical interventions prior to the administration of the Vicodin. Review of the July 2019 MAR revealed Tylenol was given on 07/03/19, 07/04/19, 07/05/19 and 07/09/19 with pain scores between three and eight. Vicodin was given on 07/01/19, 07/02/19, 07/03/19, 06/06/19, 07/06/19, 07/08/19, 07/09/19 and 07/10/19 with a pain scale between four and six. Also there was no evidence of attempting non-pharmalogical interventions prior to administration of the Vicodin. On 07/09/19 at 5:45 P.M., interview with LPN #51 with review of the orders and the MAR's for July 2019 revealed first non-pharmalogical interventions should be attempted prior to giving any as needed medications. If that does not work, Tylenol should be attempted and then if the Tylenol was ineffective the Vicodin should be given. LPN #51 verified there was no evidence non-pharmalogical interventions were attempted prior to giving the as needed pain medications and verified there were no parameters for giving the Tylenol and Vicodin where given for the same pain levels, and they should not be interchangeable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 29 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/09/19 at 5:57 P.M., interview with the resident revealed she was very hard of hearing but was interviewable. The resident stated she was always in pain but did not like to take anything unless she had to and only wanted to take Tylenol, not any narcotics. She stated she was given one Tylenol pill for mild pain and two Tylenol pills for worse pain. The resident denied knowing she took any narcotics. She stated she would not want a narcotic because the more you take it the more you need it. Questioned the resident again about the use of narcotics and she repeated the same thing. When asked if the nurses asked her to rate her pain on a scale of zero to 10 she did not understand what that meant and stated they give her one to two Tylenol pills depending on how bad her pain was at the time. On 07/10/19 at 1:30 P.M., interview with the Assistant Director of Nursing (ADON), with the Administrator present, revealed the concerns with no consistency of when the nurses were giving the Tylenol versus the Vicodin and no evidence of non-pharmalogical interventions prior to giving the as needed medications on many of the days the medications were given. The ADON verified Tylenol should be given for a pain from one to four and Vicodin for pain five to ten. She verified the May 2019 MAR did not use the pain scale prior to giving the medications. The ADON was informed the resident was not aware she was taking Vicodin and indicated she did not want to take the medication but only wanted to take Tylenol. Review of the pain assessment and recognition policy, revised March 2018, revealed the staff should use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Goals of pain treatment should be established and appropriate non-pharmalogical interventions such as local heat or ice, repositioning, massage and conversation about the pain. Medication interventions should be ordered and provided based on the resident's individual needs. An analgesic regimen should be utilized first as the lowest risk medications before using more problematic or higher risk approaches. Reduction in opioid analgesics are especially important in light of their limited efficacy in the treatment of chronic pain and their many diverse significant side effects. Based on record review, policy review and staff interview, the facility failed to ensure orders for narcotic pain medications used on an as needed basis included parameters in which the medication should be used. This affected two (Resident #3 and #77) of six residents reviewed for unnecessary medications. Findings include: 1. A review of Resident #3's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included leukemia and chronic blood clots of the deep veins of her right lower extremity. A review of Resident #3's active physician's orders included orders for her to receive Acetaminophen 650 milligrams (mg) by mouth (po) every four hours as needed (prn) for moderate pain. She also had an order to receive Oxycodone (a narcotic analgesic) 5 mg po every four hours prn for pain. The order for Oxycodone did not include parameters that directed the nurses on when to administer the medication. A review of Resident #3's medication administration record (MAR) for July 2019 revealed the resident received Oxycodone on a prn basis daily. She received between two and five doses each day for pain. The nurse administering the Oxycodone recorded the resident's pain level when the prn pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 30 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication was given. The MAR indicated the nurse administered the Oxycodone to the resident on 07/04/19 at 8:00 A.M. for a pain level of one on a one to ten scale. She received two doses of Oxycodone on 07/04/19 at 1:00 P.M. and again on 07/09/19 at 4:07 P.M. for only a pain level of three on a one to ten scale. She received a dose of the Oxycodone 5 mg on a prn basis on 07/07/19 at 9:56 A.M. for a pain level of four on a one to ten scale. The remaining doses were used when the resident's pain was rated a five or higher on a one to ten scale. Findings were verified