Below 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 Carthage Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to maintain a safe, clean, and homelike environment in both the North and South units. In the North unit, a resident's room had a dirty, mildew-smelling floor mat and cobwebs, while the South unit had a damaged countertop, missing tiles, and a stained carpet. Staffing shortages and lack of maintenance awareness contributed to these deficiencies.
The facility failed to provide palatable and properly heated meals to residents during a survey, with meals being bland and served at inadequate temperatures. Residents and staff reported consistent issues with food quality, and miscommunication between departments led to improper temperature checks during a special meal event. Staffing shortages and remote work by the dietitian contributed to the deficiency.
The facility failed to adhere to professional standards for food service safety, with improper cooling and storage of scrambled eggs and turkey salad, outdated food, and unclean kitchen surfaces. The scrambled eggs were not monitored for temperature and were found at 94°F, while the turkey salad was improperly cooled at 49.6°F. Additionally, cooked rice was stored beyond the allowed three days, and the kitchen had unclean surfaces with a steam table in disrepair and a broken dishwasher.
A facility failed to provide a timely Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage to a resident after Medicare Part A services were discontinued. The resident, with diagnoses including muscle weakness and traumatic brain injury, remained in the facility without receiving the required notice in advance. The Business Office Manager did not date the notice or track its mailing, resulting in the resident's representative receiving it late, hindering their ability to appeal the decision.
Two residents in an LTC facility did not receive necessary assistance with personal hygiene and grooming, leading to deficiencies. One resident with cerebral palsy was not shaved despite expressing a desire to be groomed, while another resident with dementia had unkempt hair and dirty nails due to missed showers and inadequate care. Staff interviews revealed inconsistencies in care documentation and execution, highlighting a failure to follow the facility's care policies.
A resident with a urinary catheter had their drainage bag improperly positioned above the bladder level, contrary to the care plan and facility policy. This was observed during a survey, and staff interviews confirmed the importance of correct placement to prevent infections. The issue arose when an LPN moved the bag to an incorrect position and forgot to adjust it back.
A resident with a history of falls and a left femur fracture was not transferred using the required sit-to-stand mechanical lift as per their care plan. Observations showed staff transferring the resident without the lift device, despite facility policies requiring its use. The mechanical sit-to-stand lift was non-functional, leading to inappropriate transfer methods that did not align with the care plan.
A resident with chronic obstructive pulmonary disease and respiratory failure expressed a desire to be discharged to an assisted living facility but was not assisted with discharge planning or updated on the status of their discharge plan. Despite being independent in most activities of daily living, the resident had been waiting for placement for several months without necessary referrals being made. Interviews with staff confirmed the resident's independence and the need for a lower level of care, but the Director of Social Work had not sent out referral packets, leading to the deficiency.
Two residents in the facility experienced deficiencies in pressure ulcer care and prevention. One resident developed multiple facility-acquired pressure ulcers due to improper air mattress settings and lack of repositioning, while another resident's heel was not consistently offloaded, risking further skin breakdown. Staff interviews revealed inconsistencies in care practices and documentation.
Two residents with hand contractures did not have their palm guards applied as recommended by occupational therapy. One resident with dementia and weakness was observed without a left palm protector, and another with Huntington's disease was seen without bilateral palm guards. The tasks for documenting the application of these guards were not properly activated, leading to a lack of documentation and awareness among staff. Interviews revealed that staff were unaware of the necessity of the guards, which could lead to worsening contractures and skin breakdown.
A resident with end-stage renal disease did not receive consistent pre and post-dialysis assessments, and staff inaccurately documented the presence of an arteriovenous fistula instead of the actual Permacath. The facility's policies required monitoring of the dialysis access site, but these assessments were not consistently performed, posing a risk to the resident's health. Interviews revealed staff were unaware of the access site's location and the importance of monitoring it for complications.
A resident with dysphagia and a physician order for nectar thick liquids was served thin liquids due to a communication breakdown in the facility. The resident's meal ticket did not reflect the correct diet consistency, leading to the error being discovered by a family member. Staff interviews revealed that the facility's process for communicating dietary orders was not followed correctly.
