Carlyle House
Inspection history, citations, penalties and survey trends for this long-term care facility in Framingham, Massachusetts.
- Location
- 342 Winter Street, Framingham, Massachusetts 01701
- CMS Provider Number
- 225541
- Inspections on file
- 18
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Carlyle House during CMS and state inspections, most recent first.
A resident with osteoporosis, dementia, and adult failure to thrive had a care plan and Kardex requiring full mechanical lift transfers with two staff assisting, consistent with facility policy that mechanical lifts be operated by at least two CNAs. Despite this, a CNA performed a Hoyer lift transfer alone, lowering the resident so that the shoulders remained several inches above the mattress and then disconnecting one upper sling strap, causing the resident’s upper body to drop onto the bed and the lift bar to strike the right side of the head. The resident immediately began bleeding from a deep temple wound, and subsequent hospital evaluation documented a right lateral temple hematoma and ulceration, minimally displaced left clavicle fractures, and acute fractures of the left superior and inferior pubic ramus. The CNA later acknowledged she knew the resident’s plan of care required two-person assistance but attempted the transfer without help.
A resident with osteoporosis, dementia, and adult failure to thrive was care planned and listed on the Kardex as requiring a full mechanical (Hoyer) lift with two-person assist for all transfers, consistent with facility policy that at least two CNAs operate mechanical lifts. Despite having completed mechanical lift competency and knowing the policy and the resident’s transfer requirements, a CNA attempted to perform a Hoyer lift transfer alone. The resident’s shoulders remained partially suspended above the mattress when the CNA detached a sling strap, causing the resident’s upper body to drop and the lift bar to strike the side of the head. The resident sustained a bleeding head wound and was later found in the ED to have a right temple hematoma and ulceration, minimally displaced left clavicle fractures, and acute fractures of the left superior and inferior pubic ramus.
A resident with Paranoid Schizophrenia and Dementia had a MOLST form completed by a legal guardian who lacked the required court-ordered authority to make decisions about life-sustaining treatments. The MOLST included DNR, DNI, DNH, and other treatment limitations, and physician orders were in place to follow these instructions despite the guardian's lack of proper authorization. Facility staff confirmed the guardian did not have the necessary legal authority.
Surveyors identified that several residents' MDS assessments were inaccurately coded, failing to reflect actual clinical treatments and medications such as IV access, antidepressant and antipsychotic use, anti-anxiety medication, and dialysis. These discrepancies were confirmed through record review and staff interviews, with the MDS Nurse acknowledging the errors.
A resident with cognitive impairment and psychiatric diagnoses was not invited to participate in required quarterly care plan meetings, and there was no documentation of efforts to involve the resident or their representative in the care planning process, contrary to facility policy.
Surveyors found that multi-dose vials of Timolol Maleate and Natural Tears eye drops on one unit and a medication cart were not labeled with open or discard dates as required by facility policy. The DON and a nurse confirmed that the vials should have been labeled with both the date opened and the use by date, but this was not done, making it impossible to determine if the medications were still viable.
A resident with a history of hemiplegia, hemiparesis, and dysphagia did not receive a pneumococcal vaccine dose as indicated by CDC guidelines, despite having consent and a physician's order. The DON confirmed the resident was eligible and should have received the vaccine, but it was not administered.
A resident with limited mobility due to a leg cast was found unresponsive with their head caught between the mattress and bed rail, resulting in death. The facility failed to conduct necessary assessments for bed rail safety and did not have a procedure to ensure these assessments were completed. The resident's care plan lacked documentation addressing bed rail use, and staff did not consistently monitor or reposition the resident during the night.
A resident with limited mobility due to a fractured patella and Parkinson's Disease died after being found unresponsive with their head caught on a bed rail. The facility failed to assess the resident for bed rail use, discuss alternatives, or obtain informed consent before installation. Despite the resident's request for bed rails to aid in mobility, the facility did not follow its policy for assessment and documentation, leading to the installation of bed rails without proper evaluation of the resident's needs and risks.
The facility failed to include bed rail use in the care plans of two residents, despite their installation and physician orders. This oversight was acknowledged by the MDS Nurse, who confirmed that the comprehensive care plans lacked documentation of interventions, treatment goals, or measurable outcomes related to the bed rails.
The facility failed to have an RN on duty for at least eight consecutive hours on 16 days between 10/1/23 and 2/11/24, placing all residents at risk. The deficiency was due to an RN on leave and another resigning, with attempts to cover shifts through staffing agencies and other RNs.
The facility failed to maintain privacy and confidentiality for a resident during personal care in the shower room. A CNA entered the shower room to use their cell phone while another CNA was assisting the resident, who was not covered, leading to the resident feeling embarrassed and worried about being recorded.
The facility failed to perform trauma assessments on admission for two residents with serious mental health diagnoses, as required by their policy. The social worker confirmed that these assessments were not completed, leading to a deficiency in trauma-informed care.
The facility failed to ensure staff adhered to infection control standards during a wound care procedure for a resident with a sacral pressure ulcer. Nurse #1 did not perform hand hygiene during four opportunities, violating facility policies and CDC guidelines.
