Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage Inn Of Steubenville during CMS and state inspections, most recent first.
Surveyors observed that the facility did not follow its approved menus and diet spreadsheets for multiple residents on reduced concentrated sweets (RCS) and pureed diets. Several residents with type 2 DM, morbid obesity, CKD, severe protein-calorie malnutrition, dementia, Parkinson’s disease, COPD, and dysphagia, who were ordered RCS or RCS mechanical soft diets, were served white or chocolate cake with frosting or fruit shortcake instead of the chilled peaches specified for RCS diets. Residents on pureed diets, whose menu called for pureed fruit shortcake, were instead given vanilla pudding because the cook had not prepared the pureed dessert. A nurse supervisor acknowledged that menus were not always followed and that diabetic residents received desserts they should not have, while dietary staff and the RD confirmed that the RCS and puree spreadsheets should have been followed and that the desserts served were not appropriate for the ordered diets.
A resident with severe cognitive impairment and upper extremity weakness was not assessed for hot liquid safety and was given hot tea in a Styrofoam cup without a lid, resulting in second-degree burns when the beverage spilled on her lap. The hot water dispenser used was not temperature-monitored and dispensed water at 176°F. Additionally, a required fall prevention intervention (Dycem in the wheelchair) was not in place as ordered and care planned.
A resident with severe cognitive impairment and multiple health conditions, including chronic kidney disease and diuretic use, did not have water maintained at her bedside as required by her care plan. Observations revealed that water was either not present or placed out of the resident's reach, and staff confirmed the resident could not access drinks as needed.
A resident with dementia and chronic kidney disease returned from the hospital with a UTI diagnosis and was prescribed Keflex, despite urine culture results showing the infection was caused by Enterobacter Cloacae, which was not sensitive to that antibiotic. The acting IP identified the mismatch but incorrectly documented the organism and did not ensure the antibiotic was changed, resulting in the resident receiving a full course of an ineffective antibiotic, in violation of the facility's antibiotic stewardship policy.
A hole in the wall behind a resident's bed, measuring about eight inches by eight inches, was found during observation and confirmed by a CNA and an LPN, who had not previously noticed it. Review of maintenance records showed no work order for repair in the past six months.
A facility failed to notify hospice of a resident's refusal to use a CPAP machine, as prescribed. The resident, with a diagnosis including Parkinson's disease and receiving hospice services, refused the CPAP treatment on all but one day over a period of time without hospice or the physician being informed. Observations showed the resident's oxygen equipment was not in use as ordered, and staff confirmed the lack of current physician orders for oxygen administration.
A facility failed to implement fall interventions for a high-risk resident with Parkinson's disease, resulting in multiple falls. The resident's care plan was not updated after a fall, and necessary interventions like a grabber and proper footwear were not provided. Staff were unaware of the resident's fall history and interventions, leading to non-compliance under Complaint Number OH00159914.
A facility failed to provide proper care for a resident's respiratory equipment, including a CPAP machine and oxygen tubing. The resident, with multiple diagnoses including acute respiratory failure, had outdated oxygen tubing on the floor and a CPAP mask with black spots on a window sill. Staff interviews revealed a lack of current physician orders and specific CPAP settings, contrary to facility policy requiring physician orders and proper equipment maintenance.
The facility failed to administer medications as ordered, resulting in a 13.7% medication error rate. Two residents were affected: one with hypertension and other conditions did not receive Isosorbide or Lopressor despite blood pressure readings above the threshold for withholding, and another with cerebral infarction received ASA enteric-coated instead of the prescribed ASA. The facility's policy requires medications to be administered as prescribed.
A facility failed to maintain a complete medical record for a resident, as the Physician's Progress Notes lacked any resident-identifiable information. This issue was discovered during a complaint investigation, and the DON confirmed the incompleteness of the record due to the absence of identifying details.
An LTC facility failed to protect residents from medication misappropriation, affecting 13 residents. An LPN was observed accessing the narcotics drawer without proper documentation, leading to an investigation. Several residents did not receive their prescribed medications, and discrepancies were found in controlled drug records. The LPN was suspended and resigned, but the facility could not conclusively prove drug diversion.
