Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Manor during CMS and state inspections, most recent first.
Food storage and service practices were not followed in multiple kitchens. Surveyors found unlabeled, undated, and improperly sealed refrigerated and frozen foods, a dented can stored with undented cans, opened cereal left exposed, undated tea, and a medicine cup left in sugar. CNAs were observed with hair not fully contained in hairnets, one CNA served food without a hairnet, and food was reheated in a microwave without temperature checks. The household dishwasher temperature could not be verified, and the microwave and oven had visible debris.
Medication storage and security were not maintained for a resident and two nurse med carts. A resident with COPD and vascular dementia had inhaled meds left in his nebulizer chamber and ampules on his overbed table after an LPN administered the treatment. In addition, locked narcotic boxes on two med carts were not permanently affixed, and an LPN was observed retrieving cart keys from an unlocked desk drawer.
Food was not served in a palatable or appetizing manner, and one observed lunch meal included BBQ brisket that was not warm and salty, fried okra that was not warm, and a hard pie crust. Multiple residents said the food was bland or did not taste good, and one resident reported meals were often cold by the time they arrived from the main building. The DON/Dietary Manager stated recipe-following in-services had not been completed recently, and the Administrator said she was unsure whether staff had been in-serviced on recipes.
A resident with Alzheimer’s disease and dementia had an admission MDS assessment completed late. The MDS Coordinator said the assessment should be done within the required timeframe but was delayed because she was working on the floor, and the Administrator stated MDSs should be completed per requirements.
Oxygen Not Set at Ordered Rate: A resident with HF and acute respiratory failure with hypercapnia had an order for oxygen at 2 L/min PRN to keep O2 saturation above 90%, but observations later showed the nasal cannula set at 3.5 L/min and then 4 L/min. The resident was unsure of the correct setting, and the MDS Coordinator, DON, Administrator, and an LPN all discussed that the nurse was responsible for checking and setting the oxygen rate.
A CNA failed to change gloves and perform hand hygiene while providing incontinent care to a resident who was totally dependent for personal care and always incontinent of bowel and bladder. In a separate event, another CNA assisted a resident with a wound and ordered EBP with urinal use while wearing gloves but no gown, despite the care plan and policy requiring gown and gloves for high-contact care. The DON, ADON, and Administrator confirmed the expected PPE and hand hygiene practices.
Late MDS Discharge Assessment Completion: A resident discharged home/community after treatment for acute respiratory failure with hypoxia and a femur fracture had a discharge MDS item set that was not completed within the required timeframe. The MDS Coordinator said discharge assessments were delayed because of competing MDS work and were not a priority, and another MDS Coordinator said she did not know the required timeframe for discharge assessments.
The facility did not label or date food stored in the kitchen's refrigerator, including items like pie, French fries, and ice cream. Interviews with the Dietary Manager, DON, and ADM confirmed that this practice was against the facility's policy, which requires all food to be labeled and dated to prevent foodborne illness. The facility's policy mandates that opened products should be labeled with the date opened and a use-by date of seven days.
The facility failed to ensure accurate MDS assessments for four residents, leading to discrepancies in documentation. A resident's MDS did not reflect the use of a chair alarm, despite its necessity due to fall risk. Another resident's MDS failed to indicate PASRR positive status for serious mental illness. A third resident's MDS did not reflect hospice care status, and a fourth resident's MDS did not document bed and chair alarms. These inaccuracies were acknowledged by the MDS coordinators.
A facility failed to include a resident's chronic heart failure diagnosis in their care plan, despite the resident's treatment with diuretics and significant assistance needs. The omission was identified during a review, and staff interviews confirmed the care plan should have included this diagnosis to ensure proper care. The facility's policy requires comprehensive, person-centered care plans, which was not followed in this instance.
A resident with an indwelling urinary catheter did not have documented orders for catheter size and bulb fluid, and received improper catheter care, risking urinary tract infections. Observations showed a CNA failed to clean the meatus and change gloves between tasks, leading to potential cross-contamination. Staff interviews confirmed the lack of adherence to aseptic techniques and proper documentation, with the DON attributing the oversight to a lapse during the resident's readmission.
The facility failed to limit PRN orders for Lorazepam to 14 days for two residents, despite repeated communications from the consultant pharmacist. Both residents, on hospice care, had ongoing PRN orders without a specified stop date or duration. Interviews with staff revealed a lack of adherence to regulatory requirements, with hospice status cited as a rationale for indefinite continuation without proper documentation.
