Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage Inn Of Cadiz during CMS and state inspections, most recent first.
Inaccurate accounting of a resident’s personal funds occurred when the facility, acting as payee for Social Security and pension, failed to apply the correct personal allowance amount and used the resident’s full Social Security payment to cover liability instead of sending the prorated amount to the POA after the resident transferred to another facility. The account was later closed with a zero balance after a check was issued to the new facility, and the BOM and Co-Owner verified the third-party biller did not provide the correct amount of personal funds due.
Surveyors found that opened wound care products were not labeled or dated, and medications requiring refrigeration were stored at improper temperatures, with logs showing inconsistent documentation. These failures in medication management were confirmed by nursing staff and had the potential to affect all residents.
Infection surveillance and oversight were deficient when the RN/ICP did not monitor microorganisms involved in infection patterns and did not document a plan after an increase in UTIs was identified. Surveillance logs showed multiple residents with UTIs, including one resident treated twice, but the records did not track the organisms involved. The RN/ICP also reported no infection-specific audits of perineal/incontinence care or handwashing, and the QA antibiotic-use report did not identify how many infections met criteria for antibiotic use.
Antibiotic stewardship was not followed for multiple residents when UTI criteria were not thoroughly reviewed, and prescribers were not informed when criteria was not met. A resident with Parkinsonism, IBS, and dementia, a resident with CHF and HTN, and a resident with COPD and anxiety disorder all had antibiotic orders despite infection review findings that did not support UTI criteria or were documented incorrectly. The facility also did not provide annual physician feedback or education on antibiotic use as required, and QA reports did not include antibiotic use when infection criteria was not met.
Individualized Activity Program Not Maintained: A resident with severe cognitive impairment, dementia, depression, and other significant diagnoses was found to have little involvement in activities, with care plan preferences for gardening and music not reflected in the activity program. Observations showed the resident often alone in her room or bed, declining bingo and other offered activities, while calendars mainly listed coffee cart, bingo, and music events. Staff reported she was difficult to engage, had no documented 1:1 or independent activity notes, and the annual MDS activities/preferences section was not completed.
A resident with multiple chronic conditions and a mechanical soft diet did not receive routine dental assistance after full mouth extractions and a later dental visit showed he could not be fitted for standard dentures. He repeatedly reported trouble getting false teeth and wanting regular foods, but staff told him his sister/POA had to arrange the appointment and the concern was not communicated to nursing or social services. Facility policy stated staff are to assist with dental appointments and routine dental care, including denture impressions and fitting.
A resident with Parkinson’s disease, severe dementia, schizophrenia, anxiety, and other chronic conditions had an active Xanax order for 0.5 mg TID, but the hospice pharmacy record and MAR reflected a PRN order instead. Nurses continued giving the medication as scheduled TID, while the DON and RN confirmed the order had been entered incorrectly as PRN and the MAR did not match the existing order.
The facility failed to maintain sanitary conditions in food preparation and service. Dietary staff were observed with improperly covered facial hair and did not change gloves between tasks, violating the facility's policy. These actions were verified by the Dietary Director.
The facility failed to maintain hot water temperatures below 120°F, posing a burn risk to 16 cognitively impaired residents. Observations revealed temperatures exceeding the facility's guideline of 115°F, with no immediate corrective actions taken. Despite the elevated temperatures, no resident burns were reported.
Inaccurate Accounting of Resident Personal Funds
Penalty
Summary
The facility failed to ensure accurate accounting of a former resident’s personal funds account. Review of the personal funds account showed the resident’s account was closed after transfer to another facility, and the facility was the payee for the resident’s Social Security and pension. The resident’s personal allowance increased from $50 to $75 on 01/01/26, but the account was still allotted a $50 allowance in January 2026. The account balance was $100.01 at the start of the year, and the resident was hospitalized until 02/03/26. In February 2026, the facility allotted the $75 allowance when a Social Security check for $2,791.00 was deposited, but the resident transferred to another facility on 02/09/26. On 02/20/26, $75.03 was withdrawn from the account, and on 03/18/26 a check for $150.06 was sent to the resident’s new facility, leaving a zero balance. The facility did not send the prorated amount of Social Security due to the new facility to the resident’s POA so she could pay the resident’s portion of the bill there. The Business Office Manager and Co-Owner verified that the third-party biller failed to provide the resident the correct amount of personal funds due and used the entire February Social Security check to pay the resident liability instead of sending the prorated amount to the POA.
Improper Medication Labeling and Inadequate Refrigeration Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and dating of opened medications and wound care products. Specifically, an opened tube of Medihoney and an opened tube of Dermasyn hydrogel wound dressing were found in the treatment cart without labels or dates. These findings were confirmed by nursing staff at the time of observation. Additionally, the facility did not maintain proper storage temperatures for medications requiring refrigeration. The medication refrigerator in one medication room was found to be at 60 degrees Fahrenheit during one observation and 50 degrees Fahrenheit during another, both outside the required range of 36-46 degrees Fahrenheit. These temperature readings were confirmed by nursing staff present during the observations. A review of the facility's temperature log for the medication refrigerator showed inconsistent documentation, including a temperature marked above 46 degrees without an actual value and a recorded temperature of 45 degrees. The facility's policy requires that medications be stored according to manufacturer recommendations, with refrigerated medications kept between 36-46 degrees Fahrenheit and temperatures documented daily. The policy also states that the maintenance department should be contacted immediately in the event of refrigerator malfunction. These deficiencies in medication labeling and storage had the potential to affect all residents in the facility.