Failure to Follow Therapeutic Diet Menus and Spreadsheets for RCS and Pureed Diets
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered therapeutic diets and the approved menu/spreadsheet for residents, particularly those on reduced concentrated sweets (RCS) and pureed diets. Surveyors observed the lunch tray line and found that multiple residents with orders for RCS diets, including those with morbid obesity, type 2 diabetes mellitus, chronic kidney disease, and severe protein-calorie malnutrition, were served high-sugar desserts that were inconsistent with their diet orders and the facility’s RCS policy. For several cognitively intact or moderately impaired residents who required setup or cleanup assistance and were care planned as being at nutritional risk, tray tickets specified chilled peaches as the dessert for RCS diets, yet staff placed large portions of white cake with cherry topping and whipped topping on their trays. Fruit was available and had been placed on other residents’ trays, but was not used for these RCS diet trays. Additional observations showed that residents on RCS mechanical soft diets were also served inappropriate desserts. Residents with diagnoses including type 2 diabetes with neuropathy, dementia, Parkinson’s disease, COPD, and dysphagia, and who were ordered RCS, no salt packet, mechanical soft diets, received chocolate cake with white frosting or fruit shortcake. The tray tickets for these residents indicated RCS mechanical soft diets, and in at least one case specified fruit shortcake, but the facility’s RCS spreadsheet indicated that RCS diets should receive chilled peaches instead of fruit shortcake. The registered dietitian and dietary technician later confirmed that chocolate cake with icing and fruit shortcake were not appropriate dessert choices for residents on RCS mechanical soft diets and that a glitch in the tray card system meant there was no spreadsheet breakdown for combination diets such as RCS mechanical soft. Surveyors also identified that the facility did not follow the puree diet spreadsheet for residents ordered pureed texture diets. The facility’s fall and winter menu and corresponding spreadsheet specified that residents on pureed diets were to receive pureed fish of the day, pureed vegetables, pureed dinner roll with margarine, and pureed fruit shortcake for lunch. However, during observation of the tray line, no pureed fruit shortcake was present, and residents on pureed diets were instead given small plastic bowls of vanilla pudding. The dietary director confirmed that the cook had not prepared the pureed fruit shortcake and that these residents were therefore receiving vanilla pudding in place of the menu-specified dessert. A registered dietitian and dietary technician confirmed that the spreadsheets needed to be followed and that residents on pureed diets should have received pureed fruit shortcake. The facility’s own policies on RCS diets and on menus and adequate nutrition required that meals be prepared consistent with RCS guidelines and that menus be followed, but these were not adhered to during the observed meal service. A registered nurse supervisor acknowledged during interview that menus were not always followed and stated that diabetic residents were receiving desserts they should not be getting, noting that everybody got cake for lunch that day. Across the cited examples, residents’ medical records consistently showed therapeutic diet orders, MDS assessments documenting therapeutic or mechanically altered diets, and care plans identifying nutritional risk with interventions to provide diet and fluids as ordered and to honor preferences as able. Despite this, the lunch service on the observed day did not follow the written menus, diet spreadsheets, or physician orders for RCS and pureed diets, resulting in desserts being served that were inconsistent with the residents’ prescribed diets and the facility’s written policies.
Failure to Assess and Implement Safety Measures for Hot Liquids and Fall Prevention
Penalty
Summary
A resident with severe cognitive impairment, upper extremity weakness, and a history of falls was not comprehensively assessed for safety with hot liquids, nor were appropriate interventions implemented to prevent burns. The resident required staff assistance with activities of daily living and had an occupational therapy plan indicating upper extremity weakness and a need for set-up or clean-up help for eating. Despite these needs, there was no assessment or care plan addressing the resident's ability to safely consume hot liquids, and no interventions were in place to reduce the risk of burns from hot beverages. On the day of the incident, the resident was provided hot tea in a Styrofoam cup without a lid by therapy staff, using water from a hot water dispenser that was not temperature-monitored and dispensed water at 176 degrees Fahrenheit. The resident attempted to balance the cup on her lap, resulting in the hot liquid spilling onto her left thigh and causing large second-degree burns. Immediate first aid was provided, and the resident required ongoing pain management and wound care. Interviews confirmed that the facility's policy required evaluation of residents for hot liquid safety and the use of lids on hot beverages, but these measures were not followed in this case. Additionally, the resident had a care plan and physician's order for the use of Dycem in her wheelchair as a fall prevention intervention, but this intervention was not in place at the time of observation. Staff interviews and observations confirmed that the Dycem was not present in the resident's wheelchair, despite being ordered and care planned. The lack of adherence to both hot liquid safety protocols and fall prevention interventions contributed to the resident experiencing actual harm.