Environmental Deficiencies in Resident Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in both the North and South units. On the North unit, a resident's room was observed to have a dirty floor mat with dried debris and a mildew smell, along with cobwebs on the wall. These conditions persisted over multiple days, indicating a lack of adequate cleaning and maintenance. The facility's policy on cleaning and disinfecting resident care items and equipment was not followed, as the floor mat was not properly cleaned or maintained. On the South unit, several environmental deficiencies were noted, including a damaged dining room countertop, missing floor and wall tiles in the shower room, and a broken wall tile in the hall bathroom. Additionally, the common area had a stained carpet, four burned-out lights, and a broken light fixture. Interviews with housekeeping and maintenance staff revealed issues with staffing shortages and a lack of awareness of the environmental concerns, contributing to the failure to maintain a homelike environment. The facility's policies on vacuuming carpets and maintaining a sanitary environment were not adhered to, as evidenced by the stained carpet and unaddressed maintenance issues.
Deficiency in Food Quality and Temperature Control
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, flavorful, and served at appetizing temperatures during the recertification survey conducted from September 23 to September 26, 2024. This deficiency was observed across three meals, including two lunch meals and a special Fall festival meal. Residents and staff reported that the food was often bland, cold, and unappetizing. Specifically, during the lunch meal on September 24, 2024, the beef stroganoff was found to be bland and rubbery, and during the Fall festival meal on September 25, 2024, the corn dog and sweet potato fries were served at temperatures below the required 140 degrees Fahrenheit. Additionally, the corn on the cob was described as bland, chewy, and mushy. Interviews with residents and staff revealed consistent complaints about the food quality and temperature. The Food Service Director acknowledged miscommunication between the activities and dietary departments, which led to improper temperature checks during the Fall festival meal. The facility was short-staffed, and the cook was performing multiple tasks, which contributed to the oversight. The registered dietitian, who previously conducted test trays, was working remotely, resulting in irregular test tray evaluations. The Director of Activities confirmed that the food was reheated using a portable stove, but there was uncertainty about the appropriate temperature maintenance, further exacerbated by the absence of kitchen staff support due to staffing shortages.
Improper Food Storage and Cooling Procedures
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the survey, it was observed that scrambled eggs were improperly cooled and stored in the main kitchen. The eggs, placed in a cooler after breakfast, were not monitored for temperature and were found to be at 94 degrees Fahrenheit, well above the safe cooling temperature. The staff member responsible for the eggs was unaware of the proper cooling requirements and did not document the cooling process, leading to the eggs being discarded voluntarily. Additionally, a large bowl of turkey salad was found improperly cooled in the walk-in cooler, covered with multiple layers of plastic wrap, and measured at 49.6 degrees Fahrenheit. The staff member who prepared the salad was unsure of the proper cooling temperature and did not document the cooling process. The turkey salad was later moved to the walk-in freezer to rapidly cool it for the day's dinner meal. The Food Service Director acknowledged that the cooling process was not properly followed, as the temperature did not change significantly after being in the cooler for nearly an hour. The survey also identified outdated food in the kitchen, with cooked rice labeled with a date indicating it had been stored for more than three days. The facility's policy required leftovers to be discarded after three days, but this process was not documented. Furthermore, the kitchen had unclean and uncleanable surfaces, with a steam table in disrepair and a dishwasher out of service. The steam table had no functioning lights, and the service rail bars were taped, making them not easily cleanable. The facility was using disposable plates and utensils due to the broken dishwasher, and the Administrator was aware of these issues but had not yet resolved them.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the appropriate liability and appeal notices to a Medicare beneficiary, specifically for a resident who remained in the facility after the discontinuation of Medicare Part A services. The facility did not issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (CMS-10055) to the resident or their representative in a timely manner, as required by policy. The facility's policy, dated July 2019, mandates that such notices be issued when Medicare payment is expected to be denied, allowing beneficiaries enough time to make informed decisions about continuing services and accepting potential financial liability. In this case, the resident had diagnoses including muscle weakness, anxiety, and traumatic brain injury, and their Medicare Part A services ended on a specified date. However, the notice was not dated, and there was no documentation of when it was mailed. The Business Office Manager admitted to not dating the letter or certified mail forms and acknowledged the lack of a tracking mechanism. The resident's representative received the notice several days after the services ended and expressed that they would have appealed the non-coverage decision if informed earlier. The facility's failure to communicate effectively and timely with the resident's representative contributed to the deficiency.
