Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Carrier Mills Nsg & Rehab Ctr during CMS and state inspections, most recent first.
A resident with dementia, impaired cognition, repeated falls, and partial to moderate assistance needs for transfers and toileting fell while moving from the bathroom area after staff assisted her from a recliner. Video showed a CNA placing a walker in front of the resident, walking away, and later standing behind a wheelchair while the resident moved without a gait belt or close hands-on assistance. The resident was later diagnosed at the hospital with multiple nondisplaced rib fractures, and staff interviews and records described the fall as occurring in the bathroom area.
Failure to wear required PPE for isolation and wound care: staff entered rooms of residents with COVID-19 isolation orders without the full PPE required by the posted precautions, and staff providing wound care under EBP did not wear disposable gowns. A CNA wore only a surgical mask despite signage calling for gown, gloves, N95, and eye protection, and an EVS staff member entered another isolation room without eye protection. During wound care, an RN and CNA used gloves and hand hygiene but did not don gowns, despite EBP being indicated for residents with wounds.
The facility failed to provide scheduled showers twice per week for two residents, one with Parkinson's disease and another with heart failure, due to missed showers and incomplete documentation. Staff interviews confirmed that showers were sometimes missed, and the required documentation was not consistently completed.
A resident with severe cognitive deficits and multiple diagnoses did not receive timely restorative programs to prevent a decline in condition. Despite recommendations for a restorative ambulation program, the facility delayed implementation for nearly a month. Observations showed the resident was tearful and unable to walk due to the lack of an oxygen tank, and the care plan lacked focus on restorative programs. The facility's policy required restorative care to promote safety and independence, but this was not adhered to in a timely manner.
The facility failed to implement planned fall interventions for two residents, leading to deficiencies in accident prevention. One resident, who required supervision for toileting, fell due to the absence of a bedside commode, while another resident with severe cognitive impairment was not provided with a concave mattress as prescribed. Staff were unaware of these requirements, indicating a lapse in following the facility's fall risk management policy.
A facility failed to include dementia care in a resident's care plan, despite the resident's diagnosis of dementia, bipolar disorder, and anxiety, and documented memory problems. The care plan lacked interventions for cognitive deficits, which was acknowledged as an oversight by the DON and Care Plan Coordinator.
Inadequate Supervision During Bathroom Transfer and Ambulation
Penalty
Summary
The facility failed to provide the identified level of supervision and assistance required to prevent an accident for one resident who had a history of dementia, unsteadiness on feet, gait and mobility abnormalities, repeated falls, and reduced mobility. The resident’s MDS documented moderately impaired cognition, and the care plan identified the resident as at risk for falls related to decreased mobility and episodes of incontinence, with interventions to assist with transfers and ambulation and to have staff remain with the resident during ambulation and transfers. The resident’s assessments also showed partial to moderate assistance was needed for toileting, sit-to-stand, chair/bed-to-chair transfers, and toileting transfers. On the morning of the fall, a CNA assisted the resident out of a recliner and placed a walker in front of her. Video review showed the CNA did not have a gait belt on the resident and walked away from her, leaving her at a distance while the resident ambulated to the bathroom with the walker. After the resident used the bathroom, the CNA placed a wheelchair near the bathroom door and stood behind it while the resident began stepping toward the wheelchair. The resident then appeared to fall backward as she came out of the bathroom. The video also showed the CNA looking away toward the television at times while the resident was moving about the room and bathroom. The fall report and staff interviews documented that the resident was found sitting on the bathroom floor beside the toilet after the fall. Staff assessed her and initially noted no apparent injuries, with neuro checks within normal limits and no bruising or skin tears observed. The resident later went to the hospital with shortness of breath and was diagnosed with bronchitis and multiple nondisplaced rib fractures. Hospital records listed the rib fractures and noted a fall at the nursing home. The resident stated she fell in the bathroom while staff were present, and family reported that the hospital found rib fractures from the fall. Staff interviews reflected differing descriptions of the resident’s transfer and ambulation assistance, including use of a gait belt and standby assist, but the video showed the resident moving without a gait belt and without close assistance at the time of the fall.