by Licensed Practical Nurse (LPN) #21. A review of the facility's policy on administering pain medications, revised October 2010, revealed residents were not at risk for addiction to narcotic analgesics if used as prescribed for moderate to severe pain. On 07/10/19 at 2:59 P.M., an interview with LPN #21 revealed Resident #3 verbalized when she had pain. He denied she was able to report the level of her pain using a one to ten scale, but they used a pain scale for residents with cognitive impairment. He reported the resident had a standard Tylenol order to be given on an a prn basis but she also had an order for Oxycodone prn. He reported he would consider mild pain to be a pain level of four or less. He would consider a pain level of five or more to be moderate to severe pain depending on how high the number was. He confirmed the order for the prn Oxycodone did not include any parameters that directed the nurse as to when to administer the prn Oxycodone. He reported the Oxycodone should not be used unless the resident was having moderate to severe pain. He denied he would use the prn Oxycodone for any pain level less than five. He reported the resident tended to sleep a lot during the day, and it could be related to her receiving the Oxycodone on an as needed basis when it was not really necessary. He had not known the resident to have any pain above a four on a one to ten scale when she was lying in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 31 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's package insert and staff interview, the facility failed to ensure their medication error rate was less than 5%. There were three errors out of 27 opportunities for a medication error rate of 11%. This affected one (Resident #41) of two residents reviewed for medication administration. Residents Affected - Few Findings include: A review of Resident #41's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atria), chronic obstructive pulmonary disease (COPD), and acute angle closure glaucoma of the left eye. A review of Resident #41's active physician's orders revealed the resident was to receive Cardizem (a calcium channel blocker used in the treatment of atrial fibrillation) 60 milligrams (mg) by mouth (po) twice daily. He also had an order to receive Brimonidine Tartrate (medication used in the treatment of glaucoma) solution 2% with directions to give one drop in the left eye twice a day. His orders also included the use of Trelegy Ellipta aerosol powder (a combination inhaler of three different medications for the treatment of COPD) 100 micrograms (mcg)- 62.5 mcg-25 mcg one puff once a day. On 07/10/19 at 7:58 A.M., an observation of a medication administration for Resident #41 noted Licensed Practical Nurse (LPN) #21 to administer the resident his morning medications. The nurse administered Brimonidine Tartrate solution 0.2% into the resident's right eye giving him two drops. After he gave the medicated eye drop in the resident's right eye, the resident pointed to his left eye and informed the nurse he should have given it in that eye. The nurse reassured the resident he gave it in the correct eye, but the resident insisted the nurse should have given it in his left eye. He stated it was always the left eye the nurses gave it in. The nurse acknowledged his mistake and told the resident he was correct, and it should have been given in his left eye. He then handed the resident his pills for him to take that included Cardizem 120 milligrams (mg) among his other pills. The nurse pulled the medications from a pre-packaged plastic bag that was sealed with all the medications that were due at that time. The front of the package listed all the medications the resident was to receive at that particular time of day. The pills were individually packaged inside that larger package with just the name of the medication and a dosage. He ended the medication administration pass by giving the resident his Trelegy Ellipta aerosol powder 100 micrograms (mcg)-62.5 mcg- 25 mcg inhaler to take. He handed the resident the inhaler after he primed it without providing any instruction to the resident. The resident inhaled the contents with one long inhalation. He handed the inhaler back to the nurse without rinsing his mouth with water. The nurse did not instruct him on the need to rinse and spit after using the inhaler. A reconciliation of Resident #41's medications that were observed to be given for the morning medication pass was completed to check against the active physician's orders for errors. The active physician's orders showed an order change that reduced the resident's Cardizem from 120 mg once daily to 60 mg twice a day. The active physician's orders confirmed the resident's Brimonidine Tartrate solution 2% was to be given in the left eye (instead of the right eye in which the nurse gave it in) and he was only to get one drop instead of two that the nurse was observed to give. Findings were verified by LPN #21. He stated he would have to contact the resident's physician and notify her of the medication errors he committed while giving the resident his morning medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 32 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm A review of Resident #41's medication