The facility failed to ensure that pneumococcal vaccinations were administered to two residents, increasing their risk for facility-acquired infections. The staff did not identify whether the residents were up to date with their vaccinations and did not administer the vaccine when eligible. The Infection Preventionist admitted that the facility was behind on vaccinations and had not assessed the vaccination status of one resident within the required 30 days following admission.
The facility failed to accurately code MDS assessments for two residents. One resident's assessments did not reflect the use of prescribed antidepressants, and another resident's discharge status was incorrectly coded as discharge to the hospital instead of home.
Improper Solo Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented a resident’s comprehensive care plan requiring two-person assistance for all mechanical lift transfers. Facility policies on resident assessment and mechanical lifts required an individualized interdisciplinary care plan and specified that at least two CNAs were needed to safely move a resident with a mechanical lift. The resident, admitted in October 2019 with diagnoses including osteoporosis, dementia, and adult failure to thrive, had an ADL care plan and electronic Kardex indicating a need for full mechanical lift transfers with two staff members assisting. Despite this, on the evening in question, CNA #1 transferred the resident alone using a Hoyer lift, contrary to the resident’s care plan and facility policy. During the transfer, CNA #1 lowered the resident onto the bed but left the resident’s shoulders suspended in the sling several inches above the mattress. She then disconnected the right upper sling strap from the lift, causing the resident’s upper body to drop quickly onto the bed and the sling bar to swing into the right side of the resident’s head. The resident immediately began bleeding from the right temple area. When Nurse #1 arrived, the resident was lying on the bed with a deep open wound on the right temple, with blood on the face and in the hair, and the towel used to apply pressure became saturated within minutes. The facility’s unusual event report and hospital emergency department records documented a right lateral temple hematoma and ulceration that could not be sutured, minimally displaced proximal and distal left clavicular fractures, and acute fractures of the left superior and inferior pubic ramus. CNA #1 acknowledged she knew how to access the Kardex, knew the resident required two-person assistance for transfers, and admitted she attempted the transfer without assistance.
Failure to Provide Required Two-Person Assistance During Hoyer Lift Transfer Resulting in Injury
Penalty
Summary
A resident with osteoporosis, dementia, and adult failure to thrive, admitted in 2019, was care planned and documented on the Kardex as requiring full mechanical (Hoyer) lift transfers with two-person assistance for all transfers. Facility policy on mechanical lifts, dated 02/26/09, required at least two nursing assistants to safely move a resident with a mechanical lift. Certified Nurse Aide (CNA) #1 had completed the facility’s required competency for mechanical lift transfers and acknowledged knowing both the policy and that this resident required two staff for all transfers. On 12/30/25 at approximately 6:00 P.M., CNA #1 attempted to transfer the resident alone using a Hoyer lift, without another staff member present, contrary to the resident’s care plan, Kardex instructions, and facility policy. During the transfer, the resident’s shoulders remained suspended three to four inches above the mattress when CNA #1 disconnected the right upper sling strap, causing the resident’s upper body to drop quickly onto the bed and the sling bar to swing into the right side of the resident’s head. The resident immediately began bleeding from the right temple area. Subsequent nursing assessment noted a deep open head wound with significant bleeding, and the resident was sent to the hospital ED, where he/she was diagnosed with a right lateral temple hematoma and ulceration, minimally displaced proximal and distal left clavicular fractures, and acute fractures of the left superior and inferior pubic ramus. Multiple staff, including CNAs and the DON, confirmed it was well-known facility policy that all Hoyer lift transfers required two staff members.
Improper Authorization for Advance Directives on MOLST Form
Penalty
Summary
The facility failed to ensure that the appropriate individual had the legal authority to make decisions regarding Advance Directives for one resident. Specifically, a MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) form was completed and signed by the resident's legal guardian, who did not have the required court-ordered expansion of authority to make decisions about life-sustaining treatments. The guardianship documents on file did not include authorization for the guardian to refuse or discontinue life-sustaining treatments on behalf of the resident. The resident involved had diagnoses of Paranoid Schizophrenia and Dementia and had been admitted to the facility with these conditions. The MOLST form, signed by the unauthorized guardian, included orders for DNR (Do Not Resuscitate), DNI (Do Not Intubate), DNH (Do Not Hospitalize), no dialysis, no artificial nutrition, and no artificial hydration. Despite the lack of proper legal authority, physician orders were in place to follow the instructions on the invalid MOLST form. Interviews with facility staff confirmed that the guardian did not have the necessary legal authority to make these decisions.
