Carriage House Manor - 4-Star Rehab Facility in Sulphur Springs, TX | PlacetClinical Quality Indicators
Long-stay residents , lower is better
Antipsychotic medication use 10.34%Falls causing major injury 4.47%Pressure ulcers (high-risk) 2.9%Admissions Contacts
No admissions contacts on file yet.
CMS Star Ratings
⚠️ Last inspected: Jun 2024 (714 days ago)🔍 Health Inspection
4/5
★★★★☆
📊 Quality Measures
2/5
★★☆☆☆
Medicare
Source: CMS MDS Quality Measures. Updated quarterly.
State avg: 26 min · US avg: 41 min
Total Nurse / Resident / Day
4h 33m
State avg: 3h 24m · US avg: 3h 53m
4 min
State avg: 4 min · US avg: 4 min
46 per 100
State avg: 51 per 100 · US avg: 46 per 100
Weekend Staffing (PBJ Q3 2024)
Weekend vs. Weekday RN
67%≈ avg
US avg: 64%
Total Nurse Weekend
3h 27m
Federal Penalties
No federal penalties in the past 3 years.
✅ No penalty records on file
Inspection Citations
Survey: June 26, 2024(15 citations)
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
Survey: June 13, 2024(6 citations)
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmPharmacy Service DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
🟡 Potential for HarmPharmacy Service DeficienciesComplaint
🟡 Potential for HarmQuality of Life and Care DeficienciesComplaint
Survey: April 26, 2023(36 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
Survey: March 3, 2022(24 citations)
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation Deficiencies
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
27.2 per 100
State avg: 25.9 · US avg: 23.9
21.8 per 100
State avg: 12.0 · US avg: 12.0
4.5 per 100
State avg: 3.3 · US avg: 3.3
2.9 per 100
State avg: 4.2 · US avg: 5.1
1.5 per 100
State avg: 1.5 · US avg: 1.6
82.8 per 100
State avg: 88.0 · US avg: 79.7
Rates shown per 100 patients · Green = better than average · Amber = average · Red = below average
VBP Performance Score
32/100
Incentive Payment
-1.34% penalty
Healthcare-Assoc. Infections
8.3 per 100
Higher performance scores lead to payment bonuses. Lower scores indicate risk of readmission penalties.
Medicare Patients/Year
117
Avg Length of Stay
32.6 days
Avg Payment / Stay
$13,270.31
Patient Complexity
2.53 × avg
Avg LOS 15-30 days is typical for short-term rehab · Patient complexity = HCC risk score (1.0 = national average; higher = sicker patient mix)
🟡 Potential for Harm
Pharmacy Service Deficiencies
Complaint
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmResident Assessment and Care Planning Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmNursing and Physician Services Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmNutrition and Dietary Deficiencies
🟡 Potential for HarmAdministration Deficiencies
🟡 Potential for HarmInfection Control Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation Deficiencies
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
🟡 Potential for HarmResident Rights Deficiencies
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation Deficiencies
🟡 Potential for HarmFreedom from Abuse, Neglect, and Exploitation Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmPharmacy Service Deficiencies
🟡 Potential for HarmQuality of Life and Care Deficiencies
🟡 Potential for HarmEnvironmental Deficiencies
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