Inspection visit

Health inspectionMay 19, 2022

CARRIAGE INN OF STEUBENVILLECMS #3652715 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #12's medical record revealed an admission date of 11/04/19 with diagnoses including Parkinson's disease, generalized anxiety disorder (05/30/18), schizophrenia (12/20/16), major depressive disorder (12/20/16), and developmental disorder of scholastic skills (12/20/16). Review of a PASARR identification screen revealed the screening did not capture the diagnosis of schizophrenia or developmental disorder (condition that resulted in impairment of general intellectual functioning or adaptive behavior). The screening form indicated Resident #12's physician ordered skilled nursing services. The review results dated 11/04/19 indicated there were no indications of serious mental illness nor a developmental disorder and no referrals were made to the Department of Developmental Disorders for an evaluation to determine if Resident #12 would benefit from specialized services. An annual Minimum Data Set (MDS) 3.0 assessment, dated 11/11/21 indicated Resident #12 was not considered by the State Level II PASARR process to have serious mental illness and/or intellectual disability or related condition. Resident #12 had clear speech, was able to understand others and make herself understood. Resident #12 was assessed as cognitively intact. Resident #12 transferred, ambulated, dressed, ate, used the toilet, and performed personal hygiene with supervision. Review of the facility policy titled, The Healthcare Electronic Notification System Pre-admission Screening and Resident Review (PASARR) Level II revealed based on information provided in the PASARR, a determination was made as to whether the individual could be admitted to the nursing facility or whether further review was required. The system automatically forwarded any documents with indications of intellectual developmental disability to the Ohio Departments of Mental Health (ASCEND) and Addiction Services (OMHAS)and/or the Ohio Department of Developmental Disabilities ([NAME]) for additional Level II review. Nursing facilities were required to complete the PASARR accurately and submit it to the OMHAS and/or the [NAME] if indications of serious mental illness and/or developmental disabilities were present. OMHAS and [NAME] would take the appropriate action to perform the Level II review and would provide the submitter with documentation of the Level II determination. On 05/17/22 at 10:58 A.M. interview with SS #502 verified the resident's screening was inaccurate. SS #502 verified if the screening was accurate it would have resulted in a Level II evaluation. There was no system in place to review PASARR for accuracy or changes. Based on record review, facility policy and procedure review and interview the facility failed to ensure Preadmission Screening and Resident Reviews (PASARR's) were completed accurately on admission and/or failed to ensure a new PASARR was completed following a change in diagnoses. This affected (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 365271 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 05/19/2022 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 0644 three residents (#12, #45, and #56) of five residents reviewed for PASARR. Level of Harm - Minimal harm or potential for actual harm Findings include: Residents Affected - Few 1. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including anxiety and dementia with behavioral disturbance. Review of Resident #56's PASARR, dated 08/01/13 only included the determination that indicated the resident had no serious mental illness or a developmental disability. On 10/25/13 the resident was diagnosed with major depression disorder single episode and on 01/29/16 the diagnosis was changed to recurrent major depression disorder. On 07/08/18 psychosis not due to a substance or known psychological condition was added. The resident had an acute hospital stay and was readmitted to the facility on [DATE]. Review of Resident #56's Minimum Date Set (MDS) 3.0 assessment, dated 10/19/21 revealed the resident did not have conditions related to serious mental illness. The resident was admitted on [DATE] and was re-admitted on [DATE] after an acute hospital stay. The resident's cognition was intact and the assessment revealed the resident was totally dependent on staff for transfers, locomotion, toilet use, bathing and personal hygiene. On 05/17/22 at 11:00 A.M. interview with Social Service (SS) #502 revealed she was not sure who was responsible for completing the PASARR section of the MDS to ensure the PASARR was accurate and correct. The SS reported Resident #56's PASARR had not been updated since her admission in 2013 and should have been updated with each new mental illness diagnoses added after original admission. SS #502 confirmed there was no evidence a new PASARR was completed on 10/25/13 when major depression disorder single episode was added and changed to recurrent major depression disorder on 01/29/16 or on 07/08/18 when psychosis not due to a substance or known psychological condition was added to ensure the resident did not require Level II review for services. Review of the facility policy and procedure titled PASARR, dated 04/2017 revealed to ensure that individuals with serious mental illness or an intellectual developmental disability who were seeking care in the nursing facility would receive appropriate care in the facility to address these conditions. A resident review was required for any nursing facility resident with a serious mental illness or intellectual developmental disability who was admitted to the facility under hospital exemption but required more than 30 days of services and had experienced a significant change of condition. 