Inaccurate MDS Coding for Clinical Treatments and Medications
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for four residents, resulting in discrepancies between clinical documentation and MDS entries. For one resident with a history of urinary tract infection and benign prostatic hyperplasia, the MDS did not reflect the presence of an intravenous (IV) line, despite physician orders and documentation confirming IV access and maintenance during the assessment period. Another resident with liver disease, dementia, and major depressive disorder was incorrectly coded as receiving an antipsychotic medication and not an antidepressant, even though physician orders and medication administration records showed daily administration of an antidepressant and no antipsychotic use. A third resident with anxiety disorder and PTSD was administered anti-anxiety medication on two occasions during the MDS look-back period, but the MDS failed to indicate any anti-anxiety medication use. The fourth resident, dependent on renal dialysis and diagnosed with end-stage renal disease, was regularly transported for dialysis treatments as documented in physician orders and medication administration records, yet the MDS did not indicate receipt of dialysis treatment. In each case, the MDS Nurse acknowledged during interviews that the assessments were coded incorrectly and did not accurately reflect the residents' clinical status or treatments received during the relevant periods.
Failure to Involve Resident in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident was provided the right to participate in the care plan process as required. Specifically, quarterly care plan meetings were not conducted with the resident's participation, and there was no documentation that the resident or their representative was encouraged or invited to participate in these meetings. The facility's policy requires that the interdisciplinary team review and revise the care plan collaboratively with the resident and/or their family or responsible party at least every 92 days, but this was not followed for the resident in question. The resident involved had diagnoses of Paranoid Schizophrenia and Dementia and was assessed as cognitively impaired, but was usually able to understand and be understood. Despite this, the resident reported being unaware of care plan meetings and expressed a desire to be invited. Review of the clinical record showed no evidence that the resident participated in or was invited to care plan meetings during the specified periods, nor was there documentation explaining the lack of participation or any refusals. Facility staff confirmed that the resident had not been invited to attend care plan meetings and could not provide documentation to the contrary.
Failure to Label and Date Multi-Dose Eye Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and storage of multi-dose vials of eye medications on the Front Unit and on one medication cart (Medication Cart A). Specifically, an open multi-dose vial of Timolol Maleate ophthalmic solution was found in the medication storage room refrigerator without an open or use by date. On Medication Cart A, an open multi-dose vial of Natural Tears eye drops was also found without an open or discard date, and two open vials of Timolol Maleate were present—one with only an open date and the other with no date at all. Neither of the Timolol vials had a use by date. Facility policy requires that multi-dose vials be labeled with both the date opened and the discard date, following manufacturer guidelines or USP 797 recommendations. Interviews with the DON and a nurse confirmed that the correct procedure is to label multi-dose vials with both the open and use by dates, and that the observed vials did not meet this requirement. The DON and nurse acknowledged that, without proper labeling, it was not possible to determine if the medications were still viable, and that the affected vials would need to be discarded. The failure to label these medications as required was directly observed and confirmed by staff during the survey.
Failure to Administer Indicated Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to one resident who was eligible and had consent from the responsible party. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon admission and offered the vaccine within ninety days if indicated. The resident in question had previously received PCV13 and PPSV23 vaccines prior to admission, and the CDC's current recommendations indicated that the resident was due for another dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine. The resident's clinical record showed that consent for the vaccine was obtained and a physician's order was in place, but there was no evidence that the vaccine was administered when the resident became eligible. The deficiency was identified through interview and record review, which confirmed that the resident, who had diagnoses including hemiplegia, hemiparesis, and dysphagia, did not receive the indicated pneumococcal vaccine despite meeting all criteria. The Director of Nursing acknowledged that the resident should have received the vaccine in 2024 but had not. This lapse was in direct violation of both facility policy and CDC recommendations for pneumococcal vaccination in adults.
Failure to Ensure Safety and Supervision Leads to Resident's Death
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with limited mobility due to a cylinder cast on their right leg. The resident, who required physical assistance for bed mobility and had requested bed rails for support, was found unresponsive with their head caught between the mattress and the bed rail. The resident was pronounced dead at the facility, highlighting a critical lapse in supervision and safety protocols. The facility's policy on bed rails indicated that residents should receive necessary assistance for bed mobility and other care needs. However, there was no documentation of a physician's order for the use of bed rails for the resident, nor was there an assessment conducted to determine if the bed rails posed a safety hazard. The Director of Nursing acknowledged that the assessment was not completed upon the resident's admission, and there was no procedure in place to audit the completion of bed rail assessments within 24 hours of admission. The resident's medical records showed no documentation of reassessment for bed rail use after a change in their condition, specifically after the placement of a heavier cylinder cast. The resident's care plan did not address the use of bed rails, and staff interviews revealed a lack of consistent monitoring and repositioning during the night. The incident underscores the facility's failure to implement and follow safety protocols, resulting in a tragic outcome for the resident.