Infection Surveillance and Oversight Deficiencies
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not adequately monitor for patterns of infection or provide oversight to identify the cause of identified infection patterns. Review of the July 2025 infection surveillance logs showed six residents had UTIs, including one resident who was treated twice for UTI, but the logs did not include information about the microorganisms involved. Review of the August 2025 infection surveillance records also showed microorganisms were not monitored. During interview, the RN/Infection Control Preventionist verified that when tracking infection patterns, she did not monitor the microorganisms involved and stated there had been an increase in UTIs during the summer. She stated there was no documented plan or course of action. She reported increased fluids and staff education regarding perineal care, but the only hydration education record available was dated 02/28/25, and there was no education provided related to perineal care or incontinence care since the pattern was identified in July 2025. She also stated the topics were addressed during an annual education day, but no records were provided. In addition, she stated there had been no audits specific to infections, and after the increase in UTIs was identified, no audits of perineal/incontinence care or handwashing were completed to determine whether they contributed to the increase in UTIs. She further stated that her QA report on antibiotic use did not address how many infections actually met criteria for antibiotic use.
Antibiotic Stewardship Program Not Followed
Penalty
Summary
The facility failed to ensure antibiotic orders were thoroughly researched to determine whether residents met criteria for infection, and when criteria was not met, the prescriber was not informed. For Resident #7, who had diagnoses including secondary Parkinsonism, irritable bowel syndrome, and dementia, a urine culture and sensitivity could not be completed from the collected sample because it had not been ordered, and Bactrim DS was ordered for UTI. The infection report form showed the UTI criteria was not met, but the evaluation was blank on the form tied to the hospital return, and the nurse did not recall telling the physician that the resident did not meet UTI criteria when the antibiotic was continued. The nurse also verified she did not check whether infection criteria had been met before contacting the physician. For Resident #61, who had CHF and hypertension, the infection report form indicated the resident did not meet UTI criteria, yet the physician reviewed admission medications and continued the hospital-ordered antibiotics; the nurse verified she did not contact the physician about the criteria not being met. For Resident #21, who had COPD and an anxiety disorder, the infection report form stated the resident met only one of two UTI criteria, but the evaluation incorrectly indicated criteria was met and cefuroxime axetil was ordered, later changed to ceftriaxone sodium. The facility’s Antibiotic Stewardship Program policy required annual feedback to each attending physician and annual education to staff, prescribers, residents, and families, but the nurse stated she did not provide annual physician training or annual antibiotic-use reports, and the quarterly QA reports did not include information about antibiotic use when infection criteria was not met.
Individualized Activity Program Not Maintained
Penalty
Summary
The facility failed to maintain an activity program specific to meet the individualized needs of Resident #40. Resident #40 was admitted with diagnoses including encephalopathy, adult failure to thrive, depression, moderate protein-calorie malnutrition, aftercare for large abdominal tumor removal, insomnia, anemia, Alzheimer's disease, and dementia with moderate mood disturbances. The quarterly MDS completed on 10/04/25 showed a BIMS score of 4/15, indicating severe cognitive deficit, with inattention and disorganized thinking that fluctuated. The annual comprehensive MDS did not answer the activities and individual preferences section, and the care plan noted that Resident #40 enjoyed spending time in the garden and listening to music, but also stated she had little involvement in activities. Observations showed Resident #40 repeatedly alone in her room or bed, often with no television or music on. On multiple occasions she was observed in her room, walking independently, sleeping, or lying awake looking at the wall, and she was unable or unwilling to elaborate on activities she participated in. During one observation, bingo was heard down the hall, but Resident #40 denied interest and declined to attend. During another, she declined a Christmas ornament-making activity and stated that most activities did not interest her. A flowered blanket brought by her son was noted, and she said it would look nicer with flowers in her room. A daily coffee cart provided coffee and handouts, but there was no documentation of 1:1 activities or independent activities being completed with her. The monthly activity calendars for October, November, and December 2025 showed daily coffee cart service and a 2:00 P.M. activity, with bingo scheduled twice a week and several music-related activities each month, but no gardening or flower-type activities. Activity participation logs from August through December 2025 showed limited participation, with several of the activities being music-related. The Activities Director stated Resident #40 was on a handwritten list for residents needing 1:1 interaction due to self-isolation, that she declined most activities, and that she sometimes responded to music events. The Activities Director also reported a tablet was available for FaceTime calls with her daughter, but the password issue had prevented use, and there were no documented notes in the medical record or activity logs of any 1:1 or independent activities. Staff interviews confirmed she rarely participated, rarely left her room, and was difficult to engage.