administration record (MAR) for July 2019 revealed the resident was to receive Cardizem 60 mg po twice daily, Trelegy Ellipta 100 mcg- 62.5 mcg- 25 mcg one inhalation once daily and Brimonidine Tartrate solution 2% with directions to instill one drop in the left eye twice a day. The nurse initialed the medications were given as ordered. The MAR did include instructions to have the resident rinse his mouth after each use. Residents Affected - Few A review of the manufacturer's package insert for the Trelegy Ellipta revealed the instructions for use included the need to rinse the mouth after use. The directions were specific to rinse the mouth with water after the use of the inhaler and to spit, do not swallow the water. LPN #21 acknowledged he did not advise Resident #41 to rinse his mouth out with water and to spit after the use of the inhaler. On 07/10/19 at 8:25 A.M., an interview with LPN #21 revealed he acknowledged his three medication errors he committed with the morning medication pass to Resident #41. He stated he was really nervous and was not used to someone watching him give medications when he erroneously administered two drops of Brimonidine Tartrate into the resident's wrong eye. He confirmed the orders was to give one drop in the left eye and not two drops in the right eye as he administered to the resident. He stated the error with the Cardizem was due to the packaging the medication came in. It still included Cardizem 120 mg capsules with the direction to give 120 mg once daily as previously ordered. He stated night shift should pull out the old package when the new prepackaged medication came in from the pharmacy with the new dosage ordered. He stated it was ultimately his responsibility to ensure he gave the correct medication, and he should have known by looking at the MAR the dosage was reduced to 60 mg twice daily. He knew the resident should have rinsed his mouth with water and spit the water out without swallowing but acknowledged he did not provide the resident the instructions to do so or hand him a cup of water to rinse and spit after the inhaler was given. He confirmed he informed the physician of the errors and stated the physician instructed them to hold the resident's evening dose of Cardizem since he administered the daily dose at one time instead of two divided doses. They were to monitor him for bradycardia (low pulse rate of less than 60 beats per minute). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 33 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff and physician interview, the facility failed to ensure a resident did not experience a significant medication error during a medication administration observation. This affected one (Resident #41) of two residents reviewed for medication administration. Residents Affected - Few Findings include: A review of Resident #41's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included chronic atrial fibrillation (an abnormal heart rhythm characterized by a rapid and irregular beating of the atria). A review of Resident #41's active physician's orders revealed he was to receive Cardizem (a calcium channel blocker used in the treatment of atrial fibrillation) 60 milligrams (mg) by mouth (po) twice a day. The resident had been on Cardizem 120 mg po every day, but an order was given to change the dose to 60 mg by mouth twice a day on 07/08/19 after the resident was transferred to the hospital for bradycardia (low heart rate of less than 60 beats per minute). On 07/10/19 at 7:58 A.M., a medication administration observation for Resident #41 noted Licensed Practical Nurse (LPN) #21 to administer the resident his morning medications. Among the medications given, LPN #21 gave the resident Cardizem 120 mg po. The medications were pulled from a prepackaged pack that contained all the medications that were due for a particular day at a particular time. The prepackaged pack from the facility's contracted pharmacy that was pulled from the medication cart for Resident #41's morning medication pass for 07/10/19 included a Cardizem 120 mg capsule. The nurse administered the medication to the resident and signed off on the medication administration record (MAR) that the medication had been given. A review of Resident #41's MAR for July 2019 revealed the MAR showed the resident was to receive Cardizem 60 mg po twice a day. The times for the Cardizem to be given were 9:00 A.M. and 9:00 P.M. LPN #21 initialed that he gave the resident Cardizem 60 mg by mouth as ordered despite giving the resident Cardizem 120 mg by mouth that was included in the pre-packaged pack sent from the pharmacy. Findings were confirmed with LPN #21. On 07/10/19 at 8:25 A.M., an interview with LPN #21 revealed he did commit a significant medication error with Resident #41 when he gave the resident double the dose of Cardizem that he should have. He stated he pulled the Cardizem from the pre-packaged pack sent from the pharmacy that still had a Cardizem 120 mg capsule in it. He was not aware the resident's Cardizem dose had recently been changed from 120 mg once a day to 60 mg twice a day due to him having bradycardia thought to be caused by receiving the Cardizem at 120 mg in a one time dose. He reported it was normally the night shift nurse's responsibility