Failure to Assess and Obtain Consent for Bed Rail Use Leads to Resident's Death
Penalty
Summary
The facility failed to ensure proper assessment and informed consent for the use of bed rails for a resident with limited mobility due to a fractured patella and Parkinson's Disease. The resident had requested bed rails to aid in bed mobility, but the facility did not complete a bed rail assessment, discuss alternatives, or obtain informed consent before installing two quarter bed rails. The facility's policy required these steps, but they were not followed, leading to the installation of bed rails without proper evaluation of the resident's needs and risks. On the morning of the incident, the resident was found unresponsive with their head and neck caught on the bed rail, leading to their death. The resident's legs were off the bed, and their head was hyperextended over the bed rail, with the back of their head against the mattress. Despite the facility's policy to periodically reassess bed rail usage, there was no documentation of reassessment after the resident's mobility was further limited by a change from a hinge brace to a cylinder cast. Interviews with staff revealed that the resident used the bed rails to assist with bed mobility but had difficulty moving their right leg due to the cast's weight. The resident was sometimes found with their legs off the mattress, but this was not reported to nursing or rehab staff. The facility did not have documentation of discussions about the risks and benefits of bed rails or informed consent, and the resident's care plan did not address the use of bed rails, contributing to the tragic outcome.
Failure to Include Bed Rail Use in Care Plans
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for two residents who had bed rails installed on their beds. Resident #1, admitted with a right patella fracture and Parkinson's Disease, had bed rails installed at the request of nursing staff. However, the comprehensive care plan for Resident #1 did not document the use of bed rails, nor did it include interventions, treatment goals, or measurable outcomes related to the bed rails. This oversight was acknowledged by the MDS Nurse during an interview. Similarly, Resident #5, admitted with low back pain and coronary artery disease, had a physician order for bed rails, and a half rail was applied to the right side of the bed. Despite this, the comprehensive care plan for Resident #5 did not address the use of bed rails until several months later. The MDS Nurse also confirmed that the omission of bed rails as an intervention in Resident #5's care plan was an oversight.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility did not have an RN working for at least eight consecutive hours on 16 days between 10/1/23 and 2/11/24. This deficiency was identified through a review of the Fiscal Year Quarter One Payroll Based Journal (PBJ) Report, which indicated no RN coverage on several specific dates. The absence of RN coverage placed all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurses Aides (CNA) that the RN was responsible for overseeing with the provision of resident care. During interviews, the Administrator confirmed that the facility had no nurse staffing waivers and acknowledged the lack of RN coverage on the reported dates. The Director of Nursing (DON) explained that the RN coverage was impacted by one RN being on a leave of absence and another RN resigning. The DON attempted to cover the shifts by working with staffing agencies, asking other RNs to cover, or coming in herself. However, additional review of nurse staffing schedules revealed four more days without RN coverage after 12/31/23. The DON provided her time card, confirming she was not in the facility on those additional days to provide the required RN coverage.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to provide privacy and confidentiality for Resident #50 during personal care in the shower room. Specifically, CNA #1 entered the shower room to use their personal cell phone while CNA #2 was assisting Resident #50 with showering. Resident #50, who was moderately cognitively impaired, felt embarrassed and worried that CNA #1 could have been recording them. CNA #2 did not cover or drape Resident #50 to prevent exposure of body parts during this incident. The facility's policies on cell phone use and resident dignity were not followed. The policy prohibits the use of cell phones in resident care areas, including shower rooms, and mandates that residents' privacy be protected during personal care. Interviews with Resident #50, the Administrator, and CNA #2 confirmed that CNA #1 was using a cell phone in the shower room and that Resident #50 was not covered during the incident.
Failure to Perform Trauma Assessments on Admission
Penalty
Summary
The facility failed to perform trauma assessments on admission for two residents, leading to a deficiency in trauma-informed care. Resident #7, admitted in December 2022 with a diagnosis of Bi-Polar Disorder, did not have any documentation indicating that an assessment for trauma and the prevention of potential re-traumatization had been initiated. Similarly, Resident #45, admitted in November 2022 with diagnoses including Schizophrenia and Major Depressive Disorder, also lacked documentation of a trauma assessment. During an interview, the social worker confirmed that trauma-informed care assessments should be completed for all residents upon admission and annually. However, the assessments for Residents #7 and #45 were not completed as required by the facility's policy. The policy, last revised in January 2023, mandates universal screening for trauma on admission and annually, and includes trauma-informed care as part of the QAPI plan to identify and address needs and problem areas.
