Health inspection·February 27, 2026

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some due having diagnoses which included type two diabetes with diabetic neuropathy and morbid obesity and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:14 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #5's meal tray. The tray ticket sitting on the meal tray indicated Resident #5 was on a RCS regular diet consistency diet with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #5's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach in refrigerator by the tray line and had been placed on other residents' meal trays.1c. Review of the medical record for Resident #1 revealed an admission date of 01/01/26. Pertinent diagnoses included type two diabetes mellitus with neuropathy and morbid obesity due to excess calories. The physician had ordered on 02/23/26 for the resident to receive a RCS, regular texture with regular/thin liquids diet.Further review of Resident #1's medical record revealed a Medicare Five Day MDS assessment, dated 01/05/26, which indicated the resident was cognitively intact, required setup or clean up assistance with meals, had no significant weight changes, and was receiving a therapeutic diet.Continued review of Resident #1's medical record revealed a care plan, initiated on 02/23/26, which stated the resident was at nutritional risk due having diagnoses which included obesity, diabetes mellitus, dementia, and Alzheimer's and being on a therapeutic diet with an interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:06 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #1's meal tray. The tray ticket sitting on the meal tray indicated Resident #1 was on a RCS regular diet consistency diet with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #1's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach in refrigerator and had been placed on other residents' meal trays.1d. Review of the medical record for Resident #68 revealed an admission date of 02/11/26. Pertinent diagnoses included type two diabetes mellitus without complications and chronic kidney disease stage three. The physician had ordered on 02/11/26 for the resident to receive a RCS, no salt packet, regular texture with regular/thin liquids diet.Further review of Resident #68's medical record revealed the admission Five Day MDS assessment was in progress.Continued review of Resident #68's medical record revealed a care plan, initiated on 02/23/26, which stated the resident was at nutritional risk due having diagnoses which included type two diabetes mellitus and chronic kidney disease stage three and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:15 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #68's meal tray. The tray ticket sitting on the meal tray indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 2 of 6 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 02/27/2026 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #68 was on a RCS no salt packet diet regular diet consistency with regular/thin liquids. Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #68's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two-door reach in refrigerator by the tray line and had been placed on other residents' meal trays.1e. Review of the medical record for Resident #59 revealed an admission date of 02/03/26. Pertinent diagnoses included type two diabetes mellitus with foot ulcer. The physician had ordered on 02/09/26 for the resident to receive a RCS, no salt packet, regular texture with regular/thin liquids diet.Further review of Resident #59's medical record revealed the Medicare Five Day MDS assessment, dated 02/07/26, indicated the resident was cognitively intact, required set up or clean up assistance for eating, had no significant weight changes and received a therapeutic diet.Continued review of Resident #59's medical record revealed a care plan, initiated on 02/09/26, which stated the resident was at nutritional risk due to having diagnoses which included type two diabetes and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:16 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #59's meal tray. The tray ticket sitting on the meal tray indicated Resident #59 was on an RCS no salt packet diet regular diet consistency with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #59's meal tray. Continued observation of the tray line revealed fruit had been dished up and was available in the two door reach in refrigerator by the tray line and had been placed on other residents' meal trays1f. Review of the medical record for Resident #98 revealed an admission date of 02/06/26. Pertinent diagnoses included chronic kidney disease stage four, severe protein calorie malnutrition and type two diabetes mellitus. The physician had ordered on 02/09/26 for the resident to receive a RCS, no salt packet, regular texture with regular/thin liquids diet.Further review of Resident #98's medical record revealed the admission Medicare five day MDS assessment, dated 02/10/26, indicated the resident was cognitively intact, required set up or clean up assistance for eating, had no significant weight changes and received a therapeutic diet.Continued review of Resident #98's medical record revealed a care plan, initiated on 02/16/26, which stated the resident was at nutritional risk due to having diagnoses which included type two diabetes mellitus, chronic kidney disease stage four, and severe protein calorie malnutrition and being on a therapeutic diet with interventions which included to provide diet and fluids as ordered and to assess food preferences and honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:19 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #98's meal tray. The tray ticket sitting on the meal tray indicated Resident #98 was on an RCS no salt packet diet regular diet consistency with regular/thin liquids . Further review of the tray ticket revealed the resident was to receive chilled peaches for the dessert. An interview with DA #325 at the time of the observation confirmed the white cake with fruit topping and a whipped topping had been placed on Resident #98's meal tray. Continued observation of the tray line revealed fruit had been dished (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 3 of 6 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 02/27/2026 