to remove the pre-packaged packs that contained the old medications when a change in dosage occurred and the new packages arrived, but it was ultimately his responsibility to make sure he administered the proper dose. He acknowledged he should have noted the Cardizem was changed to 60 mg in two divided dosages instead of 120 mg in one dose by looking at the MAR. He indicated he would have to contact the physician to notify her of his medication error. On 07/10/19 at 8:40 A.M., a follow up interview with LPN #21 revealed he had contacted the physician and notified her of his medication error pertaining to giving the resident twice the dose of his Cardizem. He stated the resident received 60 mg of Cardizem the evening of 07/09/19 and he gave 120 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 34 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mg the morning of 07/10/19. The physician instructed them to hold the evening dose of Cardizem 60 mg that was scheduled for 07/10/19 at 9:00 P.M. The physician reported she would evaluate the resident when she visited the facility that day. A review of a physician progress note for 07/10/19 revealed the physician had seen Resident #41 for a medication error. The physician indicated she had been in the facility when LPN #21 notified her of giving Resident #41 the wrong dose of Cardizem as he gave the resident 120 mg when 60 mg was ordered. The physician stated in her note she had recently changed the resident's dose over the weekend for bradycardia. The resident was asymptomatic when examined by the physician. She encouraged him to increase his fluid intake that day in an effort to flush out the medication. Poison control had been contacted by the facility's nursing administration staff at the direction of the physician and they were directed to just monitor the resident without any further recommendations. The resident's cardiologist was also notified of the medication error. An appointment with the cardiologist was made for August 2019 to follow up after the recent change in his Cardizem dosage. The physician requested an electrocardiogram (EKG) which showed sinus bradycardia of 56 nonspecific changes were noted. She ordered vital signs every hour until 6:00 P.M. that evening and then every shift that night thereafter. She directed them to hold the Cardizem 60 mg that evening and then for a heart rate less than 55 beats per minute. A review of Resident #41's orders after his physician visit revealed the facility's nursing staff were also to notify the physician if the resident had any dizziness, lightheadedness or if his heart rate was less than 50 beats per minute. They could resume the Cardizem 60 mg po twice a day beginning 07/11/19. On 07/10/19 at 9:50 A.M., an interview with Physician #500 revealed she assessed Resident #41 after it was reported to her that there was a medication error that pertained to his Cardizem. She reported the resident was currently stable and he was asymptomatic. His heart rate was regular at 60 beats per minute. She stated that was their concern now (referring to his heart rate). She reported they had obtained an EKG that was normal. She confirmed her orders were to obtain vital signs every hour until 6:00 P.M. that evening and then to obtain vital signs every shift through the remainder of the night. They planned to hold his evening dose of Cardizem. She indicated they had contacted the resident's cardiologist about the medication error and had also contacted him the day prior to about his heart rate being in the high 30's over the weekend. She reported the resident had been sent to the hospital for an evaluation the prior weekend for bradycardia. It was then, they decided to divide his daily dose of Cardizem into two divided doses giving him 60 mg twice a day instead of 120 mg once a day. She confirmed he had a follow up with the cardiologist scheduled for some time the first week or two of August. She reported they were considering the use of intravenous (IV) fluids if he became symptomatic but he was drinking well on his own. The cardiologist did not recommend IV fluids to be given due to him having a history of congestive heart failure. She wanted the nursing staff to monitor the resident for dizziness, lightheadedness and a heart rate less than 55 beats per minute. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 35 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation and interview, the facility failed to ensure all items met the minimum temperatures required at the start of tray line. This had the potential to affect the 99 residents who received meals from the facility. The facility identified one resident (Resident #11) who did not receive meals from the facility. The facility census was 100. Findings include: On 07/09/19 tray line observations from 4:30 P.M. until 5:06 P.M., revealed no temperature was obtained for the hot dogs, grilled cheese, pre-poured soups or pre-poured milk prior to or at any time during the observation. The hamburger temperature was 150 degrees Fahrenheit. (F). This was verified by [NAME] #89 at the time of the observations. On 07/09/19 at 4:42 P.M., interview with [NAME] #89 verified she was done taking all the temperatures and was ready to begin serving the dinner meal. [NAME] #89 