Failure to Adhere to Infection Control Standards During Wound Care
Penalty
Summary
The facility failed to ensure that its staff adhered to infection control standards during a wound care procedure for one resident. Specifically, the staff did not perform appropriate hand hygiene during four opportunities while treating a sacral pressure ulcer. The facility's policies and CDC guidelines require hand hygiene before and after glove use, but these were not followed by Nurse #1 during the procedure. Nurse #1 removed and replaced gloves multiple times without performing hand hygiene, which is against the facility's infection control policies and CDC guidelines. Resident #25, who has Alzheimer's Disease and a sacral pressure ulcer, was the patient involved in this incident. The resident's physician had ordered specific wound care procedures, which Nurse #1 and the Assistant Director of Nurses (ADON) were performing. Despite the clear guidelines, Nurse #1 did not use hand sanitizer or wash hands between glove changes, leading to potential contamination and spread of infection. The ADON acknowledged the lapse, noting that hand hygiene was not performed because it would have required leaving the wound care supplies to access a sink.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that the Pneumococcal Vaccination was administered to two residents, increasing their risk for facility-acquired pneumococcal infections. Specifically, the facility staff did not identify whether the residents were up to date with their pneumococcal vaccinations and did not administer the vaccine when the residents were eligible to receive it. This deficiency was identified during a review of the facility's policy, medical records, and interviews with staff members. Resident #42, who was admitted in December 2022 with diagnoses including diabetes mellitus and dementia, had a physician's order for the pneumococcal vaccine and a signed consent form from the resident's representative. However, the resident's immunization report indicated that only one dose of PCV13 was received, with no evidence of any other pneumococcal vaccine doses. Similarly, Resident #36, admitted in February 2024 with chronic leukemia and diabetes mellitus, had a physician's order for the pneumococcal vaccine and a signed consent form but had no evidence of receiving any pneumococcal vaccination. The Infection Preventionist (IP), who had been working at the facility for about 30 days, admitted that the facility was behind on pneumococcal vaccinations and had not offered the vaccine to any residents other than new admissions. The IP acknowledged that the vaccination status of Resident #36 had not been assessed within the required 30 days following admission and that both residents were eligible for the vaccine but had not received it. The IP also mentioned that a facility-wide audit was conducted, but individual assessments had not been completed.
Inaccurate MDS Coding for Medications and Discharge Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for two residents. For Resident #45, who was admitted with diagnoses including Schizophrenia and Major Depressive Disorder, two consecutive MDS assessments did not indicate the use of prescribed antidepressant medications, despite the resident being on Celexa and Remeron. The MDS Nurse confirmed that the assessments dated 2/21/24 and 4/9/24 were inaccurately coded and should have reflected the use of these medications. For Resident #55, who was admitted with a diagnosis of Hypertension, the MDS assessment inaccurately coded the resident's discharge status. Although the resident was discharged home with medications and services, the MDS assessment incorrectly indicated that the resident was discharged to the hospital. The MDS Nurse acknowledged the error, confirming that the discharge location should have been coded as discharge to home/community.
Latest citations in Massachusetts
A resident with metabolic encephalopathy, cardiac disease, a G-tube, and an indwelling urinary catheter had a urine culture and sensitivity ordered, with preliminary results reported to a provider who chose to wait for final results. The final culture showed two bacterial organisms and listed effective antibiotics, but nursing staff did not notify a physician, PA, or NP of these abnormal results or document any notification, despite facility policy requiring such communication and documentation. The PA later stated she was never informed of the results, and the NP reported that during an examination she was not told about the culture findings. Antibiotic orders and administration did not occur until several days after the abnormal results were available, causing a delay in treatment.
A resident with severe dementia and significant anxiety and depression, who was fully dependent on staff for ADLs, verbally said “no” and “stop” during morning dressing care. A CNA floated from another unit continued providing care in an abrupt manner despite these refusals, and the resident appeared anxious, later repeating that she hurt and that the CNA was bad. Two nurses and a weekend supervisor, all familiar with the resident, observed the resident’s anxious behavior and heard her complaints, and the CNA later admitted she did not stop care when the resident told her to stop, contrary to staff expectations that care be stopped when a resident resists or refuses.
A resident with sacral and buttock pressure injuries had physician orders for daily wound care and was assessed by a wound NP, who documented specific wound measurements, drainage, odor, and worsening status over time. However, review of the TAR showed that, although daily dressing changes were recorded, nursing staff did not document required wound characteristics such as appearance, measurements, drainage type and amount, or odor with each treatment, despite an EMR template and standard practice calling for this level of detail. The DON acknowledged that staff should have documented these wound details at each dressing change and noted that EMR order modifications had removed the supplemental documentation prompts, resulting in noncompliance with professional standards and facility policy.
A resident with an unstageable sacral pressure injury, chronic kidney disease, and polyosteoarthritis repeatedly reported and exhibited pain that interfered with participation in PT, including verbal pain ratings of 5–7/10, agitation, tension, and refusal to get out of bed. PT staff documented that the resident was in pain and at times noted the resident was premedicated and that nursing was aware, but the MAR showed no administration of ordered PRN acetaminophen during the period when pain was repeatedly observed. The NP, who documented increased tenderness at the sacral ulcer and noted the resident’s refusal to get out of bed due to hip pain, was unaware of the ongoing pain during therapy sessions and that nursing had not given Tylenol. The DON stated that departments should communicate about pain and document such communication, but there was no documented follow-through by nursing despite the resident’s ongoing verbal and non-verbal indicators of pain.
A resident with chronic kidney disease, polyosteoarthritis, and an unstageable sacral pressure injury had inconsistent and inaccurate wound documentation, with nursing admission records and the TAR reflecting pressure injuries on the right and left buttocks while the wound NP identified a single sacral wound. Despite NP orders and notes recommending q2h repositioning and strict adherence to pressure injury prevention protocols, CNA flow sheets contained no documentation that the resident was repositioned every two hours. Staff interviews confirmed reliance on flow sheets for repositioning documentation and revealed that the option to record q2h repositioning had been missing from the CNA documentation for this resident.