Failure to Maintain Accessible Hydration for At-Risk Resident
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, diabetes, chronic kidney disease, and a history of falls, was identified as being at risk for dehydration. Her care plan specifically required that water be maintained at her bedside at all times to support adequate hydration, especially given her use of diuretic medication and potential for fluid imbalance. During an observation, it was noted that the resident did not have any water or beverage available in her room, and there was no evidence of a Styrofoam cup or other drinking vessel as provided to other residents. A CNA confirmed that she had not provided water to the resident that morning and could not locate a cup in the room, suggesting it may have been discarded by housekeeping, although this was not the case in other rooms. On a subsequent observation, the resident was found to have a Styrofoam cup with water, but it was placed on an overbed table near the entry door, out of the resident's reach. Another CNA confirmed that the placement of the table and cup made it inaccessible to the resident, preventing her from obtaining a drink when needed. These findings demonstrate that the facility failed to ensure the resident had water maintained at her bedside and within reach, as required by her care plan.
Failure to Implement Effective Antibiotic Stewardship for UTI Treatment
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program when a resident returned from the hospital with a new order for Keflex to treat a urinary tract infection (UTI). The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and chronic kidney disease, was sent to the emergency room for chest pain and returned with a UTI diagnosis and an order for Keflex. Hospital records showed that a urine culture identified Enterobacter Cloacae as the causative organism, which was not sensitive to Keflex. Despite this, the resident received the full seven-day course of Keflex as ordered. The acting Infection Preventionist (IP) at the facility was responsible for reviewing antibiotic use for residents returning from the hospital. The IP identified that the organism causing the UTI was not sensitive to the prescribed antibiotic and completed an antibiotic time-out, reaching out to the resident's physician. However, the Antibiotic Time Out report incorrectly documented the organism as E. coli, for which Keflex would have been appropriate, rather than Enterobacter Cloacae. The physician was informed of the incorrect organism and did not respond until the antibiotic course was nearly complete, instructing to finish the course despite its ineffectiveness against the identified organism. Facility policy required the IP to monitor antibiotic use, review laboratory results, and ensure antibiotics were appropriate for the identified infection. The policy also stated that the Medical Director was responsible for setting standards for antibiotic prescribing and overseeing adherence. In this case, there was no evidence that the antibiotic was changed to one effective against the organism identified in the culture, and the resident received an ineffective antibiotic regimen, contrary to the facility's antibiotic stewardship policy.
Failure to Repair Wall Damage in Resident Room
Penalty
Summary
A hole measuring approximately eight inches by eight inches was observed in the wall behind the head of a resident's bed, near the baseboard. This issue was identified during an observation and was confirmed by interviews with a CNA and an LPN, both of whom stated they had not previously noticed the hole. Review of the facility's maintenance work orders for the past six months showed no documentation of a request to repair the hole in the resident's room. The deficiency was identified as part of a complaint investigation and had the potential to affect one of five resident rooms observed, with a facility census of 78 at the time.
Failure to Notify Hospice of Respiratory Treatment Refusal
Penalty
Summary
The facility failed to notify hospice of a resident's refusal of respiratory treatments, specifically the use of a CPAP machine. Resident #83, who was admitted with a diagnosis including Parkinson's disease, was receiving hospice services and had a history of falls. The resident was prescribed a CPAP machine to be worn at bedtime, but the order did not include the required settings. The resident refused the CPAP treatment on all but one day between November 1 and December 18, 2024, without hospice or the physician being notified of these refusals. Observations revealed that the resident was lying in bed with an oxygen concentrator present, but the nasal cannula was on the floor, and the oxygen tubing was dated from November 9, 2024. Interviews with facility staff, including a CNA and an LPN, confirmed that there were no current physician orders for the resident's oxygen administration, and the resident did not wear the oxygen continuously. The LPN verified the lack of notification to hospice or the physician regarding the CPAP refusals. This deficiency was identified during a complaint investigation.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with Parkinson's disease who was severely impaired in daily decision-making and receiving hospice services. The resident had a history of falls, some resulting in injuries. Despite being identified as a high fall risk, the care plan interventions, such as keeping the call light within reach, assisting with proper footwear, and ensuring the resident wore glasses, were not consistently implemented. Observations revealed the resident was often without gripper socks, glasses, and the call light was not within reach, increasing the risk of falls. After a fall on 12/16/24, the resident's care plan was not updated to include new interventions, such as the use of a grabber or ensuring the resident was in a geri-chair when out of bed. Staff interviews confirmed a lack of awareness and education regarding the resident's fall and the necessary interventions. Additionally, the facility did not have the ordered grabber available for the resident's use, and no alternative interventions were implemented to prevent further falls. The deficiency was noted under Complaint Number OH00159914.