indicated all meats should be a minimum of 165 degrees F and she verified the hamburger was only 150 degrees F, and she did not attempt to increase the temperature. She also verified she did not take the temperature of the hot dog, grilled cheese, pre-poured soups or pre-poured milk. On 07/10/19 at 4:00 P.M., interview with the Administrator verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 36 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure foods were at a palatable temperature and the puree foods were prepared according to the recipe to ensure optimal palatability. The facility identified one resident (Resident #11) who did not receive meals from the facility. The facility census was 100. Residents Affected - Many Findings include: On 07/08/19 at 10:16 A.M., [NAME] #91 was observed preparing the pureed chicken patties. She put 13 patties and two cups of water into the Robot Coupe. Pureed them together, removed the chicken from the Robot Coupe and placed in the steamer to keep warm. On 07/08/19 at 10:24 A.M., interview with [NAME] #91 verified she did not follow a recipe and just added water to the chicken patties to puree them. She was not able to find the recipe for the puree patties when asked. On 07/09/19 at 4:36 P.M., [NAME] #89 took the tray line temperatures which included the turkey salad and macaroni salad which were both 40 degrees Fahrenheit (F) and the mixed vegetables which were 160 degrees F. At 4:42 P.M., the started plating the main entree for the 16 residents on the skilled unit. The main entree was cold turkey salad sandwich, cold macaroni salad, soup and milk. She plated the cold items on a heated pellet with a heated plate. The plates were then covered with an insulated lid and placed in the cart for delivery. At 4:46 P.M., the surveyor verified with [NAME] #89 she was placing items that were to remain cold on heated pellets and plates, she verified this and continued with the process. At 5:06 P.M., the skilled unit cart including the test tray left the kitchen. All 16 trays were passed by 5:10 P.M. On 07/09/19 at 5:11 P.M., the test tray was tasted by the surveyor and the temperatures were taken by Dietary Manager (DM) #32 utilizing the facility thermometer with the following results: the milk tasted warm and was 48 degrees F, the mixed vegetables were luke warm and were 90 degrees F, the macaroni salad was warm and was 59 degrees F, the vegetable soup was luke warm and was 89 degrees F. This was verified by DM #32 at the time of the findings. On 07/09/19 at 5:38 P.M., interview with DM #32 verified the milk was prepoured and was not placed in ice on tray line and the soup was prepoured and in insulated bowls and covered with lids but no heating element was used to keep them hot. Review of the food committee meeting minutes dated 06/12/19 revealed the residents expressed concerns the cold colds including potato salad were served on hot plates. Review of the puree chicken patty recipe revealed to add chicken broth to the chicken patties. On 07/10/19 at 4:00 P.M., interview with the Administrator verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 37 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure proper sanitation during the operation of the dish machine, during tray line, and for the ice machine. This had the potential to affect the 99 residents who received meals from the facility. The facility identified one resident (Resident #11) who did not receive meals from the facility. The facility census was 100. Findings include: On 07/08/19 during the initial tour of the kitchen between 10:00 A.M. and 10:30 A.M., revealed there was a Dietary Aide (DA) #123 and [NAME] #89 operating the dish machine. They were half way done with the breakfast dishes. Interview with [NAME] #89 verified she did not know if the dish machine was a high temperature or chemical and did not test nor did she know how to test to ensure the dish machine was properly operating. Interview with DA #123 verified she did not check the dish machine for proper operation but stated it was a chemical DM. Neither the cook nor the DA were able to locate the dish machine log. On 07/08/19 at 10:15 A.M., this was verified by Dietary Manager (DM) #32, who also was not able to locate the dish machine log. On 07/08/19 at 10:25 A.M., observation of the ice machine revealed a thick black buildup of a slimy substance the distance across the entire lip of the inside of the machine were the ice was dispensed. This was verified by DM #32 at the time of the observation. On 07/09/19 during tray line observation between 4:30 P.M. and 5:06 P.M., revealed flies and gnats were flying around and landing on the various food items on tray line including the buns, turkey salad, macaroni salad and hot dogs. This was verified by [NAME] #89 and Dietary Aid (DA) #123, who indicated it had been an ongoing problem. At 4:36 P.M., [NAME] #89 began taking the food temperatures. [NAME] #89 took the temperature of the pureed macaroni salad, turkey salad, macaroni salad and did not clean or sanitize the thermometer before or after each temperature was taken. [NAME] #89 then grabbed another thermometer and took the temperature of the mixed vegetables and then the pureed soup without cleaning or sanitizing between temperatures