A resident with dysphagia and a physician order for a house diet with ground texture and nectar thick liquids was served a regular-texture lunch tray containing chicken cut into pieces instead of ground. While eating in a secondary dining room, the resident began choking and was observed using the universal choking sign; an RN performed the Heimlich maneuver, successfully expelling a piece of chicken and stabilizing the resident. Post-incident review showed that the tray did not match the diet order, the dietary department had sent the wrong texture, and nursing staff had not checked this or any other lunch trays against meal tickets as required by facility policy, despite their acknowledged responsibility to verify diet accuracy before meal service.
A resident with dysphagia, parkinsonism, and a physician order for a house diet with ground texture and nectar-thick liquids was served a regular texture lunch including whole chicken instead of the ordered ground diet. The dietary aide reported that he likely called out the wrong diet order to the cook and did not verify the plated meal against the resident’s meal ticket before placing it on the tray, contrary to facility procedure. Nursing staff, who were responsible for checking trays against meal tickets before service, also did not verify the meal. During lunch, the resident began choking, was observed using the universal choking sign, and a nurse performed the Heimlich maneuver, expelling a piece of chicken. Review of the diet order and the facility’s internal report confirmed that the meal had not been prepared or checked according to the resident’s prescribed ground diet.
A resident with multiple fractures and non-Hodgkin lymphoma, who was cognitively intact and dependent on staff, was standing in the bathroom holding a grab bar when the resident reported being unable to continue standing due to knee weakness. A CNA lowered the resident to the floor, then independently lifted the resident, placed the resident in a wheelchair, and transferred the resident back to bed before notifying nursing staff, despite facility policy requiring a nursing assessment for injury before moving a resident found on the floor. Nursing staff later learned of the event only after the resident was back in bed and initially were informed only of a skin tear sustained during a transfer, not that the resident had been lowered to the floor, resulting in the resident not being assessed by a nurse prior to being moved.
Two severely cognitively impaired residents with dementia and impaired decision-making were found by a CNA engaged in sexual touching in a bedroom where one did not reside. The CNA immediately removed one resident and reported the incident to a nurse, but the nurse delayed notifying the DON for several hours and the DON and Administrator did not become aware until many hours later. The facility’s written abuse policy referenced a two-hour internal notification timeframe and a 24-hour reporting timeframe to the state, which did not align with current expectations that abuse allegations be reported immediately to administration and to the State Agency within two hours, contributing to delayed reporting of this resident-to-resident sexual abuse allegation.
Two cognitively impaired residents were found by a CNA engaging in sexual contact in a resident’s room, with one resident touching the other’s genital area while reciprocal touching occurred. The CNA immediately removed one resident and informed an RN, but the RN delayed effectively notifying the DON and administration, and the ADON reported no recollection of being informed. As a result of these delays, administrative staff did not become aware of the allegation until many hours later, and the incident was not reported to the State Survey Agency within the required two-hour timeframe, contrary to facility policy requiring prompt reporting of suspected abuse.
Failure to Promptly Notify Provider of Abnormal Urine Culture Results
Penalty
Summary
The facility failed to ensure prompt notification of abnormal laboratory results to a provider for a resident who required a urine culture and sensitivity test. The resident, admitted in January 2026 with diagnoses including metabolic encephalopathy, atherosclerotic heart disease, a gastrostomy tube, and urinary retention with an indwelling urinary catheter, had an order for a urinalysis with culture and sensitivity on 01/19/26. Nursing progress notes on 01/21/26 documented that urinalysis and preliminary culture results were obtained and reported to the in-house provider, who chose to wait for the final culture and sensitivity results. The urine culture and sensitivity report dated 01/23/26 showed two types of bacteria and listed effective antibiotics for treatment of a urinary tract infection. From 01/21/26 through 01/28/26, there was no documentation in the nursing progress notes that a physician, PA, or NP was notified of the final culture and sensitivity results, despite the facility’s policy requiring nurses to contact the physician about abnormal test results and document the notification and response. The first antibiotic orders for ciprofloxacin and nitrofurantoin were not written until 01/28/26, and the MAR showed the first doses were administered that day at 5:00 p.m., five days after the abnormal culture and sensitivity results were available. The PA stated she was not notified of the abnormal results, and the NP reported that when she examined the resident on 01/26/26, nursing staff did not inform her of the culture and sensitivity findings. The DON acknowledged awareness of the prolonged period between availability of the urine culture results and initiation of treatment and stated that nurses were responsible for following up on lab results, which did not occur in this case, resulting in a delay in treatment.