A resident with severe cognitive impairment and a high elopement risk was able to leave the facility without staff noticing, as they did not have a Wanderguard on. The care plan did not reflect the resident's elopement risk, and there was no documentation of the Wanderguard being checked. Staff interviews revealed confusion about the resident's Wanderguard status, and the facility's policy on wandering and elopements was not effectively implemented.
A medication error occurred when an LVN administered hydrocodone/APAP to a resident who was not prescribed the medication, due to misidentification. Both residents involved had the same last name, leading to the error. The facility's policy on verifying resident identity before medication administration was not followed, resulting in the wrong resident receiving the medication.
Food Storage, Labeling, Hair Restraint, and Temperature Monitoring Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in Kitchen #1, Kitchen #2, and Kitchen #3. In Kitchen #1, surveyors observed multiple refrigerated and frozen items that were not properly labeled, dated, or sealed, including spaghetti sauce, jalapeno peppers, lettuce, sweet tea, unsweet tea, prune juice, apple juice, orange juice, cranberry juice, frozen cheese pizza, pepperoni, and potato wedges. A dented can of diced potatoes was also found stored with undented cans in dry storage. The Dietary Manager stated that all food items were supposed to be labeled and dated with receive, open, and expiration dates, and that staff had completed in-services on labeling and dating, but she also stated she had not completed in-services on resealing refrigerated and frozen food items. During lunch service in Kitchen #2, CNA B was observed plating food with a strand of hair hanging outside the hairnet, and CNA C was observed with a hairnet that did not restrict the bottom half of her shoulder-length hair while taking uncovered plates to the dining table. In Kitchen #3, surveyors observed opened bags of Honey Nut cereal and Crisp cereal left unsealed and exposed to air, two pitchers of tea without dates, and a medicine cup left inside the sugar container. Additional observations in Kitchen #3 showed opened cottage cheese, pancakes, sliced ham, sausage patties, and tea without open dates or use-by dates. CNA G stated that opened cereal should be sealed, tea should be dated, and the medicine cup should not be left in the sugar because it could result in contamination. The report also documented food service and sanitation issues during meal preparation and dishwashing. In Kitchen #2 and Kitchen #3, CNA G used the household dishwasher but could not verify a temperature to ensure proper sanitation. In Kitchen #2, CNA G was observed serving food without a hairnet and heating lunch food in the microwave without taking the food temperature before serving. The microwave and oven also contained crumbs and black crustlike substances. The Dietary Manager stated she had been focused on Kitchen #1 and was not aware she was supposed to be checking Kitchens #2 and #3, and the Administrator stated the Dietary Manager was responsible for all kitchens to run in the same manner as the main kitchen.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional principles for one resident and two nurse medication carts. Resident #24 had diagnoses including COPD and vascular dementia, with a BIMS score of 9 indicating moderately impaired cognition. His orders included budesonide suspension and Perforomist inhalation nebulization solution, and his care plan noted he used his own nebulizer machine to receive aerosol medications as ordered. During an observation, Resident #24 had two ampules of formoterol fumerate on his overbed table, and clear liquid was observed in the chamber of his nebulizer. Resident #24 said the medication was his breathing treatment, but he did not identify who left it there or how long it had been there. LVN A later stated she had left Resident #24's budesonide and formoterol fumerate in his nebulizer that morning and had tried to tell him to do the breathing treatments later. She said she should not have left the treatment in the nebulizer and should have stayed with him until it was completed. The facility also failed to ensure controlled substances were secured in permanently affixed locked compartments on the Building #2 and Building #3 medication carts. During observations, staff removed locked narcotic boxes from both carts and placed them on top of the carts. Staff stated they were not aware the narcotic boxes were supposed to be permanently affixed. In addition, LVN F was observed taking the Building #3 medication cart keys from an unlocked desk drawer at the nurse station, and she stated the keys had not been placed in a locked secured place. The facility's policy stated medications and biologicals are to be stored in locked compartments and controlled substances are to be separately locked in permanently affixed compartments.
Food Served Bland and at Improper Temperature
Penalty
Summary
Food and drink were not provided in a palatable, attractive, and appetizing manner for one observed lunch meal and for five residents reviewed for food palatability and temperature. During the lunch meal observation, the BBQ brisket was described as warm by dietary staff but was observed and tasted by surveyors as not warm and salty; the fried okra was not warm; the potato salad tasted like potato salad; and the vanilla pie dessert crust was hard. The menu for that meal included BBQ brisket, potato salad, fried okra, sliced bread, and vanilla pie dessert. Several residents stated the food was bland or did not taste good. One resident said the food was often cold because it was brought from the main building and was cold by the time it reached the residents. The Dietary Manager stated she had not completed an in-service on following recipes since becoming dietary manager in March 2025 and said she would in-service staff on following the recipe. The Administrator stated she did not know whether staff had recently completed in-services on following recipes and said food complaints were handled by informing the Dietary Manager. The facility policy stated food in the danger zone between 41 degrees and 135 degrees promotes rapid growth of pathogenic microorganisms and that potentially hazardous food must be maintained below 41 degrees or above 135 degrees.
