Carrier Mills NSG & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Carrier Mills NSG & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689May 26, 2026

  Based on interview, observation, and record review the facility failed to provide the identified level of supervision and assistance required to prevent an accident for 1 of 3 (R1) residents reviewed for accidents in a sample of 9. This failure resulted in R1 falling and having multiple rib fractures.This past noncompliance occurred on 05/06/26.The findings include:R1's admission Record documents an admission date of 08/02/25, with diagnoses in part of unspecified dementia, bursitis of unspecified shoulder, unilateral primary osteoarthritis right hip, primary generalized osteoarthritis, unsteadiness on feet, unspecified abnormalities of gait and mobility, repeated falls, cognitive communication deficit, and other reduced mobility.R1's MDS (Minimum Data Set) dated 02/27/26 documents in… […]

• No harm, potential for more than minimal, widespreadF925Aug 26, 2022

  Based on observation, interview, and record review the facility failed to maintain a pest free environment. This has the potential to affect all 72 residents living in the facility. Findings include: R9's face sheet documented diagnoses including: nontraumatic subacute subdural hemorrhage, neuralgia and neuritis, major depressive disorder, and [CONDITION(S)]. R9's 5/20/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, meaning R9 was interviewable. On 8/23/22 at 10:17 AM, R9 said there had been bugs in his room for the past couple months. R9 said he had reported to facility management his concerns with bugs in his room and nothing had been done about it. […]

• No harm, potential for more than minimal, patternF880Sep 25, 2025

  Based on observation, interview, and record review the facility failed to ensure personal protective equipment was worn per current standards of practice for 5 of 9 (R5, R34, R44, R57, R76) residents reviewed for transmission-based precautions in the sample of 33. Findings Include:1. R34's admission Record with a print date of 09/25/2025 documents R34 was admitted to the facility on [DATE] with diagnoses that include heart failure and hypertension. R34's MDS (Minimum Data Set) dated 7/4/2025 documents R34 has a BIMS (Brief Interview for Mental Status) score of 07, indicating R34 has a severe cognitive deficit. R34's Order Summary Report dated 09/25/2025 documents a physician order dated 9/22/25 of, Isolation, due to covid positive, per facility protocol. […]

• No harm, potential for more than minimal, isolatedF677Jun 4, 2026

  Based on interview and record review the facility failed to ensure that residents who require assistance receive a shower for 2 (R20 and R1) of 3 residents reviewed for Activities of Daily Living in the sample of 20.This past non-compliance occurred between 4/1/26 and 5/26/26.1. R20's admission Record dated 6/2/26 documented an admission date of 2/18/26 and included diagnoses of fracture of left femur, dementia, lack of coordination, reduced mobility and generalized muscle weakness.R20's most recent Care Plan documents a focus area for self-care deficit dated 2/23/26. […]

• No harm, potential for more than minimal, isolatedF686Jun 4, 2026

  Based on interview and record review, the facility failed to ensure wound treatments were completed as ordered by the physician for 3 of 3 residents (R1, R19 and R20) reviewed for pressure ulcers in the sample of 20.This past non-compliance occurred between 4/1/26 - 5/26/26.1. R1's admission Record with print date of 6/2/26 documented an admission date of 3/28/26 and included diagnoses of infection and inflammatory reaction due to other cardiac vascular devices implants and grafts and end stage renal disease.R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is at risk for developing pressure ulcers and that he has two unhealed pressure ulcers that are unstageable. […]