Failure to Assist Resident With Routine Dental Services and Denture Needs
Penalty
Summary
The facility failed to provide routine dental services for Resident #53, who was admitted with multiple diagnoses including kidney disease, enlarged prostate, lung disease, anemia, hypertension, reflux, Alzheimer's disease, dementia, anxiety, and depression. The resident's most recent MDS indicated he was cognitively intact with a BIMS score of 15/15, used a wheelchair, required supervision or minimal assistance with transfers and personal care, had no swallowing disorder, and was on a mechanical soft diet. Dental records showed a full mouth extraction was completed, and a later dental evaluation documented that he had no maxillary or mandibular bone to fabricate dentures on and would need to look into dental implants or implant-supported dentures. This information was relayed to the resident and the Social Worker Designee during the appointment. Interviews showed the resident reported trouble getting new false teeth and said he had notified the Activities Director weeks earlier, but was told his sister had to make the appointment and handle insurance. He also reported being tired of the mechanical soft diet and wanting regular foods. During resident council, he again voiced concern about not getting dentures and said he had been told he would have to live without them. The Activities Director stated she told the resident's sister, who was the POA, that she needed to schedule the appointment, and later said she had not notified nursing or social services about the resident's concerns. The Social Worker Designee stated she had not received reports or concerns about the resident wanting new dentures and confirmed the dentist had told her and the resident that he would not be able to wear dentures. Facility policy stated the facility is to assist residents in obtaining routine dental care, including making dental appointments and arranging transportation, and routine dental services include taking impressions for dentures and fitting dentures.
Inaccurate Xanax Order and MAR Documentation
Penalty
Summary
The facility failed to ensure Resident #26’s medication orders and medication administration record were accurate. Resident #26 was admitted on 06/25/21 and had multiple diagnoses including Parkinson’s disease, severe dementia with agitation, schizophrenia, bipolar disorder, anxiety disorder, depression, and other chronic conditions. The MDS indicated the resident could not complete the BIMS because he was rarely or never understood, had no hallucinations or delusions, and was wheelchair bound and dependent for all ADLs. The resident had an active order for Xanax 0.5 mg one tablet by mouth three times daily for anxiety, but a hospice prescription sticker and pharmacy prescription reflected Xanax 0.5 mg by mouth three times daily as needed for anxiety and agitation. The MAR showed the resident received Xanax 0.5 mg three times daily from 11/17/25 through 12/09/25 despite the PRN order from the pharmacy. The CPT confirmed the PRN prescription was ordered, the DON confirmed nurses were giving Xanax scheduled three times daily rather than as needed, and an RN stated the order should never have changed from scheduled to PRN because the hospice on-call nurse had entered it incorrectly.
Sanitation Deficiency in Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food in a sanitary manner, as observed during a survey. Dietary staff members, including the Dietary Director and another dietary staff member, were seen with facial hair that was not properly covered while working in the kitchen. Specifically, one staff member had a beard net that was not fully covering his beard and his mustache was left uncovered while washing dishes and serving food. The Dietary Director was also observed with an uncovered mustache during meal service, despite being present and aware of the situation. Additionally, another dietary staff member was observed handling food without changing gloves between tasks. This staff member washed his hands, donned gloves, and then handled hamburger buns with the same gloves after using a utensil to open the bun package. This practice was verified by the Dietary Director, who was present during the observation. The facility's policy requires hair coverings in food preparation areas and beard restraints for those with facial hair, which were not adhered to during these observations.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures below 120 degrees Fahrenheit, which posed a potential burn risk to 16 cognitively impaired residents who were independent with mobility. These residents resided on the 200 and 300 halls, which were serviced by a hot water tank set to 140 degrees Fahrenheit. During an observation, the Maintenance Director confirmed that the hot water temperatures in several resident rooms exceeded the facility's guideline of 115 degrees Fahrenheit, with temperatures ranging from 120.6 to 121.7 degrees Fahrenheit. The report highlights that the facility's procedure for monitoring hot water temperatures was not effectively implemented, as the Maintenance Director typically tested only two rooms per unit per week and usually in the afternoon. Despite the elevated temperatures, there were no reports of residents receiving burns, as confirmed by a Registered Nurse. The facility's procedure required immediate correction of water temperatures outside the range of 105 to 115 degrees Fahrenheit, but this was not adhered to, leading to the deficiency.
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What surveyors actually found near you
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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 Cadiz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gables Care Center | 6.2 mi | ★★★★★ | 28 | 0 |
| Sienna Hills Nursing & Rehabilitation | 11.5 mi | ★★★★★ | 0 | 0 |
| Cumberland Pointe Care Center | 13.3 mi | ★★★★★ | 0 | 0 |
| Belmont Manor | 14 mi | ★★★★★ | 5 | 0 |
| Park Health Center | 14.2 mi | ★★★★★ | 5 | 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.