Late completion of admission MDS assessment
Penalty
Summary
The facility failed to complete Resident #43’s comprehensive admission MDS assessment within 14 calendar days after admission. Resident #43 was a male admitted with diagnoses including Alzheimer’s disease and dementia with severe behavioral disturbance. Record review showed the admission assessment had an ARD of 06/03/2025 and was marked as an admission assessment required by day 14, with an entry date of 05/22/2025. The MDS completion date in Section Z0500B was 06/13/2025, indicating the assessment was completed 9 days late. During interview, the MDS Coordinator said she was responsible for completing the admission MDS assessment and stated it should be completed within 14 days of admission. She said she kept a calendar to track assessments and completed Resident #43’s assessment late because she was working on the floor. The Administrator stated the MDS Coordinators should complete assessments per the requirements and said the delay could affect payment.
Oxygen Not Set at Ordered Rate
Penalty
Summary
The facility failed to ensure that Resident #33 received respiratory care as ordered when oxygen was not provided at the ordered rate. Resident #33 was a readmitted male with diagnoses including heart failure and acute respiratory failure with hypercapnia. His record showed he had oxygen therapy related to ineffective gas exchange, with a care plan indicating oxygen via nasal cannula at 2 liters per minute for shortness of breath and oxygen saturation of 90%. His order summary also directed oxygen at 2 liters as needed to maintain oxygen saturation greater than 90% and required oxygen saturation checks every shift. On 07/22/25, the MAR showed oxygen was administered at 2 liters in the morning, but observations later that day found Resident #33 receiving oxygen at 3.5 liters per minute and then 4 liters per minute via nasal cannula. The resident said he had started using oxygen about a week earlier and did not know what it was supposed to be set at. The MDS Coordinator observed the oxygen setting at 4 liters, reviewed the order for 2 liters, and stated the nurse was responsible for ensuring the oxygen was set at the ordered rate. LVN M stated she marked the oxygen task completed that morning and said the nurse was responsible for ensuring the oxygen was set correctly. The DON and Administrator stated oxygen administration was a nursing function and expected the nurse to check the oxygen rate during morning rounds.
Infection Control Failures During Incontinent Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection prevention and control practices during incontinent care for a resident who was totally dependent on staff for toileting, showering, dressing, and personal hygiene and who was always incontinent of bowel and bladder. During an observation, a CNA provided incontinent care after the resident had a bowel episode, unfastened the brief, tucked it underneath the resident, and then removed clean linen from a trash bag and placed it on the bed while wearing the same dirty gloves. The CNA did not change gloves or perform hand hygiene before continuing care, and after removing the gloves, did not perform hand hygiene before applying the mechanical lift pad. The CNA later stated she should have changed gloves after touching the dirty brief and before touching clean linen, and should have performed hand hygiene after removing the gloves. The facility also failed to ensure enhanced barrier precautions were followed for a resident with a surgical incision and wounds. The resident had an order for enhanced barrier precautions and a care plan directing staff to wear gloves and gowns for high-contact care activities, including dressing, bathing, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. During an observation, a CNA assisted the resident with use of a urinal while wearing gloves but no gown, leaned against the bed, uncovered the resident, lowered his pants and brief, and held the urinal in place. The CNA stated she was not aware the resident required enhanced barrier precautions and said PPE should be worn when necessary to prevent germs from getting on the resident and from the resident. Staff interviews confirmed the expectations for glove changes, hand hygiene, and gown use during enhanced barrier precautions. The DON, ADON, and Administrator stated staff should change gloves when moving from dirty to clean tasks, perform hand hygiene after removing gloves, and wear gown and gloves when assisting the resident with the urinal. The facility policy on enhanced barrier precautions stated gloves and gown are applied before high-contact resident care activities, and the hand hygiene policy stated hand hygiene should be performed after removing gloves.