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some up and was available in the two door reach in refrigerator by the tray line and had been placed on other residents' meal trays.Review of the facility's fall and winter menu titled Classic Four PB FW 25-26 revealed the menu for lunch on day six (Friday) of week one was fish of the day, roasted sweet potatoes, sauteed cabbage, dinner roll/margarine, and fruit shortcake.Review of the spreadsheet for the facility spring and winter menu for lunch on day six of week one revealed RCS diets were to receive three ounces of fish of the day, one tablespoon tartar sauce, one number eight scoop (four ounces) of roasted sweet potatoes, one four ounce spoodle (a type of serving utensil) of sauteed cabbage, one each dinner roll/margarine, and one number eight scoop (four ounces) of chilled peaches as the dessert instead of the fruit shortcake.Interview on 02/27/26 at 1:57 P.M. with Registered Dietitian #444 and Dietary Technician Registered (DTR) #411 revealed the spread sheet for the RCS diet should have been followed and the resident should have received chilled peaches instead of the fruit shortcake. Interview on 02/27/26 at 3:33 P.M. with Registered Nurse (RN) Supervisor #423 revealed menus were not always followed and went on to state diabetic residents were getting desserts that they shouldn't be getting. RN Supervisor #423 stated everybody got cake today for lunch.Review of the facility policy titled Reduced Concentrated Sweets (RCS) Diet, revised 12/11/25, revealed the RCS diet was designed to moderate simple sugar intake while maintaining adequate nutrition, hydration, resident satisfaction, and quality of life. An RCS diet may limit food high in simple sugars (concentrated sweets) but did not eliminate carbohydrates. Sweetened desserts was one of the examples listed in the policy as an example of a concentrated sweets item. The policy went on to state the facility would provide RCS diets to support blood glucose management for residents with diabetes or impaired glucose tolerance and would prepare meals consistent with RCS guidelines. 2a. Review of the medical record for Resident #86 revealed an admission date of 07/05/25. Pertinent diagnoses included type two diabetes with diabetic neuropathy, dementia, Parkinsons, chronic obstructive pulmonary disease (COPD), and dysphagia (difficulty swallowing). The physician order had ordered on 11/05/25 for the resident to receive a RCS, no salt packet, mechanical soft diet, with regular/thin liquids.Further review of Resident #86's medical record revealed a quarterly MDS assessment, dated 02/07/26, which indicated the resident was cognitively intact, required setup or clean up assistance with meals, had no significant weight changes, and received a therapeutic and mechanically altered diet.Continued review of Resident #86's medical record revealed a care plan, initiated on 07/21/25, which stated the resident was at nutritional risk due to being on a therapeutic and mechanically altered diet with an intervention to provide diet as ordered and to honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:02 P.M. a small plate with a piece of chocolate cake with white frosting approximately two inches by two inches and one inch tall was placed on Resident #86's meal tray. The tray ticket sitting on the meal tray indicated Resident #86 was on a RCS No Salt Packet diet with a mechanical soft texture. An interview with DA #325 at the time of the observation confirmed the chocolate cake with white frosting had been placed on Resident #86's meal tray.2b. Review of the medical record for Resident #33 revealed an admission date of 02/04/26. Pertinent diagnoses included type two diabetes with diabetic polyneuropathy and oral phage dysphagia. The physician had ordered on 02/24/26 for the resident to receive a reduced concentrated sweets, no salt packet, mechanical soft diet, with regular/thin liquids.Further review of Resident #33's medical record revealed a Medicare five day Minimum Data Set (MDS) assessment, dated 02/08/26, which indicated the resident was moderately impaired cognitively, required setup or clean up assistance with meals, had no significant weight changes, and was receiving a mechanically altered diet but not a therapeutic diet.Continued review of Resident #33's medical record revealed a care plan, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 4 of 6 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 02/27/2026 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some initiated on 02/16/26, which stated the resident was at nutritional risk due to being on a therapeutic and mechanically altered diet with an intervention to provide diet as ordered and to honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:03 P.M. a small plate with a piece of chocolate cake with white frosting approximately two inches by two inches and one inch tall was placed on Resident #33's meal tray. The tray ticket sitting on the meal tray indicated Resident #33 was on a RCS No Salt Packet diet with a mechanical soft texture. Further review of the tray ticket revealed the resident was to receive fruit shortcake for the dessert. An interview with DA #325 at the time of the observation confirmed the chocolate cake with white frosting had been placed on Resident #33's meal tray.2c. Review of the medical record for Resident #73 revealed an admission date of 02/18/26. Pertinent diagnoses included type two diabetes mellitus, dementia, and dysphagia. The physician had ordered on 02/25/26 for the resident to receive a reduced concentrated sweets, no salt packet, mechanical soft diet, with regular/thin liquids.Further review of Resident #73's medical record revealed the admission MDS assessment was in progress of being completed.Continued review of Resident #73's medical record revealed a care plan, initiated on 02/25/26, which stated the resident was at nutritional risk due to diagnoses which included type two diabetes mellitus, having chewing/swallowing problems, and being on a therapeutic and mechanically altered diet being with an intervention to provide diet as ordered and to honor choices as able.Observations conducted on 02/27/26 of tray line between approximately 11:50 A.M. and 12:22 P.M. revealed at 12:21 P.M. a plate with a piece of white cake topped with a layer of cherry topping and another layer of