Inadequate Respiratory Equipment Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for oxygen and respiratory equipment for a resident diagnosed with Parkinson's disease, generalized anxiety disorder, pneumonia, and acute respiratory failure with hypoxia. The resident was admitted with orders for a CPAP machine to be worn at bedtime and to continue home settings, as well as hospice orders for oxygen via nasal cannula at two to five liters per minute continuously. Observations revealed that the oxygen tubing was lying on the floor and dated over a month old, while the CPAP mask was resting on a window sill with visible black spots and without a protective barrier. Interviews with facility staff, including a CNA and an LPN, confirmed that the oxygen and CPAP equipment should be stored in a bag and changed regularly. The LPN acknowledged the lack of current physician orders for the resident's oxygen and the absence of specific settings for the CPAP machine, indicating a need to contact the physician for clarification. The facility's policy on oxygen administration requires that oxygen be administered under physician orders and that equipment be cleaned and maintained according to facility policies. This deficiency was identified during a complaint investigation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 13.7%. This deficiency was observed during the medication administration for two residents. Resident #50, who was admitted with diagnoses including hypertension, congestive heart failure, coronary artery disease, and anxiety, had specific physician orders for medications such as chewable aspirin, Isosorbide Dinitrate, and Lopressor, with parameters to hold the latter two if the systolic blood pressure (SBP) was less than 100 mmHg. On December 17, 2024, RN #209 assessed Resident #50's blood pressure at 108/72 mmHg, which was above the threshold to withhold the medications. However, RN #209 decided not to administer Isosorbide or Lopressor, despite the blood pressure reading exceeding the parameters for withholding the medications. Resident #58, admitted with a diagnosis of cerebral infarction, had an order for ASA 81 mg. During the same observation period, RN #209 administered ASA enteric-coated 81 mg instead of the prescribed ASA 81 mg. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered as prescribed. The failure to adhere to these orders and policies resulted in the identified medication errors, which were investigated under Complaint Number OH00159914.
Incomplete Medical Record Due to Lack of Resident Identification
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, which was identified during a complaint investigation. A review of the closed medical record for a resident revealed that the Physician's Progress Notes, dated 10/25/24 and 10/31/24, were not labeled with any resident-identifiable information such as a name, identification number, or room number. This lack of identifying information made it impossible to verify which resident the notes pertained to. An interview with the Director of Nursing confirmed that the progress notes were part of the closed record for the resident, but without the necessary identifying information, the medical record was deemed incomplete.
Medication Misappropriation Incident
Penalty
Summary
The facility failed to protect residents from the misappropriation of medications, affecting 13 residents. The incident was discovered when the Administrator observed suspicious activity by an LPN on the facility's video cameras. The LPN was seen accessing the narcotics drawer without documenting on the medication administration record or narcotic count sheets. An immediate investigation was launched, revealing that medications were unaccounted for, and some routine medications were found discarded in the trash. The investigation into the incident revealed that several residents did not receive their prescribed medications. For instance, one resident was not administered risperidone and buspirone as ordered, while another resident was missing doses of prednisone and sertraline. Additionally, discrepancies were found in the controlled drug records, with pills missing and not documented as administered. These findings were consistent across multiple residents, indicating a pattern of misappropriation. The facility's investigation could not conclusively prove that the LPN had committed drug diversion, but the evidence of discarded medications and discrepancies in narcotic counts substantiated the misappropriation allegations. The LPN was suspended and subsequently resigned. The facility's policy on abuse, neglect, and exploitation defines misappropriation as the wrongful use of a resident's belongings, which was evident in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Steubenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Vista Royale Llc | 0.7 mi | — | 3 | 0 |
| Steubenville Country Club Manor | 0.9 mi | — | 0 | 0 |
| Laurels Of Steubenville The | 1.1 mi | — | 2 | 0 |
| Catherine's Care Center, Inc | 2.4 mi | — | 0 | 0 |
| Sienna Skilled Nursing & Rehabilitation | 2.5 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.