Late MDS Discharge Assessment Completion
Penalty
Summary
The facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted within the required timeframe for one resident. Resident #86, an [AGE]-year-old female, was admitted with diagnoses including acute respiratory failure with hypoxia and a fracture of the neck of the right femur, and was discharged home/community on 04/26/2025. Her Nursing Home Discharge Item Set showed an ARD of 04/26/2025, but the assessment was signed completed on 05/15/2025 by the MDS Coordinator, which was documented as 5 days late. The MDS Final Validation Report also indicated the discharge item set was completed more than 14 days after the ARD. During interview, the MDS Coordinator stated she was responsible for completing the discharge assessment and said the discharge day plus 14 days was the timeframe for completion, but acknowledged the assessment was completed a couple of days late. She stated discharge assessments were hard to complete in a timely manner because she was swamped with other MDS assessments and discharge assessments were not a priority, and that another MDS Coordinator helped her keep them up to date. A second MDS Coordinator said the discharge assessment was probably not completed in a timely manner and stated she did not know the required timeframe for discharge assessments. The Administrator stated the MDS Coordinators were responsible for completing discharge assessments and expected them to be completed per requirements.
Failure to Label and Date Food in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not labeling or dating food stored in the kitchen's refrigerator. During an observation, it was noted that several food items, including a whole pie, a slice of pie, French fries, tater tots, a gallon of partially eaten ice cream, and two bags of hard-boiled eggs, were not labeled or dated. This oversight was identified during a review of the kitchen's sanitation practices. Interviews with the Dietary Manager, Director of Nursing (DON), and Administrator (ADM) revealed that there was an expectation for all staff to follow the dietary policy, which includes labeling and dating all foods stored in the kitchen. The Dietary Manager acknowledged that failing to do so could place residents at risk of foodborne illness. The facility's policy document, titled 'Storage of Frozen and Refrigerated Foods,' specifies that foods should be labeled with the date placed in the refrigerator, time, expiration or use-by date, and that opened products should have the date opened written on them, with a use-by date of seven days from the date opened.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for four residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident #53's MDS did not reflect the use of a chair alarm, despite her care plan and physician's orders indicating its necessity due to her fall risk. Observations confirmed the presence of a chair alarm, yet the MDS was inaccurately coded, which was acknowledged by the Director of Nursing (DON) and the Administrator (ADM) as a responsibility of the MDS nurse. Resident #14's MDS assessment failed to indicate her PASRR positive status for serious mental illness, despite her diagnosis of schizoaffective disorder and documentation in her care plan and PASRR Comprehensive Service Form. The MDS coordinators admitted the oversight, noting that the PASRR section typically prepopulates, but it was not marked correctly in this instance. Resident #73's significant change MDS did not reflect her hospice care status, although her physician's orders and care plan confirmed her admission to hospice services. Similarly, Resident #186's MDS did not document the use of bed and chair alarms, which were observed in use and noted in his care plan. The MDS coordinators acknowledged these inaccuracies, emphasizing the importance of accurate MDS assessments for proper care planning.
Failure to Implement Comprehensive Care Plan for Heart Failure
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with chronic combined systolic and diastolic congestive heart failure. This deficiency was identified during a review of the resident's care plan, which did not include heart failure as a diagnosis, despite the resident's medical history and current treatment with diuretic medication. The absence of this critical information in the care plan could lead to inadequate care and management of the resident's condition. The resident, who had been admitted to the facility with diagnoses including hypokalemia, hypertension, and heart failure, required significant assistance with activities of daily living and had moderate cognitive impairment. The resident's medical records indicated the use of Torsemide, a diuretic, to manage heart failure symptoms. However, the care plan only mentioned hypertension and the use of a diuretic, omitting the heart failure diagnosis entirely. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that the care plan should have included the heart failure diagnosis to guide the resident's care effectively. The ADON acknowledged the oversight and the potential risks associated with not having a comprehensive care plan, such as fluid overload and respiratory issues. The facility's policy emphasized the importance of a person-centered care plan that includes all pertinent information to meet the resident's needs, which was not adhered to in this case.