whipped topping, which was approximately three inches by three inches and two inches tall, was placed on Resident #73's meal tray. The tray ticket sitting on the meal tray indicated Resident #73 was on a RCS diet with a mechanical soft texture. Further review of the tray ticket revealed the resident was to receive fruit shortcake for the dessert. An interview with DA #325 at the time of the observation confirmed fruit shortcake had been placed on Resident #73's meal tray.Review of the facility's fall and winter menu titled Classic Four PB FW 25-26 revealed the menu for lunch on day six (Friday) of week one was fish of the day, roasted sweet potatoes, sauteed cabbage, dinner roll/margarine, and fruit shortcake.Review of the spreadsheet for the facility spring and winter menu for day six of week one revealed the spreadsheets were for regular, mechanical soft, pureed, reduced concentrated sweets, or renal modified diets. At the bottom of the spread sheet there were additional instructions for no salt packet on tray and gluten free diets and for when fortified enhanced foods were ordered. There was no additional guidance for when a combination diet such as an RCS mechanical soft diet had been ordered. Continued review of the spreadsheet for the facility spring and winter menu for lunch on day six of week one revealed RCS diets were to receive three ounces of fish of the day, one tablespoon tartar sauce, one number eight scoop (four ounces) of roasted sweet potatoes, one four ounce spoodle ( a type of serving utensil) of sauteed cabbage, one each dinner roll/margarine, and one number eight scoop (four ounces) of chilled peaches as the dessert instead of the fruit shortcake.Interview on 02/27/26 at 1:57 P.M. with RD #444 and DTR #411 revealed there was a glitch in the tray card system the facility was using and the tray tickets for residents on an RCS mechanical soft diet should have stated that the resident would receive canned peaches instead of fruit shortcake. RD #444 stated the dietary menu platform they were using for tray cards either had a spread sheet for RCS diet or a different spread sheet for mechanical soft diet, but confirmed there was no spreadsheet breakdown for combination diet of RCS mechanical soft. Both RD #444 and DTR #411 indicated chocolate cake with icing or the fruit shortcake were not appropriate dessert choices for a resident on an RCS mechanical soft diet.Interview on 02/27/26 at 3:33 P.M. with RN Supervisor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365271 If continuation sheet Page 5 of 6 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 02/27/2026 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete #423 revealed menus were not always followed and went on to state diabetic residents were getting desserts that they shouldn't be getting. RN Supervisor #423 stated everybody got cake today for lunch.Review of the spreadsheet for the facility spring and winter menu for day six of week one revealed the spreadsheets were for regular, mechanical soft, pureed, reduced concentrated sweets, or renal modified diets. At the bottom of the spread sheet there were additional instructions for no salt packet on tray and gluten free diets and for when fortified enhanced foods were ordered. There was no additional guidance for when a combination diet such as an RCS mechanical soft diet had been ordered.Review of the facility policy titled Reduced Concentrated Sweets (RCS) Diet, revised 12/11/25, revealed the RCS diet was designed to moderate simple sugar intake while maintaining adequate nutrition, hydration, resident satisfaction, and quality of life. An RCS diet may limit food high in simple sugars (concentrated sweets) but did not eliminate carbohydrates. Sweetened desserts were one of the examples listed as a concentrated sweets. The policy indicated the facility would provide RCS diets to support blood glucose management for residents with diabetes or impaired glucose tolerance and would prepare meals consistent with RCS guidelines. 3. Review of the facility's fall and winter menu titled Classic Four PB FW 25-26 revealed on day 6 (Friday) of the facility's Week One's menu fish of the day, roasted sweet potatoes, sauteed cabbage, dinner roll/margarine, and fruit shortcake was to be served for lunch. Review of the facility's diet spread sheet lunch on day 6 (Friday) of the facility's fall and winter menu revealed residents who were on a puree diet consistency were to receive one number eight scoop (four ounces) of pureed fish of the day, one tablespoon of mayonnaise, one number eight scoop (four ounces) of pureed sweet potatoes, one number 12 scoop (two and two-third ounces) of pureed sauteed cabbage, one number 16 (two ounces) scoop of pureed dinner roll with margarine, and one number six scoop (five and one third ounces) of pureed fruit shortcake.Review of the facility document titled Order Listing Report, dated 02/27/26, revealed Resident #10, #17, #40 and #100 were ordered a pureed texture diet. Observations conducted on 02/27/26 from approximately 11:50 A.M. to 12:22 P.M. of the facility's tray line revealed there was no observation of any pureed fruit shortcake being around the tray line, and staff were observed placing small plastic bowls filled with vanilla pudding on the meal trays of residents who were on a pureed diet consistency. An interview with Dietary Director (DD) #319 at the time of the observation confirmed residents on a puree diet were getting pudding instead of the pureed fruit shortcake for lunch. When asked why those residents who were on a puree diet were not getting the puree fruit shortcake as stated they would be according to the spreadsheet, DD #319 stated my cook didn't prep the puree fruit shortcake, so they are getting vanilla pudding .An interview conducted on 02/27/26 at 1:57 P.M. with RD #444 and DTR #411 revealed spreadsheets needed to be followed and residents on a puree diet consistency should have received pureed fruitcake instead of the vanilla pudding for lunch that day.Review of the facility policy titled Menus and Adequate Nutrition, revised 01/03/26, revealed the facility would provide residents with nourishing, palatable, well-balanced diets, and menus would be followed.This deficiency represents non-compliance investigated under Complaint Number 2748862. Event ID: Facility ID: 365271 If continuation sheet Page 6 of 6