Failure to Honor Resident’s Verbal Refusal of Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity by honoring the resident’s verbal refusals of care. The facility’s Resident Rights policy, revised 10/04/23, requires that each resident be treated with respect and dignity and that their rights be protected and promoted. On 02/28/26, after receiving care, Resident #1 repeatedly stated that a CNA had hurt her and referred to the CNA as “bad.” The resident was known to have unspecified dementia with psychotic disturbance, generalized anxiety disorder, and major depressive disorder, and a recent MDS dated 02/17/26 documented severe cognitive impairment (BIMS score of 3/15) and dependence on staff for ADLs such as dressing, bathing, and hygiene. On the morning of 02/28/26, CNA #1, who had been floated from another unit, entered Resident #1’s room to provide care. Nurse #1, who knew the resident well, went to the room to check on CNA #1 and observed CNA #1 trying to put a shirt on the resident in an abrupt manner, noting that the resident had an anxious facial expression. Nurse #1 intervened, took over dressing the resident, and was able to put the shirt on without issue. After briefly leaving to speak with another nurse and the Weekend Supervisor about her concerns regarding the interaction, Nurse #1 returned to the room and found the resident seated at the edge of the bed, appearing anxious and repeating the words “stop, don’t hurt me.” Nurse #1 and CNA #1 then assisted the resident into a wheelchair and brought the resident to the nurses’ station. Nurse #2, who also knew the resident well, reported that around this time CNA #1 wheeled the resident to the nurses’ station and parked the resident next to her medication cart. The resident repeatedly said “I hurt, I hurt” while hugging herself and was unable to clearly express what was upsetting her, consistent with her usual difficulty expressing herself and tendency to speak in “word salad.” The Weekend Supervisor later attempted to speak with the resident and observed the resident with arms crossed, appearing anxious, and saying something like “she hurt me.” During the subsequent interview with the DON and Weekend Supervisor, CNA #1 acknowledged that while providing care that morning the resident said “no” and “stop,” and that she did not stop providing care at that time. Multiple nursing staff stated that the expectation is that when a resident resists care or verbally says to stop, staff are to stop what they are doing, regardless of the resident’s dementia status.
Failure to Document Wound Characteristics and Treatment Effectiveness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that wound care services met professional standards of quality for a resident with pressure injuries. The facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, detailed wound assessment data (including wound bed color, size, drainage), any change in condition, and how the resident tolerated the procedure. The resident was admitted with an unstageable pressure injury on the right buttock and another pressure injury on the left buttock, and had physician’s orders for daily and as-needed wound care, including cleansing, application of calcium alginate, and foam dressing. Subsequent wound nurse practitioner assessments documented an unstageable sacral wound with specific measurements, moderate serosanguineous drainage, and later worsening status with increased size, malodor, and continued moderate serosanguineous drainage, with treatment changes recommended. Despite these orders and assessments, review of the Treatment Administration Records for January and February showed that while nurses documented that daily dressing changes were performed, they did not document the wound’s appearance, measurements, drainage amount and type, or odor during those dressing changes. Interviews with two nurses confirmed that standard practice and the electronic TAR template called for documenting wound description, including appearance, drainage, odor, and whether the wound had improved or worsened, with each dressing change. The DON also stated that nursing staff should have been documenting the appearance and specific characteristics of the wounds with each dressing change and identified that when nursing staff modified the wound care order in the electronic medical record, the supplemental documentation prompts were mistakenly removed, contributing to the lack of required wound documentation.
Failure to Manage and Document Pain for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for a resident admitted with an unstageable sacral pressure injury and multiple pain-related diagnoses, including chronic kidney disease and polyosteoarthritis. The facility’s pain policy required staff to identify signs and symptoms of pain, consider cognitive and behavioral indicators, and anticipate pain related to conditions such as pressure ulcers and interventions such as wound care, ambulation, and repositioning. The resident’s MDS showed moderate cognitive impairment, and the resident had PRN acetaminophen orders for pain, as well as a recently discontinued scheduled methocarbamol due to lethargy. Physical therapy documentation over several days showed the resident repeatedly reporting and exhibiting pain that interfered with participation in therapy. On multiple PT treatment dates, the resident declined to get out of bed, reported being “too sore,” and rated pain levels between 5/10 and 7/10, describing pain in the lower back, bilateral hips, and “all over,” with behaviors such as agitation, tension, and avoidance of touch. PT notes indicated the resident was premedicated prior to some sessions and that nursing was aware of the pain, yet the Medication Administration Record for the same period showed no documentation that any analgesics were administered from 02/06/26 through 02/12/26. Interviews with staff further demonstrated a lack of effective pain management and communication. The PTA stated she reported the resident’s pain to nursing and believed the resident was given Tylenol, and she documented that the resident was premedicated on one date because she thought it had occurred. The Nursing Supervisor reported that if therapy staff informed him of pain, he would assess and medicate, but he could not recall giving pain medication and none was documented on the MAR. The Nurse Practitioner, who noted increased tenderness at the sacral ulcer and the resident’s refusal to get out of bed due to bilateral hip pain, was unaware that the resident had been reporting pain during several PT visits and that nursing had not administered Tylenol. The DON acknowledged that departments should communicate about pain and that such communication should be documented, but there was no documentation of follow-through when the resident displayed ongoing verbal and non-verbal indicators of pain.
