Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carriage House Manor during CMS and state inspections, most recent first.
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.
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.
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 69 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 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 | — | 4 | 1 |
| Birchwood Nursing And Rehabilitation | 16.2 mi | — | 0 | 0 |
| Avir At Commerce | 18.3 mi | — | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Carriage House Manor.
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 August 2026) and official state health department websites.