Failure in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, a female with a history of unspecified dementia, urinary tract infection, acute kidney failure, and urine retention, did not have documented orders for the size and amount of fluid in the bulb of her catheter. This oversight was confirmed during interviews with the Director of Nursing (DON) and other staff, who acknowledged the absence of these critical orders in the resident's chart. Additionally, the facility did not ensure proper catheter care for the resident. During an observation, a Certified Nursing Assistant (CNA) performed catheter care without cleaning the resident's meatus or mons pubis and failed to change gloves between cleaning different areas, which could lead to cross-contamination. Interviews with other CNAs and Licensed Vocational Nurses (LVNs) revealed that the CNA did not follow the correct procedure for catheter care, which includes changing gloves and washing hands between steps to prevent infections. The facility's policies and staff interviews highlighted the importance of aseptic techniques and proper documentation for catheter care. However, the failure to adhere to these protocols and the lack of proper documentation for catheter orders placed the resident at risk for urinary tract infections. The DON and Assistant Director of Nursing (ADON) acknowledged the lapses in documentation and care, attributing the missing orders to an oversight during the resident's readmission process.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications, specifically Lorazepam, were limited to 14 days unless a documented rationale for extension was provided by the attending physician or prescribing practitioner. This deficiency was identified for two residents, both of whom had ongoing PRN orders for Lorazepam without a specified stop date or duration, despite repeated communications from the consultant pharmacist highlighting the regulatory requirement for a 14-day limit. Resident #58, a female with severe cognitive impairment and multiple diagnoses including heart failure, depression, and Parkinson's disease, was on hospice care. Her PRN Lorazepam orders, initiated in February 2024, lacked a stop date or duration, and she did not receive the medication from February through June 2024. Despite the consultant pharmacist's monthly communications to the physician about the need for a 14-day stop date, the physician's responses consistently noted the resident's hospice status without providing a specific duration for the medication. Similarly, Resident #73, diagnosed with dementia, Alzheimer's, and anxiety disorder, had a PRN Lorazepam order starting in May 2024, also without a stop date or duration. The resident received the medication only a few times in May and not at all in June. The consultant pharmacist's communication in June 2024 reiterated the need for a 14-day limit, but the physician's response was to continue the medication due to the resident's hospice status, again without specifying a duration. Interviews with facility staff, including the ADON and DON, revealed a lack of clarity and adherence to the regulatory requirement for PRN psychotropic medications to have a 14-day stop date, with hospice status being cited as a rationale for indefinite continuation without proper documentation.
Resident Elopes Due to Lack of Wanderguard and Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for a resident identified as an elopement risk. The resident, who had severe cognitive impairment due to dementia and other conditions, was able to elope from the facility without staff noticing. The resident did not have a Wanderguard on at the time of the incident, which would have triggered an alarm when exiting the building. The resident's care plan did not indicate that they were an elopement risk or required a Wanderguard, despite previous assessments showing a high elopement risk score. The facility's records showed no documentation of the resident's Wanderguard being checked on multiple dates leading up to the incident. Interviews with staff revealed that the resident had been to the hospital, and it was suggested that the Wanderguard might have been removed and not replaced. On the night of the incident, staff members were unaware of the resident's absence until they heard him outside the building. The resident was found outside without any injuries, and it was confirmed through surveillance that he did not leave the property. Staff interviews indicated that the door alarms did not sound, and there was confusion about whether the resident had a Wanderguard on. The facility's policy on wandering and elopements was not effectively implemented, as the resident's care plan lacked necessary interventions to prevent such incidents.
Medication Administration Error Due to Misidentification
Penalty
Summary
The facility failed to ensure the accurate administration of medications, resulting in a medication error involving two residents. Licensed Vocational Nurse (LVN) A did not adhere to the facility's Administering Medications policy, which led to Resident #1 receiving a hydrocodone/APAP tablet that was prescribed for Resident #2. This error occurred because LVN A mistakenly pulled the wrong medication card due to both residents having the same last name and administered the medication without verifying the correct resident. Resident #1, who was admitted with diagnoses including dementia, cognitive communication deficit, and chronic pain, was not prescribed hydrocodone/APAP but was given the medication intended for Resident #2. Resident #1's care plan indicated she rarely experienced pain and was prescribed Tramadol for pain management. However, there was no documentation of Tramadol being administered during the relevant period, and Resident #1 did not report any pain during the observation. Resident #2, who had a history of chronic pain and was dependent on staff for most activities of daily living, was prescribed hydrocodone/APAP for pain management. The medication error was discovered during a narcotic count at shift change when LVN B noticed the count was off by one tablet. Video surveillance confirmed that LVN A administered the hydrocodone to the wrong resident. The facility's policy required verification of the resident's identity before medication administration, which was not followed in this instance.
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Illustrative
What surveyors actually found near you
We read the 83 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sulphur Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunny Springs Nursing & Rehab | 0.2 mi | ★★★★★ | 15 | 0 |
| Sulphur Springs Health And Rehabilitation | 0.5 mi | ★★★★★ | 16 | 0 |
| Rock Creek Health And Rehabilitation | 2.1 mi | ★★★★★ | 15 | 1 |
| Birchwood Nursing And Rehabilitation | 16.2 mi | ★★★★★ | 1 | 0 |
| Avir At Commerce | 18.3 mi | ★★★★★ | 19 | 0 |
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