Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage House Nursing And Rehabilitation during CMS and state inspections, most recent first.
A high fall‑risk resident with vascular dementia, severe cognitive impairment, prior falls with injury, and existing vertebral fractures experienced three unwitnessed falls in their room over a short period. The resident required extensive ADL assistance and had a documented high fall‑risk care plan, yet each fall occurred in the room without staff present, resulting in elbow bruising and skin tears and a deep laceration to the hand that required sutures. The DON acknowledged awareness of the resident’s fall history and risk factors and reported that the facility did not provide continuous bedside supervision, instead relying on increased visualization and more frequent room checks, which did not prevent the repeated unwitnessed falls.
The facility failed to properly label and secure medications, with multiple instances of unlabeled and undated medications found in medication carts and refrigerators. Additionally, medication refrigerator temperature logs were incomplete, and a treatment cart was left unlocked. Staff interviews revealed non-compliance with facility policies on medication storage and monitoring.
The facility failed to ensure the accuracy of the CMS 802 form for three residents, leading to incorrect documentation of antibiotic treatment for UTIs and omission of dialysis therapy. The errors were due to manual entry mistakes and issues with updating the form, resulting in incomplete resident assessments.
A resident reported that an LPN left unrecognized pills in their room without explanation, which were later identified as Tums instead of the prescribed Simethicone. The LPN admitted to administering Tums without a healthcare provider's order and leaving medications at the bedside, assuming the resident could self-administer. The facility's DON confirmed that medications should not be given without orders, indicating a breach in protocol.
The facility failed to monitor drug regimens for four residents, leading to unnecessary medication administration. A resident received Risperidone without proper indication, while another was given Ramelteon and Aripiprazole without relevant diagnoses. A third resident was on a prophylactic antibiotic without a risk-benefit analysis, and a fourth received Olanzapine without documented consent or specific behavior identification.
A resident received levothyroxine with other medications and supplements instead of on an empty stomach as prescribed. The facility's policy requires medications to be administered safely and as prescribed, but the medication was given at 7:00 AM instead of the prescribed 5:00 AM. The error was due to an incorrect medication order entry by an LPN, which was confirmed by the RN Unit manager.
A resident with severe cognitive impairment and specific dining needs was not consistently provided with required assistive dining equipment, such as a Scoop plate and Kennedy cup, as outlined in their care plan. Observations revealed the resident often ate without these aids, and the Kennedy cup was found empty and unused. The DON was informed of these deficiencies.
The facility failed to maintain proper infection control practices, as observed with improper storage of gloves and handling of clean linen. Gloves were found exposed on a counter, and a CNA carried clean linens against their uniform, contrary to facility expectations. The DON confirmed the improper storage, and the IC Nurse was informed.
A resident with dementia and bone disorders reported ankle pain after an incident, but the facility failed to document the administration of Tylenol and the resident's complaints. Despite staff awareness, there was no record of the pain or medication in the resident's medical records, leading to a deficiency in care.
A resident was discharged from an LTC facility with another resident's medications due to a failure in following proper discharge procedures. The nurse responsible did not complete the necessary medication reconciliation or verify the medications, resulting in the resident receiving multiple incorrect medications. The facility's policy for a safe and orderly discharge was not adhered to, leading to this deficiency.
Failure to Adequately Supervise High Fall‑Risk Resident Resulting in Repeated Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment for a high fall‑risk resident, resulting in three unwitnessed falls in the resident’s room. The resident was admitted with wedge compression fractures of T7–T8, a fracture of the first thoracic vertebra, vascular dementia, anxiety, and a history of falls with injury prior to admission, including falls at an assisted living facility. A Brief Interview for Mental Status on 3/26/2026 showed severely impaired cognition, and the resident required extensive assistance with ADLs. A fall assessment dated 3/30/2026 identified the resident as high risk for falls, and the fall‑risk care plan cited vascular dementia, history of falls with injuries, history of CVA, new surroundings, and self‑transferring in a deconditioned state as contributing factors. Despite these identified risks, the resident experienced three unwitnessed falls in their room over a 10‑day period. On 3/20/2026 at 2:45 PM, staff were called to the resident’s room and found the resident on the floor by the bathroom; the resident was newly admitted, confused, unable to describe what happened, and sustained a bruise and skin tears to the elbows. On 3/26/2026 at 3:45 PM, the resident was again found on the floor near the dresser with a back brace and cervical collar in place and a deep, jagged laceration to the right palm, with minimal bleeding and no reported pain; the incident was unwitnessed, and the root cause was documented as confusion and self‑transferring. An After Visit Summary from that date documented placement of two sutures in the resident’s hand and provided fall prevention information. On 3/30/2026 at 8:45 AM, a nurse heard a loud crash from the hallway and found the resident on the floor next to the bathroom door, again in the room, with head toward the door and feet toward the bed, wearing nonskid socks, a cervical collar, and brace. The resident stated they fell but could not provide further details, and no injuries were noted at that time. All three falls were unwitnessed and occurred in the resident’s room. During interview, the DON acknowledged awareness of the resident’s fall risk, including prior falls at assisted living and admission with back fractures from falls, and stated that the facility did not provide continuous bedside supervision, instead relying on increased visualization and more frequent room checks. The pattern of unwitnessed falls in the room for a resident with severe cognitive impairment, high fall risk, and known history of falls reflects the facility’s failure to provide appropriate supervision to prevent accidents as required.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications across multiple medication carts and treatment areas. Observations revealed that medications were not labeled with open dates, including Dorzolamide eye drops, Fiasp insulin pens, Ventolin inhalers, Timolol ophthalmic solutions, Flonase nasal spray, and Latanoprost eye drops. Additionally, loose tablets were found in medication cart drawers, and a treatment cart containing prescription medications was left unlocked and unattended. The facility also failed to maintain accurate and complete medication refrigerator temperature logs. The logs showed numerous instances where temperatures were not recorded, and some entries indicated temperatures outside the recommended range. This issue was compounded by the improper handling of controlled substances, as evidenced by crossed-out entries on the control substance record for Lorazepam, which is not the correct procedure for documenting narcotic waste. Interviews with nursing staff revealed a lack of adherence to the facility's policies on medication storage and temperature monitoring. Staff were unable to provide accurate information on when certain medications were opened, and there was a general lack of accountability for ensuring medication carts and refrigerators were properly secured and monitored. These deficiencies indicate a systemic issue with medication management within the facility.