2. Review of Resident #45's medical record revealed an initial admission date of 07/27/21 and a readmission date of 03/29/22 (the resident had left the faciity on [DATE] for one day). Resident #45 had diagnoses (dated 05/07/21) including anxiety disorder, major depressive disorder, essential hypertension, weakness and unspecified heart failure. On 03/18/22 a new diagnosis of psychotic disorder with hallucinations and Parkinson's disease was added. Resident #45's PASARR, dated 07/27/21 revealed the question of does the individual have a diagnosis(es) of any of the mental disorders listed below with the boxes beside mood disorder and panic or other severe anxiety disorder marked on the form. A PASARR, dated 03/29/22 revealed the questions of does the individual have a diagnosis(es) of any of the mental disorders listed below with the box (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 2 of 12 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 05/19/2022 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 0644 beside no marked on the form. Level of Harm - Minimal harm or potential for actual harm Resident #45's care plan, dated 03/29/22 revealed the resident was at risk for drug related complications related to psychotropic medication use of antidepressant and anti-anxiety medications. Residents Affected - Few Resident #45's physician's orders revealed an order, dated 03/29/22 for the resident was to have psychiatric evaluations as indicated. The resident also had medication orders, dated 03/29/22 for Fluoxetine HCL 50 mg (milligram) by mouth one time a day for depression and anxiety, Nuplazid 34 mg by mouth one time a day for Parkinson's disease psychosis. On 05/15/22 an order was obtained for Ativan 0.5 mg by mouth every eight hours as needed for anxiety and agitation. Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment, dated 04/05/22 revealed the resident had moderate cognitive impairment and was not currently considered by the State Level II Preadmission Screening/Resident Review Identification Screen (PASARR) to have serious mental and/or intellectual disability or related condition. The MDS revealed the resident was receiving an anti-depressant medication. On 05/16/22 at 2:19 P.M. interview with Resident #45 revealed he did not receive any type of psychiatric services. On 05/17/22 at 8:53 A.M. interview with Admissions #536 revealed she had completed the 03/29/22 PASARR which did not reflect the resident having any mental health diagnoses or mental health medications marked. She reported she does not usually do the PASARR's. Admissions #536 revealed the liaison who usually does them wasn't in the facility so she did it. She reported since Resident #45 had only left for one day she did it to get it in the system. She verified she didn't know how to complete a PASARR and verified it was not accurate. On 05/17/22 at 10:59 A.M. interview with SS #502 revealed on 03/18/22 a new diagnosis of psychotic disorder with hallucinations was noted and a new PASARR should have been completed. SS #502 revealed she was not aware of the diagnosis change on 03/18/22 but indicated she does have access to the electronic health record (EHR) were diagnoses were listed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 3 of 12 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 05/19/2022 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, facility policy and procedure review and interview the facility failed to ensure the discharge summary completed for Resident #85 included a recapitulation of the resident's stay. This affected one resident (#85) of one resident reviewed for discharge. Findings include: Closed record review revealed Resident #85 was admitted to the facility on [DATE] and discharged to another skilled nursing facility on 03/11/22. The resident's diagnoses included severe protein malnutrition, osteomyelitis of vertebra, symbolic dysfunctions, dysphagia, weakness and need for assistance with personal care, pressure ulcer of sacral region, history of pulmonary embolism, encephalopathy, hyperlipidemia, gastrostomy, discitis and type II diabetes. A discharge note, dated 03/11/22 revealed follow up instruction education was provided to the transferring facility. The resident was made aware of transfer and signed discharge paper and verbalized understanding. Review of Resident #85's electronic medical record (EMR) revealed a recapitulation of resident's stay was not completed nor was a summary of the resident's status. A recapitulation of the resident's stay described the resident's course of treatment while residing in the facility. The recapitulation was to include but was not limited to: diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including any pending lab results. Items required to be in the final summary of the resident's status included: identification and demographic information, customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, physical functioning and structural problems, continence disease diagnoses and health conditions, dental and nutritional status, skin condition, activity pursuit, medications, special treatments and procedures, discharge planning (as evidenced by most recent discharge care plan), documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS and documentation of participation in assessment. This refers to documentation of who participated in the assessment process. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care/direct access staff members on all shifts. Review of Resident #85's paper medical record revealed Resident #85 signed a discharge instruction of care sheet that included the name and address to the facility the resident was being transferred to, current treatment orders to the sacrum, right and left heel and feeding tube site. There was a notation to See attached medication review, however there was no evidence of an attachment or the resident's current physical status. There was no evidence of the resident's complete status at the time of discharge. On 05/18/22 at 10:55 A.M. interview with Registered Nurse (RN) #701 revealed a recapitulation of stay was not completed for Resident #85. The facility had only completed the paper discharge instruction for care form and the facility did not keep a copy of the mediation review to ensure all medication were reconciled from admission. Review of the facility policy and procedure titled Discharge Process, dated 07/2019 revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 4 of 12 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 05/19/2022 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 0661 final discharge summary would be completed and a signed copy of the discharge and discharge medication list should be filed in the resident's chart. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 5 of 12 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 05/19/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy and procedure review and interview the facility failed to ensure psychotropic medications were only administered when there were indications for use, failed to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medication ordered on an as necessary basis and/or failed to ensure orders for psychotropic medications were accurate and complete providing clear directions for use. This affected two residents (#8 and #48) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #8's medical record revealed diagnoses including anxiety disorder and dementia with behavioral disturbance. Resident #8 had a physician's order for Ativan (anti-anxiety medication) 0.5 milligrams (mg) every four hours as necessary. Resident #8 also had an order for narcotic pain medication (Oxycodone HCL) 5 mg every four hours as needed for moderate to severe pain. Orders revealed staff were to monitor behaviors including screaming/yelling/calling out, picking at her skin, verbal and physical aggression, resisting care, non-compliance with treatment/medication regimen, anxiety and tearfulness. Review of the March 2022 Medication Administration Record (MAR) revealed no record of anxiety on the behavior tracking. Eleven doses of Ativan were administered without documentation of the rationale or attempts to provide non-pharmacological interventions prior to administration. Six of the 11 Ativan doses were administered concurrently or within two minutes of the administration with the Oxycodone HCL. Review of the April 2022 MAR revealed no documented behaviors for the resident. The MAR indicated 21 doses of Ativan were administered without documentation of the rationale or attempts to provide non-pharmacological interventions prior to administration. Seventeen of the 21 doses of Ativan were administered with Oxycodone. Of the 17 doses, 16 of them were administered between 7:30 P.M. and 9:00 P.M. The order for Ativan was revised for use for anxiety or insomnia on 04/28/22. Review of the May 2022 MAR revealed no behaviors documented for the resident between 05/01/22 and 05/19/22. Fifteen doses of Ativan were administered without documentation of anxiety/insomnia or non-pharmacological interventions attempted prior to the Ativan administration. On 05/19/22 at 9:35 A.M. the concerns related to the use of Ativan ordered on an as necessary basis without documentation of indications for use or attempts at non-pharmacological interventions were addressed with the Director of Nursing (DON). The DON reported she definitely knew Resident #8 had periods of anxiety but could not state why the episodes were not documented in the behavior tracking or why attempts of non-pharmacological interventions were not documented or provided. On 05/19/22 at 10:18 A.M. Psych Nurse Practitioner (NP) #702 was interviewed regarding the frequency of the Ativan ordered on an as necessary basis without documentation of the need/indication for its use or without evidence of non-pharmacological interventions being attempted. NP #702 