taken. Now each of the two thermometers had a build up of food on them. [NAME] #89 asked DA #123 to rinse off the thermometers. DA #123 with her gloved hands went to the dish machine and used the hose to rinse off the thermometers and returned holding the thermometers by the stems with her same gloved hands. [NAME] #89 then used one of the thermometers to take the temperature of the hamburgers. After this [NAME] #89 verified the above concerns and requested Dietary Manager (DM) #32 get her a different thermometer. DM #32 returned with a new thermometer that had never been used by the staff. [NAME] #89 placed the thermometer in the cream of mushroom soup. After this [NAME] #89 verified she did not clean the thermometer prior to use because it came from the packet and had never been used. The above was verified by DM #32. On 07/09/19 at 5:07 P.M., interview with DM #32 verified the DA monthly cleaning schedule did not include cleaning of the ice machine, and she was not able to say the last time the ice machine was cleaned and verified the ice machine serviced the entire facility. On 07/10/19 at 4:00 P.M., interview with the Administrator verified the above findings. Review of the DA monthly cleaning schedule revealed it did not including cleaning of the ice (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 38 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 machine. Level of Harm - Minimal harm or potential for actual harm Review of the cleaning instructions for the ice machine and equipment, not dated, revealed the ice machine should be cleaned and sanitized on a regular basis following the manufacturer's instructions. Residents Affected - Many Review of the dish machine temperature log, not dated, revealed the temperatures were monitored to ensure proper sanitizing of dishes. The log would be posted near the dish machine. Review of the American Dish Service owners manual, dated 05/08, revealed to monitor chemicals to ensure proper sanitation between 50 and 100 parts per million. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 39 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of the infection control log, observation, interview and policy review, the facility failed to ensure Legionella monitoring, a comprehensive infection control program was implemented, and ensure proper washing/handling of isolation laundry. This had the potential to affect all 100 residents residing in the facility. Residents Affected - Many Findings include: 1. Review of the infection control log dated 06/19 to 07/19 revealed no evidence of infection control log for 06/19 for the skilled unit, second floor and the third floor, only tract infections for the first three days (06/01/19 to 06/03/19). There was no evidence of an infection control log for 07/19. Interview on 07/10/19 at 2:47 P.M., with the Director of Nursing (DON) revealed she was not able to locate the complete infection control log for 06/19 except for one page for the third floor started for the first three days of June. There was no infection control log for 07/19. 2. The surveyor requested evidence of Legionella program and monitoring per the facility policy during the survey progress, however the facility was not able to provide documentation. Review of Legionella Water Management Program policy, dated 07/17, revealed the facility was committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The water management program would be overseen by the water management team. The program would identify areas in the water system where Legionella bacteria could grow and spread. The water management program would include a team, description and diagram of the water system in the facility, identifying areas of growth, specific measures used to control the introduction or spread of Legionella (water temperatures, disinfectants), control limits/parameters, system to monitor the control limits and the effectiveness of control measure, a plan when the control limits were not met or not effective, and documentation of the program. Interview on 07/10/19 at 1:28 P.M., with Administrator reported she was not able to locate the monitoring for the Legionella program. The previous Maintenance Director (MD) had resigned, and the facility was not able to find any of his documentation, including diagram of the water system and monitoring. 3. Interview and observation of the laundry room with Housekeeper #111 on 07/11/19 at 9:21 A.M., revealed all laundry was delivered to the laundry room through a laundry shoot. The laundry was observed to be in clear trash bag liners. The bags were not identified as isolation (MRSA and C-diff). The housekeeper reported isolation laundry used to come to the laundry room in red bags and was washed separately from the other laundry, however recently he was told red bags were no longer required. He confirmed there was no way to identify if the current laundry bags were isolation since the change. Currently all laundry, including isolation, would be sorted and put in the in the proper bin and then washed all together. There was a bin noted for bed lines, gowns, etc. All linens/gowns were washed in bleach, however personal laundry items would not be washed in bleach. The nursing staff try to encourage residents in isolation to wear gowns, so they can be bleached. Observation of the washing machine hot water temperatures revealed the water was 143 degrees Fahrenheit (F). The MD reported the highest hot water temperature he reached was 156. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 40 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Interview on 07/11/19 at 1:19 P.M., with the Administrator revealed the facility did not have a policy or procedure for washing isolation laundry. This is an example of continued noncompliance from the survey completed on 06/25/19. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 41 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the infection control log, interview and policy review, the facility failed to implement a comprehensive antibiotic stewardship program. This had the potential to affect all 100 residents residing in the facility. Residents Affected - Many Findings included: Review of the infection control log dated 01/01/19 to 07/01/19 revealed no evidence an antibiotic stewardship program was implemented. Interview on 07/01/19 at 2:47 P.M., with the Director of Nursing (DON) verified the facility had not implemented an antibiotic stewardship program at this time. The facility plans to implement the [NAME] criteria this month. Review of antibiotic stewardship policy and procedure dated 11/17 revealed the facility would adapt an antibiotic stewardship program to monitor the use of antibiotics with each resident. The facility would educate and train staff and practitioners about the facility antibiotic stewardship program, including appropriate prescribing, monitoring, and surveillance of antibiotic use and outcomes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 42 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to the ensure call light was in reach for Resident #45. This affected one of one resident observed for call lights. Residents Affected - Few Findings included: Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including repeated falls, muscle wasting and atrophy, hydrocephalus, adult failure to thrive, rhabdomyolysis, diabetes, hypertension, weakness, and polyneuropathy. Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment, dated 05/16/19, revealed the resident required extensive assistance with bed mobility and was totally dependent for transfers. Observation on 07/08/19 at 2:45 P.M. and 07/09/19 at 1:16 P.M., revealed Resident #45's call light was noted on the floor and not within the residents reach. Interview on 07/09/19 at 1:16 P.M., with Licensed Practical Nurse (LPN) #19 confirmed the resident's call light was lying on the floor and not within the resident's reach. The LPN confirmed the resident was able to use his call light when it was within reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 43 of 44 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carriage Inn of Steubenville 3102 St Charles Drive Steubenville, OH 43952 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure an effective pest control program was in place. This had the potential to affect the 100 residents residing in the facility. Residents Affected - Many Findings include: Review of the monthly pest control treatments dated 04/29/19, 05/21/19, 06/05/19 and 07/08/19 revealed there was no evidence the technician was notified of the fly and gnat activity in the kitchen in order to eradicate them. On 07/08/19, during the initial tour of the kitchen between 10:00 A.M. and 10:30 A.M., revealed there were several flies and gnats flying around the kitchen. This was verified by Dietary Manager (DM) #32 at the time of the observations, who indicated she had worked at the facility for four months, and there had always been flies and gnats in the kitchen and other areas of the facility. On 07/09/19 during the tray line observation between 4:30 P.M. and 5:06 P.M., revealed many gnats and several flies were observed flying around the kitchen and landing on foods, including the turkey salad, macaroni salad, buns and hot dogs. This was verified by [NAME] #89 and Dietary Aide (DA) #123, at the time they were observed swatting at the bugs during tray line operation. On 07/10/19 at 11:20 A.M., interview with Dietary Manager (DM) #32 verified the pest control company comes monthly, and she had not requested any additional services despite the ongoing concerns with flies and gnats. She revealed she just read the policy which indicated she could call for additional visits when concerns were identified. On 07/10/19 at 3:35 P.M., during the state ran resident council meeting with Resident's #41, #46, #55, #63, #71, #78, #79 and #92 revealed they had concerns with flies and had informed the facility but nothing had been done to eradicate the flies. On 07/11/19 at 11:10 A.M., on the second floor Resident #11, who was not able to move arms, had a fly land on his head a couple times. On 07/10/19 at 4:00 P.M., interview with the Administrator was informed of the above concerns. Review of the pest control policy, not dated, revealed if pests were seen in the kitchen appropriate action should be taken to eliminate the situation. Preventative treatment programs would be in place but additional visits would be completed as concerns arise. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 44 of 44