Inaccurate CMS 802 Form for Resident Care Categories
Penalty
Summary
The facility failed to ensure the accuracy of the CMS 802 form, which is used to list all current residents and note pertinent care categories, for three residents. Resident #48 was inaccurately listed as being administered an antibiotic for a current UTI, despite the Medication Administration Record (MAR) indicating that the antibiotic treatment had ended in February. Similarly, Resident #93 was also incorrectly noted as receiving antibiotic treatment for a UTI, although the treatment had concluded on March 1, 2025. The Infection Preventionist confirmed that Resident #93 was not currently being treated for a UTI, and the MDS Coordinator acknowledged the oversight in updating the CMS 802 form, attributing it to manual completion errors. Resident #49's CMS 802 form failed to identify the resident's dialysis therapy, despite the resident being on a hemodialysis schedule. During an interview, the Licensed Practical Nurse confirmed the resident's dialysis schedule and the presence of a hemodialysis catheter. The MDS assessment nurse admitted to missing the dialysis category on the CMS 802 form, citing issues with the update process and manual entry errors. The oversight was attributed to the failure to transfer the information from the electronic medical record to the CMS 802 form, resulting in an incomplete and inaccurate resident assessment overview.
Medication Administration Deficiency Due to LPN's Actions
Penalty
Summary
The facility failed to ensure the competency of licensed nursing staff in medication administration, resulting in a deficiency involving a resident. A resident, who was cognitively intact and required supervision for certain activities, reported a negative experience with a new LPN during the night shift. The resident stated that the LPN left two unrecognized pills in their room without explanation. Upon inquiry at the nurses' station, the resident discovered the pills were Tums, not the prescribed Simethicone, and the LPN reacted rudely when confronted. The Unit Manager confirmed the resident's concerns and revealed that the LPN administered Tums instead of Simethicone because they could not locate the prescribed medication. The LPN admitted to leaving the medications at the resident's bedside, assuming the resident was capable of self-administration, despite not knowing the facility's policy on medication self-administration. The LPN also acknowledged administering Tums without a healthcare provider's order and failing to document the administration. The Director of Nursing stated that the facility does not administer medications without orders, highlighting a breach in protocol. The LPN's actions, including administering medication without an order, leaving medications at the bedside, and failing to document the administration, contributed to the deficiency. The report indicates a lack of adherence to professional standards and facility policies regarding medication administration.
Inadequate Monitoring of Drug Regimens and Documentation
Penalty
Summary
The facility failed to effectively monitor the drug regimens of four residents, leading to the administration of unnecessary medications. Resident #60 was prescribed Risperidone for Major Depressive Disorder, which is not an appropriate indication for this medication. Although the resident had a diagnosis of psychosis, it was not integrated into the resident's diagnoses list, leading to inappropriate medication use. Resident #256 was prescribed Ramelteon and Aripiprazole without any mental health or sleep disorder diagnoses, and the signed consent forms did not specify the conditions being treated. It was later discovered that these medications were prescribed for hospital-acquired delirium, but the diagnoses were not updated in the clinical record. Resident #76 was administered a prophylactic antibiotic, Cephalexin, for recurrent urinary tract infections without a documented risk versus benefit analysis by the physician. The facility's antibiotic stewardship policy requires documentation of specific criteria supporting the use of antibiotics, which was not adhered to in this case. The lack of a risk versus benefit analysis for the prophylactic use of antibiotics was acknowledged by the Infection Control Preventionist, who confirmed that such documentation should have been obtained. Resident #85 was prescribed Olanzapine for unspecified dementia with psychotic disturbance, but the consent form did not identify specific behaviors being treated. The Social Worker and Registered Nurse involved in obtaining consent acknowledged that the diagnosis was incorrect and that the consent form lacked necessary details. Additionally, there was no documentation of phone consent from the resident's guardian, as required by the facility's procedures. This oversight in documentation and consent processes contributed to the inappropriate administration of antipsychotic medication.