stated with each psychiatric visit, the psychiatric provider documented non-pharmacological interventions to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 6 of 12 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 05/19/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attempt to address behaviors. NP #702 stated staff had not reported increased anxiety at night for the resident. NP #702 stated without more comprehensive documentation, it was difficult to determine if there were underlying factors causing increased anxiety at night which resulted in use of Ativan. Review of the facility policy titled, Use of Psychotropic Medication, implemented 04/01/22 revealed the indications for initiating, withdrawing, or withholding medications, as well as the use of non-pharmacological approaches would be determined by assessing the resident's underlying condition, current signs, symptoms, expressions and preferences and goals for treatment and identification of underlying causes (when possible). Residents who received psychotropic drugs should also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Psychotropic medication ordered on an as necessary basis should be used only when the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record and for a limited duration. Use of psychotropic medications for enduring conditions required the symptoms and therapeutic goals be clearly and specifically identified and documented. An evaluation should be documented to determine the resident's expressions or indications of distress were not due to a medical condition or problems that could be expected to improve or resolve as the underlying condition was treated or the offending medications were discontinued, not due to environmental stressors alone that could be addressed to improve the symptoms or maintain safety, not due to psychological stressors, anxiety or fear stemming from misunderstanding related to his or her cognitive impairment that could be expected to improve or resolve as the situation was addressed and persistent and negatively affect his or her quality of life. 2. Record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, mental disorder due to known physiological condition, intracranial injury, convulsion, hydrocephalus, major depressive disorder, conduct disorder, adult personality and behavior disorder and dementia with behavioral disturbance. Review of a controlled substance sheet, dated 03/24/22 revealed the Ativan/Benadryl (AB) Gel 0.5-12.5 mg/ml was originally ordered on 03/23/22. The order was to apply one ml topically twice daily and to discard on 04/22/22 or sooner. The pharmacy sent 30 one ml syringes. Review of Resident #48's current orders and medication administration records, dated 05/2022 revealed the resident was ordered Ativan/Benadryl (AB) gel 0.5 milligrams (mg)/12.5 mg one application topically twice daily as needed for anxiety. There was no indication where to apply the topically medication, the amount of the application, or a stop date. Further review revealed on 05/12/22 16 syringes were destroyed. Review of pharmacy communication note, dated 05/18/22 revealed the AB gel should be applied topically to the inner wrist. Review of a pharmacy non-sterile compounding worksheet, dated 03/22/22 and faxed to the facility on [DATE] revealed Resident #48 was ordered AB Gel 0.5-12.5 mg/ml to be applied topically twice daily. There was no indication were to apply the topically gel. The medication expired within 30 days after compounding. On 05/18/22 at 11:28 A.M. and 2:40 P.M. interview with Registered Nurse (RN) #700 revealed the order for the AB gel should have been discontinued on 05/12/22 when the medication was destroyed, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 7 of 12 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 05/19/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few however the order was not written. The current order did not include were to apply the topically gel, but the pharmacy indicated on 05/18/22 it should have been applied on the resident's inner wrist. RN #700 confirmed the medication expired within 30 days after being compound on 03/23/22, however was not destroyed until 05/12/22. The resident's last dose received was 04/02/22. The facility in-house psych physician had written the original prescription to be given scheduled twice a day, however the in-house physician changed the order to as needed on 03/30/22 but did not indicate a stop date. The RN revealed staff reported the in-house physician gave a verbal order on 05/12/22 to discontinue the medication due to non-use, however there was no documentation of the verbal order nor was the medication discontinued. The medication was still listed as a current medication order. Review of the facility policy and procedure titled Use of Psychotropic Medication, dated 04/01/22 revealed as needed orders for all psychiatric drugs shall be used only when the medication was necessary to treat diagnosed specific conditions that were documented in the clinical record and for a limited duration (i.e. 14 days). If the attending physician or prescribing physician believed it was appropriate for the as needed order to be extended beyond the 14 days, he or she shall document their rational in the resident's medical record and indicate the duration for the as needed order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 8 of 12 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 05/19/2022 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 0791 Provide or obtain dental services for each resident. 