Deficiencies in Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for two residents, leading to deficiencies in personal hygiene and grooming. Resident #43, who has cerebral palsy and requires assistance with personal hygiene, was observed with unwanted facial hair over several days. Despite the resident's expressed desire to be shaved, the staff did not provide the necessary grooming, which was confirmed through interviews with multiple staff members who acknowledged the importance of maintaining the resident's dignity through proper hygiene. Resident #15, diagnosed with dementia and requiring maximum assistance for hygiene care, was found with unkempt hair and long, dirty fingernails. The resident reported not having their hair washed for two weeks and missing a scheduled shower. Interviews with staff revealed inconsistencies in the documentation and execution of care, with some staff members failing to report or address the resident's hygiene needs adequately. The facility's policy on activities of daily living care and support was not followed, as evidenced by the lack of proper grooming and hygiene for these residents. Staff interviews highlighted a gap in communication and documentation, with aides not consistently reporting refusals or incomplete care to nursing staff. This failure to adhere to care plans and policies resulted in a deficiency in maintaining the residents' dignity and personal hygiene.
Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the urinary catheter drainage bag of a resident with a history of urinary tract infections and chronic kidney disease was observed positioned above the level of the bladder, contrary to the facility's policy and the resident's care plan. The care plan required the drainage bag to be maintained below the bladder level to prevent urinary tract infections. Observations revealed that the resident's catheter drainage bag was initially clipped to the top of the wheelchair's backrest, which was above the bladder level. A nurse aide later moved it to the bottom of the wheelchair after noticing the incorrect placement. Interviews with staff confirmed the importance of keeping the drainage bag below the bladder to prevent backflow and infections. However, a lapse occurred when an LPN moved the bag to the top of the wheelchair and forgot to reposition it correctly, leading to the deficiency.
Failure to Use Required Transfer Equipment for Resident
Penalty
Summary
The facility failed to ensure adequate supervision and use of appropriate transfer equipment for a resident with a history of falls and a left femur fracture. The resident was dependent on staff for all transfers and required a sit-to-stand mechanical lift as per their care plan. However, observations revealed that staff repeatedly transferred the resident without using the required lift device, contrary to the care instructions and facility policy. During multiple observations, certified nurse aides and an LPN were seen transferring the resident without the use of a lift device, despite the care plan indicating the need for a sit-to-stand mechanical lift. Interviews with staff confirmed that the resident's transfer status was documented in the care plan and should have been followed. The facility had a mechanical sit-to-stand lift, but it was not functioning and had been stored in the basement for months, leading staff to use alternative methods that were not in line with the care plan. The facility's policies required the use of two staff members for transfers involving mechanical lifts to ensure safety. Despite this, staff were observed transferring the resident with assistance of one, using the resident's arms instead of the prescribed equipment. Interviews with the Director of Nursing and therapy staff highlighted the importance of following therapy recommendations to prevent injuries, yet these were not adhered to, resulting in a deficiency in providing adequate supervision and accident prevention.
Failure to Develop and Communicate Discharge Plan for Resident
Penalty
Summary
The facility failed to ensure the discharge needs of Resident #54 were identified and resulted in the development of a discharge plan. Resident #54, who was admitted with chronic obstructive pulmonary disease, respiratory failure, and dependence on supplemental oxygen, expressed a desire to be discharged to an assisted living facility. Despite being cognitively intact and independent in most activities of daily living, the resident was not assisted with discharge planning or updated on the status of their discharge plan. The facility's policy required the Social Worker, acting as the Discharge Coordinator, to develop a discharge plan beginning at admission and to document the steps taken for discharge planning in the resident's medical record. However, there was no documented evidence that the Director of Social Work discussed discharge goals with Resident #54 or made necessary referrals for assisted living placement. The resident had been waiting for assisted living placement for several months and repeatedly inquired about the status of their discharge plan without receiving updates or assistance. Interviews with facility staff, including a Certified Nurse Aide, Licensed Practical Nurse, and the Director of Social Work, confirmed that the resident was independent in activities of daily living and would benefit from a lower level of care. Despite this, the Director of Social Work had not sent out any referral packets for the resident's discharge to an assisted living facility, citing long wait lists and unfamiliarity with facilities in the resident's preferred area. The lack of communication and action regarding the resident's discharge plan led to the deficiency identified during the survey.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident #66 developed three facility-acquired pressure ulcers and a vascular wound, with the air mattress not set to the correct weight, and the resident was not turned and repositioned as care planned. Observations showed the air mattress was set incorrectly, and documentation did not reflect the necessary interventions for pressure relief. Interviews with staff revealed inconsistencies in the understanding and execution of care instructions, with some staff unaware of the importance of setting the air mattress to the resident's weight. Resident #66 had multiple diagnoses, including hemiplegia, osteomyelitis, and severe malnutrition, which increased their risk for pressure ulcers. Despite being on comfort care, the resident's care plan lacked specific interventions for pressure relief, and the air mattress was often set to an inappropriate weight, potentially exacerbating the pressure ulcers. Staff interviews indicated a lack of proper documentation and understanding of the air mattress settings, with some staff adjusting the settings based on subjective assessments rather than documented weights. Resident #379, a new admission with osteomyelitis of the left foot, was also at risk for skin breakdown. Observations showed the resident's heel was not consistently offloaded as required, with the heel boot often not in use. Staff interviews confirmed the importance of the heel boot for wound prevention and comfort, yet it was not consistently applied. The facility's failure to ensure proper use of pressure-relieving devices and adherence to care plans contributed to the deficiencies in pressure ulcer care for both residents.