Improper Administration of Levothyroxine
Penalty
Summary
The facility failed to ensure the proper administration of medication for a resident, resulting in the resident receiving levothyroxine, a thyroid hormone replacement, with other medications and supplements. According to the facility's 'Medication Administration' policy, medications should be administered in a safe and timely manner, as prescribed, and within one hour of their prescribed time unless specified otherwise. Levothyroxine is recommended to be given on an empty stomach, preferably one hour before breakfast. However, the resident received levothyroxine at 7:00 AM with other medications and supplements, contrary to the prescribed administration time of 5:00 AM on an empty stomach. The issue was identified during an observation and interview with a Registered Nurse (RN) who administered the medication. The RN provided the resident with cranberry juice after a blood sugar check and then administered the medications, including levothyroxine, with a Med pass supplement and other medications. The Licensed Practical Nurse (LPN) manager confirmed that the medication order was incorrectly entered for 7:00 AM instead of 5:00 AM. The RN Unit manager also confirmed that levothyroxine should be administered at 5:00 AM on an empty stomach. This discrepancy in medication administration timing led to the deficiency noted by the surveyors.
Failure to Provide Assistive Dining Equipment
Penalty
Summary
The facility failed to provide necessary assistive dining equipment to a resident, resulting in a deficiency in care. The resident, who was admitted with diagnoses including amnesia, anorexia, and seizures, required assistance with activities of daily living and had severely impaired cognition. The care plan for the resident specified the use of a Scoop plate and a Kennedy cup to aid in dining, but these were not consistently provided. Observations over several days showed that the resident was often given meals without the required Scoop plate and Kennedy cup, or the equipment was not used correctly. On multiple occasions, the resident was observed eating without the necessary assistive devices, and when the Kennedy cup was provided, it was found empty and upside down. A CNA explained that the resident did not like to use the Kennedy cup, but this was not addressed in the care plan. The Director of Nursing was informed of the oversight, indicating a lapse in following the care plan interventions designed to maintain the resident's nutritional and hydration status.
Infection Control Deficiency: Improper Storage and Handling of Linen and Gloves
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by the improper storage and handling of clean linen and gloves. During an observation, a box of clear gloves was found on a counter with gray gloves piled on top, some of which were touching the counter surface. A resident confirmed that staff used these gloves. Additionally, a CNA was observed carrying a pile of clean linens against their uniform, which was uncovered, contrary to facility expectations. The Director of Nursing confirmed that gloves should not be stored exposed, and the Infection Control Nurse was informed of these observations.
Failure to Document Pain Management and Assessment
Penalty
Summary
The facility failed to document the administration of pain medication and complaints of ankle pain for a resident, resulting in a lack of documented assessments and treatment. The resident, who had a history of dementia and bone disorders, reported ankle pain after getting her foot caught in the bed. Despite the resident's complaints and the administration of Tylenol by a nurse, there was no documentation of the pain or the medication given in the resident's medical records. The incident involved multiple staff members who were aware of the resident's complaints and the administration of Tylenol, yet failed to document these events. The Director of Nursing conducted an investigation and found that the resident had complained of pain and received Tylenol, but these actions were not recorded in the progress notes or medication administration record. This lack of documentation led to a deficiency in providing appropriate treatment and care according to the resident's needs and preferences.
Resident Discharged with Incorrect Medications
Penalty
Summary
The facility failed to maintain professional standards and ensure a comprehensive and safe discharge for a resident, resulting in the resident being discharged with another resident's medications. The incident involved a resident who was discharged with multiple medications that were not prescribed to her. The resident, who was only prescribed 2-3 medications, received a large number of medications upon discharge, which she found unusual. It was later discovered by her home health care nurse that the medications belonged to another resident. The Director of Nursing (DON) reported that the nurse responsible for the discharge, Nurse L, did not complete the necessary medication reconciliation or review the medications given to the resident. Nurse L admitted to being busy and not verifying the medications due to room changes on the day of discharge. The medications that were incorrectly sent home included several blister packs of various drugs not prescribed to the resident. The facility's investigation revealed that the medications were indeed in the facility at the time of discharge, but Nurse L failed to locate them and instead provided medications from the cart. The facility's policy required a safe and orderly discharge process, including providing written and oral instructions and completing a medication reconciliation form. However, these procedures were not followed, leading to the resident receiving incorrect medications. The incident was further complicated by miscommunication and a lack of proper documentation, as Nurse L did not complete the medication reconciliation form or provide the correct discharge instructions.
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Illustrative
What surveyors actually found near you
We read the 162 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Bay City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bay Shores Senior Care And Rehab Center | 1.6 mi | ★★★★★ | 13 | 0 |
| Caretel Inns Of Tri-cities | 3.8 mi | ★★★★★ | 3 | 0 |
| Hampton Nursing And Rehabilitation | 4.6 mi | ★★★★★ | 0 | 0 |
| Huron Woods Nursing Center | 6.7 mi | ★★★★★ | 15 | 0 |
| Bay County Medical Care Facility | 7.8 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.