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, facility policy and procedure review and interview the facility failed to ensure Resident #2 was provided timely dental services to meet her needs. This affected one resident (#2) of three residents reviewed for dental care. Residents Affected - Few Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebral palsy, type two diabetes, essential hypertension, hyperlipidemia and adult failure to thrive. Review of Resident #2's physician's orders revealed an order, dated 08/20/18 for dental consult as needed. The resident had an order, dated 08/23/18 for the use of a mechanical (Hoyer) lift for transfers. Review of Resident #2's care plans revealed the following: A plan of care (initiated 08/24/18) revealed a focus on alteration in mobility related to her using a wheelchair. The goal was for Resident #2 to participate with mobility by staff assisting her with transfers as needed, by providing a wheel chair as needed, and by using a Hoyer lift for all transfers per order. A plan of care (initiated 08/10/21) revealed a focus on dental care related to the resident had her own teeth without complaints of pain or discomfort at that time. She did have a filling that fell out and the dentist appointment was canceled due to COVID-19 restrictions and limitations. A plan of care (initiated 10/25/21) revealed Resident #2 had gone to the dentist but she was unable to get treatment due to not being able to transfer. At this time she was having pain when eating cold foods due to having two broken teeth on the left bottom side of her mouth. The goals of the care plan were Resident #2 would have have dental consult for assessment and treatment of oral health problems as needed and she would be free of infection, pain or bleeding in the oral cavity. The interventions included encouraging Resident #2 to keep appointment for dental consult by explaining the need and importance and provide assistance as needed to prepare Resident #2 for the appointment. A health status note, dated 02/14/20 at 4:30 P.M. revealed the resident complained of her mouth hurting. Her primary physician examined her and found red and inflamed gums on the left lower side of her mouth. She was started on Clindamycin (an antibiotic fort tooth infections) at that time. An infection progress note, dated 02/15/20 revealed the resident had an ongoing dental infection and the staff at the facility were to schedule a dental consult per Resident #2's primary physician directive. The facility reached out to the dentist who came onsite to schedule an emergency visit. A health status note, dated 03/04/20 revealed an appointment had been set up with an offsite dental provider for 03/11/20. A health status note, dated 03/10/20 revealed the appointment scheduled for 03/11/20 had been canceled and a new appointment with a different offsite dental provider had been made for 03/26/20. The next progress note regarding dental, dated 06/01/20 revealed appointment scheduled for 06/01/20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 9 of 12 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 05/19/2022 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 0791 was canceled and rescheduled for 06/09/20. Level of Harm - Minimal harm or potential for actual harm The next progress note regarding dental, dated 08/30/21 revealed an appointment was set for an offsite dentist for 09/15/21. Residents Affected - Few Review of Resident #2's appointment return progress note, dated 09/15/21 revealed the dentist she had seen wanted her to see an oral surgery center for teeth extraction. Her appointment return progress note, dated 10/11/21 at 1:58 P.M. revealed the dentist at the oral surgery center refused to see her since she couldn't transfer. Review of Resident #2's progress notes revealed these were the only two appointment return progress notes in her record. Review of the Minimum Data Set (MDS) 3.0 assessments, dated 08/05/21, 10/20/21 and 05/02/22 all revealed the resident was cognitively intact, had mouth or facial pain, discomfort or difficulty with chewing, was totally dependent and needed two+ persons to physically assist for transfer. On 05/17/22 at 1:33 P.M. Resident #2 was observed to with some of her teeth darkened in color. On 05/16/22 at 10:49 A.M. interview with Resident #2 revealed she had sensitive teeth and needed to have have two teeth pulled. The resident reported the facility couldn't find a dentist to help her. She revealed she needed assistance with transfers from her wheelchair to the dental chair. Resident #2 denied pain but reported the cold sensitivity was a problem and prevented her from eating things she liked, example of ice cream. On 05/19/22 at 12:56 PM interview with the Director of Nursing (DON) revealed the facility had attempted to get Resident #2 into other dentists, but they were having problems finding a dentist who accepted