Failure to Apply Palm Guards for Residents with Contractures
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Specifically, two residents with hand contractures did not have their palm guards applied as recommended by occupational therapy. Resident #15, who had diagnoses including dementia and weakness, was observed multiple times without the left palm protector that was supposed to be worn at all times except during functional tasks. The care instructions for Resident #15 included the use of a left palm protector, but the task was not properly activated in the electronic record, preventing certified nurse aides from documenting its application. Similarly, Resident #7, who had severe cognitive impairment and functional limitations due to Huntington's disease, was observed without bilateral palm guards on several occasions. The care plan for Resident #7 required the use of palm guards at all times except during hygiene care. However, the task for documenting the application of these guards was not properly activated, leading to a lack of documentation and awareness among staff about the necessity of the guards. Interviews with staff, including certified nurse aides, LPNs, and the Director of Nursing, revealed a lack of awareness and proper documentation regarding the application of palm guards for both residents. The failure to apply the palm guards as recommended by occupational therapy could lead to worsening contractures and skin breakdown, as noted by the Director of Nursing and other staff members. The deficiency was attributed to the improper activation of tasks in the electronic record, which prevented staff from documenting the application of the palm guards.
Inadequate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, as evidenced by the lack of ongoing assessments and oversight before and after dialysis treatments. The resident, who had end-stage renal disease and required hemodialysis, was documented to have an arteriovenous fistula, which they did not possess. The facility's policies required that the dialysis access site be monitored for function, signs of infection, and other complications, but these assessments were not consistently documented or performed. The resident received hemodialysis treatments at a community-based dialysis center, and there was no documented evidence of pre-dialysis evaluations on several occasions. Additionally, post-dialysis evaluations were missing on multiple dates. The nursing staff failed to accurately document the type of dialysis access the resident had, incorrectly noting the presence of an arteriovenous fistula instead of the actual Permacath. This discrepancy in documentation and lack of consistent monitoring posed a risk to the resident's health and safety. Interviews with nursing staff revealed a lack of awareness regarding the resident's dialysis access site and the importance of monitoring it for bleeding and signs of infection. The Assistant Director of Nursing confirmed that pre and post-dialysis assessments were not consistently completed, which was crucial for monitoring any changes in the site appearance or the resident's vital signs. The failure to perform these assessments and accurately document the resident's condition led to the deficiency identified during the survey.
Failure to Provide Correct Liquid Consistency for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that Resident #383 received food and liquids prepared in a form designed to meet their individual needs. Resident #383, who had a physician order for a nectar thick consistency for all liquids due to dysphagia associated with Parkinson's disease, was served thin liquids instead. This deficiency was identified during a recertification survey conducted from September 23 to September 26, 2024. The deficiency occurred because the facility's process for communicating and implementing dietary orders was not followed correctly. Although the resident's hospital discharge summary and physician orders specified a nectar thick liquid diet, the meal ticket for Resident #383 only documented a pureed diet without the required nectar thick liquids. This oversight led to the resident being served thin liquids for both dinner on September 23 and breakfast on September 24, 2024. Interviews with facility staff revealed a breakdown in communication and procedure. The Director of Food Services and other staff members were unaware of the nectar thick liquid order, and the meal ticket did not reflect the correct diet consistency. The error was discovered when a family member questioned the consistency of the liquids on the resident's tray, prompting staff to remove the thin liquids. The facility's policy required that diet orders be communicated to the food services department, but this did not occur effectively in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carthage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lewis County General Hospital-nursing Home Unit | 14 mi | ★★★★★ | 0 | 0 |
| Samaritan Senior Village, Inc | 15.3 mi | ★★★★★ | 0 | 0 |
| Samaritan Keep Nursing Home Inc | 16.1 mi | ★★★★★ | 12 | 1 |
| Sunset Nursing And Rehabilitation Center, Inc | 37.4 mi | ★★★★★ | 7 | 3 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Carthage Center For Rehabilitation And Nursing.
100% money-back within 48 hours.
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.