Failure to Wear Required PPE for Isolation and Wound Care
Penalty
Summary
The facility failed to ensure personal protective equipment was worn according to current standards of practice for residents on transmission-based precautions and for residents receiving wound care under Enhanced Barrier Precautions (EBP). The deficiency involved 5 of 9 residents reviewed for transmission-based precautions in a sample of 33, including residents with COVID-19 isolation orders and residents with wounds or other conditions requiring EBP. The report also states that several of the affected residents had severe cognitive deficits based on BIMS scores and that some care plans did not document focus areas related to COVID-19 and/or transmission-based precautions. For two residents sharing a room, both had physician orders for isolation related to COVID-19 and the room door displayed a green sign indicating airborne/contact/droplet precautions requiring gloves, gown, N95 mask, and eye protection. A CNA entered the room wearing only a surgical mask and carrying a meal tray, without donning the required gown, gloves, N95, or eye protection. The CNA stated she had missed the sign because the door was open. The Director of Clinical Operations later stated eye protection is supposed to be worn when entering a room where a resident has tested positive for COVID-19, and when asked whether the CNA should have worn eye protection, a gown, and an N95, she stated she would have to check on that. For another resident with a COVID-19 isolation order, an Environmental Services staff member entered the room after donning a gown, gloves, and an N95, but did not wear eye protection. The staff member stated there was no eye protection available on the unit, although face shields were observed in bins and door storage on the same unit during the same time frame. The Administrator stated staff should wear full PPE, including gown, gloves, eye protection, and N95 when entering a room where a resident has tested positive for COVID-19 and is on droplet precautions. The report also describes failures during wound care for two residents on EBP. One resident had EBP signage on the door and supplies outside the room, but the RN providing wound care did not wear a disposable gown while treating multiple bilateral lower-extremity wounds. The RN stated she should have donned a disposable gown before providing wound care and agreed EBP was not fully followed. Another resident had EBP due to a wound and other skin issues, but during dressing changes to the coccyx and buttocks, the RN and CNA were observed wearing gloves and performing hand hygiene between wounds without wearing disposable gowns. There was no EBP signage or EBP/PPE supplies at or near that resident’s room. The DON stated EBP should be used for wound care and that disposable gowns and gloves should be worn, and agreed the staff should have donned disposable gowns for the wound care provided.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide showers or bathing alternatives twice per week for two residents, R7 and R56, as required. R7, who was admitted with diagnoses including muscle weakness and Parkinson's disease, required partial moderate assistance for showering. Despite being cognitively intact, R7 reported not receiving scheduled showers on Tuesdays and Fridays, with documentation missing for several dates over a three-month period. Similarly, R56, who had diagnoses of heart failure and moderate cognitive impairment, required substantial maximum assistance for bathing. R56 reported not receiving scheduled showers on Wednesdays and Sundays, with documentation missing for multiple dates. Interviews with staff revealed that showers were sometimes missed due to workload, and documentation was not consistently completed or available. The facility's policy required documentation of showers and any refusals, but this was not adhered to, as confirmed by the Director of Nursing. The lack of documentation and adherence to the shower schedule resulted in the deficiency noted by the surveyors.
Failure to Implement Restorative Programs for Resident
Penalty
Summary
The facility failed to implement restorative programs for a resident, R35, to prevent a decline in condition. R35 was admitted with diagnoses including heart failure, heart disease, insomnia, and obstructive and reflux uropathy. The Minimum Data Set (MDS) indicated a severe cognitive deficit, but did not document any restorative programs or physical therapy. Observations revealed that R35 was tearful and expressed a desire to walk, but was unable to due to the lack of an oxygen tank. The Director of Nursing acknowledged that physical therapy did not have R35 on their list, and the resident's care plan lacked a focus area for restorative programs or therapy. R35's Physical Therapy Discharge Summary recommended a restorative ambulation program, but the Nursing Restorative Care Program did not start until nearly a month later. The program included exercises with weights, but the walking program was not included. The Director of Rehabilitation confirmed that the initial restorative programs were turned in before 10/22/24, but could not explain why they were not started earlier. The Restorative Aid confirmed that no restorative programs were in place for R35 prior to 10/22/24. The facility's policy stated that residents should receive restorative nursing care to promote safety and independence. However, the delay in starting R35's restorative programs was acknowledged by the Director of Rehabilitation, who noted that a decline in condition could occur within thirty days. The facility has since started weekly meetings to ensure residents begin restorative programs promptly after therapy, but this was not in place at the time of the deficiency.
Failure to Implement Fall Interventions for Two Residents
Penalty
Summary
The facility failed to implement planned fall interventions for two residents, leading to deficiencies in accident prevention and supervision. The first resident, R7, who was cognitively intact and required supervision for toileting, fell while attempting to walk to the bathroom unassisted. Despite the care plan indicating the need for a bedside commode to prevent such incidents, observations over several days revealed that the commode was not present in the resident's room. The resident confirmed that the facility staff did not provide or offer a bedside commode after the fall. The second resident, R52, who had severe cognitive impairment, was found on the floor next to the bed. The care plan included the use of a concave mattress to prevent falls, but observations showed that a regular mattress was in use instead. The Director of Nursing and a Certified Nursing Assistant were unaware of the requirement for a concave mattress, indicating a failure to implement the prescribed intervention. The facility's policy on fall risk management emphasizes the need for specific interventions to prevent falls, which were not followed in these cases.
Failure to Address Dementia in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for a resident diagnosed with dementia, which included appropriate treatment and services to maintain the highest practicable well-being. The resident, admitted with diagnoses of dementia, bipolar disorder, and anxiety, was documented as having short and long-term memory problems and was unable to participate in a Brief Interview for Mental Status assessment. Despite these cognitive deficits, the resident's care plan did not include any focus area or interventions specifically addressing dementia care. Interviews with the Director of Nursing and the Care Plan Coordinator revealed that the omission of dementia care in the resident's care plan was an oversight, as it was expected to be included for residents with such a diagnosis.
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Illustrative
What surveyors actually found near you
We read the 137 citations issued within 25 miles in the last 12 months — including the 2 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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carrier Mills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Axiom Healthcare Of Harrisburg | 4.9 mi | ★★★★★ | 5 | 0 |
| Saline Care Nursing & Rehab | 5.3 mi | ★★★★★ | 0 | 0 |
| Eldorado Rehab & Healthcare | 13.3 mi | ★★★★★ | 1 | 0 |
| Integrity Hc Of Marion | 15.8 mi | ★★★★★ | 24 | 1 |
| Parkway Manor | 19.6 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.