Cycle 1
Health 2025-07-23 · Fire 2025-07-23
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Sulphur Springs, TX
Carriage House Manor
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
210 Pipeline Rd, Sulphur Springs, TX
(903) 885-3589
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-07-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.05
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
5.10
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,839
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.75
Baseline 21.94% · Performance 20.34% · Measure score 2.75 · Achievement 2.35 · Improvement 2.75
Healthcare-associated infections
0
Baseline 6.59% · Performance 8.35% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.20
Baseline 44.23% · Performance 50.59% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Adjusted total nurse staffing
6.67
Baseline 3.19 hours · Performance 4.98 hours · Measure score 6.67 · Achievement 6.67 · Improvement 6.39
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.52% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 189 · Observed rate 5.29% · Lower 95% interval 6.11% |
| Discharge to community | 50.15% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 175 · Observed rate 46.86% · Lower 95% interval 42.44% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 51.06% |
95.27%
44.2 pts worse
|
Numerator 72 · Denominator 141 |
| Falls with major injury | 2.13% |
0.77%
1.4 pts worse
|
Numerator 3 · Denominator 141 |
| Discharge self-care score | 63% |
53.69%
9.3 pts better
|
Numerator 63 · Denominator 100 |
| Discharge mobility score | 74% |
50.94%
23.1 pts better
|
Numerator 74 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 2.84% |
2.29%
0.5 pts worse
|
Numerator 4 · Denominator 141 · Adjusted rate 2.78% |
| Healthcare-associated infections requiring hospitalization | 8.35% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 138 · Observed rate 7.97% · Lower 95% interval 5.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 42.16% |
42%
0.2 pts better
|
Numerator 43 · Denominator 102 |
| Discharge function score | 73% |
56.45%
16.5 pts better
|
Numerator 73 · Denominator 100 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | 98.61% |
96.28%
2.3 pts better
|
Numerator 71 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 6.15% |
25.2%
19 pts worse
|
Numerator 4 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
97.1%
1.7 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 98.4% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
97.9%
0.6 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.3%
1.2 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.8% · Q3 4.9% · Q4 6.8% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
18.9%
1 pts better
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 20.8% · Q3 13.7% · Q4 14.8% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.3% |
10.8%
0.5 pts better
|
16.7%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 9.5% · Q3 8.7% · Q4 11.6% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.2% |
15.4%
22.8 pts worse
|
16.3%
21.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.7% |
16.1%
15.6 pts worse
|
14.9%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 38.3% · Q3 22.0% · Q4 34.6% · 4Q avg 31.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.5%
0.3 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
0.8%
1.3 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.6% · Q3 1.6% · Q4 3.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.4% |
15.0%
15.4 pts worse
|
19.8%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 27.4% · Q3 37.5% · Q4 17.6% · 4Q avg 30.4% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.2%
1.3 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.5% · Q3 3.6% · Q4 3.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
89.7%
8.9 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 98.4% · Q3 97.9% · Q4 99.2% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.8% |
12.0%
9.8 pts worse
|
12.0%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 19.6% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.0% · Q4 1.2% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.8% |
88.0%
5.2 pts worse
|
79.7%
3.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
25.9%
1.3 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 23.7% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-26 · Fire 2024-06-26
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-04-26 · Fire 2023-04-26
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-25
F · Potential for more than minimal harm
2024-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-14
E · Potential for more than minimal harm
2023-04-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-04-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-31
E · Potential for more than minimal harm
2025-07-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-23
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-31
B · Minimal harm
2025-07-23
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-08-31
F · Potential for more than minimal harm
2024-06-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-06-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-26
E · Potential for more than minimal harm
2023-04-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-04-26
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-31
E · Potential for more than minimal harm
2023-04-26
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-04-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-26
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-26
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-26
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-31
Penalties and ownership
What sits behind the stars
Ownership
Apolinar, Adam
Corporate Officer · Individual
Arnecke, Darren
Corporate Director · Individual
Carriage House Manor Inc
Operational/Managerial Control · Organization
Contreras, Terri
Operational/Managerial Control · Individual
Contreras, Terri
Corporate Officer · Individual
Harrington, Jennifer
Corporate Director · Individual
Tanton, Arvis
5% Or Greater Direct Ownership Interest · Individual
Tanton, Sharla
Operational/Managerial Control · Individual
The Tanton Family Trust
5% Or Greater Direct Ownership Interest · Organization
Uvalde County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Sunny Springs Nursing & Rehab
Sulphur Springs, TX
2-star overall rating with 2-star inspections with $15,265 in total fines with 19 recent health deficiencies
#2
Sulphur Springs Health And Rehabilitation
Sulphur Springs, TX
2-star overall rating with 2-star inspections with $44,044 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Rock Creek Health And Rehabilitation
Sulphur Springs, TX
4-star overall rating with 4-star inspections with $32,034 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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