Medicaid. On 05/19/22 at 3:06 P.M. interview with Registered Nurse #700 revealed there was no written evidence of the facility calling other dentists since October 2021 to find a dentist who would take Resident #2's payment source. Review of facility policy titled Dental Services, dated 04/01/22 revealed it was the policy of the facility to assist residents in obtaining routine (to he extent covered under the state plan) and emergency dental care. The policy also revealed referrals to dental providers shall be made as appropriate and all actions and information regarding dental services, including any delays related to obtaining dental services, would be documented in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 10 of 12 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 05/19/2022 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 - Some 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 facility policy review the facility failed to monitor refrigerator temperatures on one of three resident units and failed to ensure refrigerators were maintained in a clean manner to prevent contamination and/or food borne illness. This had the potential to affect 19 residents (#33, #41, #49, #59, #76, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #233, #234 and #235) who resided on the Transitional Care unit (TCU) of 85 residents residing in the facility. Findings include: On 05/16/22 at 5:50 P.M. interview with Licensed Practical Nurse (LPN) #514 revealed if food was provided for residents on the Transitional Care unit (TCU) and the resident did not have their own refrigerator, the food was placed in the refrigerator in the Occupational Therapy (OT) room. On 05/16/22 at 5:50 P.M. observation of the refrigerator in the OT room revealed the thermometer in the refrigerator read 73 degrees Fahrenheit. Among the items stored in the refrigerator were two containers of cream cheese with no name noted. There were red and brown sticky substances on the top left shelf of the refrigerator door and discolored dry red areas on the bottom refrigerator shelf and in the bottom two drawers. A posting on the refrigerator indicated refrigerator temperature logs could be located on the housekeeping cart. On 05/16/22 at 5:52 P.M. LPN #514 verified the thermometer in the refrigerator read 73 degrees Fahrenheit and the refrigerator did not feel cold. LPN #514 verified the refrigerator was not clean, stating it was housekeeping's responsibility (to clean it). Review of the facility Food Safety Requirements policy, dated 04/01/22 revealed foods that required refrigeration should be refrigerated immediately upon receipt. Practices to maintain safe refrigerated storage included monitoring food temperatures and functioning of the refrigeration equipment daily. On 05/16/22 at 6:10 P.M. interview with Registered Nurse (RN) #700 revealed there had been no food borne illnesses in the facility. RN #700 revealed she had access to the temperature logs for the refrigerators. At 6:35 P.M. RN #700 revealed the temperature logs would have to be provided the following day. On 05/17/22 at 10:19 A.M. RN #701 provided nursing and resident refrigerator temperature logs for the TCU which had recordings for refrigerator temperatures in the nursing station and rooms 401-410. RN #701 revealed they were the only logs available and they could find no temperatures recorded since February 2022. RN #701 verified there was no evidence of the refrigerator in the OT room being monitored. RN #701 revealed the refrigerator had not been functioning correctly and it was not supposed to be used. At 10:50 A.M. RN #701 revealed she was not sure who the cream cheese belonged to that was in the refrigerator. Review of the facility Use and Storage of Food Brought in by Family or Visitors policy, implemented 04/01/22 revealed all food items taken to facility were required to be labeled and dated. Infection control logs did not reveal outbreak related to food borne illnesses from September 2021 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 11 of 12 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 05/19/2022 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 to May 2022, the time period reviewed. Level of Harm - Minimal harm or potential for actual harm The facility identified Resident #33, #41, #49, #59, #76, #81, #82, #83, #84, #85, #86, #87, #88, #89, #90, #91, #233, #234 and #235 who resided on TCU. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 12 of 12

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Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0661GeneralS&S Dpotential for harm
F661 - Quality of life
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0791GeneralS&S Dpotential for harm
F791 - Dental Services
Provide or obtain dental services for each resident.

FAQ · About this visit

Common questions about this visit

What happened during the May 19, 2022 survey of CARRIAGE INN OF STEUBENVILLE?

This was a inspection survey of CARRIAGE INN OF STEUBENVILLE on May 19, 2022. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CARRIAGE INN OF STEUBENVILLE on May 19, 2022?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as neede..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 19, 2022