Inaccurate Wound Documentation and Missing Repositioning Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with pressure injuries, specifically regarding wound location and repositioning frequency. The resident, admitted with diagnoses including chronic kidney disease, polyosteoarthritis, and an unstageable pressure injury of the sacral region, was documented on the nursing admission assessment as having an unstageable pressure injury on the right buttock and an unstaged pressure injury on the left buttock. A subsequent wound NP assessment identified a single unstageable wound on the sacrum, but the Treatment Administration Record for the following month continued to show nursing staff signing off wound care for unstageable pressure injuries on the right and left buttocks. In interviews, a nurse described the wounds as being on the coccyx or buttocks area, and the DON acknowledged that nursing documentation listed the wounds on the right and left buttocks despite the NP’s identification of the sacrum as the anatomical site. The facility also failed to ensure documentation of the recommended repositioning frequency for the same resident. The wound NP’s progress notes included recommendations to offload pressure and reposition the resident every two hours, and later emphasized strict adherence to pressure injury prevention protocols, including frequent repositioning. However, review of CNA flow sheets for the months in question showed no documentation supporting that the resident was repositioned every two hours as recommended. A CNA reported that the resident required assistance with repositioning and that staff were supposed to document repositioning on the flow sheet. The DON stated that the option to document every two-hour repositioning was not automatically appearing on the CNA flow sheets and had been missed for this resident.
Choking Incident Due to Failure to Provide Ordered Ground Diet and Verify Meal Tray Accuracy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with dysphagia remained as free from accident hazards as possible when the resident was served a meal inconsistent with ordered diet texture, resulting in a choking episode that required staff intervention. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and was assessed as moderately cognitively impaired with a BIMS score of 12. Physician’s orders and the lunch meal ticket for the resident specified a house diet with ground texture and nectar thick liquids. Despite these orders, the facility’s lunch menu for the day included chicken parmesan, spaghetti noodles, cauliflower, and a garlic bread knot, and the resident was served chicken that was cut into pieces rather than ground. At approximately 12:15 p.m., while the resident was eating lunch in the secondary dining room/dayroom with another resident, another resident asked if the resident was choking. Nursing staff at the nearby nurses’ station (Nurse #1, Nurse #2, and Nurse #3) heard this and observed the resident performing the universal choking sign. Nurse #3 immediately entered the room, confirmed by nod that the resident was choking, and performed the Heimlich maneuver, expelling a piece of chicken from the resident’s mouth. After the intervention, the resident was able to breathe, speak in full sentences, and was assessed with normal breathing, warm, dry, pink skin, and stable vital signs. Subsequent review by nursing staff and facility leadership determined that the resident’s lunch tray did not match the ordered ground diet texture. Nurse #3 reported that upon checking the diet order after the incident, she found the resident had an order for a ground diet but had been given a regular texture diet, with chicken cut into pieces rather than ground. Nurse #1 confirmed that the resident had an order for a ground diet and that the chicken on the plate was cut up, not ground. Nurse #1 and Nurse #2 both acknowledged that nurses were responsible for checking all residents’ meal trays against their meal tickets to ensure correct diet texture, but each stated they had not checked this resident’s tray or any other residents’ trays that day. The former Administrator and the DON both stated that nurses were supposed to check all meal trays for accuracy prior to being served, and it was also identified that the Dietary Department had sent the wrong diet texture for the resident’s meal, resulting in the resident being served an incorrect meal texture that contributed to the choking incident. Additional staff interviews further described the breakdown in the tray-checking process. CNA #1, who helped pass lunch trays, could not recall whether nurses had checked the trays before they were passed. CNA #2, who was behind on morning care when the food trucks arrived, reported helping pass trays and stated that when she asked CNA #1 and CNA #3 if the nurses had checked the trays, both CNAs said yes. The former Administrator’s investigation concluded that the nurses on the unit had not checked the resident’s tray or any other trays at lunch prior to service, and he could not determine which staff member actually handed the tray to the resident. The DON stated that the Dietary Department had sent the wrong diet texture and that nursing staff had not checked the tray against the meal ticket before the meal was served, contrary to facility expectations and policy that require food and nutrition services staff and nursing staff to ensure that each resident receives the correct meal according to their diet orders.
Incorrect Diet Texture Served to Dysphagic Resident Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with dysphagia received food prepared in the correct texture as ordered by the physician. The resident had diagnoses including dysphagia, parkinsonism, dysarthria, cerebral infarction, hyperlipidemia, and anxiety, and had a physician’s order for a house diet with ground texture and nectar-thick liquids. On the date of the incident, the lunch menu included chicken parmesan with spaghetti noodles, cauliflower, and a garlic bread knot. The resident’s lunch meal ticket correctly reflected a house diet with ground texture and nectar-thick liquids, but the meal actually prepared and served to the resident was a regular texture diet, including a whole piece of chicken that had not been ground. According to interviews, the facility’s process required a dietary aide to call out each resident’s diet order, restrictions, allergies, and preferences from the meal ticket to the cook, who then prepared the plate and handed it back to the dietary aide. The dietary aide was responsible for double-checking that the meal on the plate matched the resident’s meal ticket before covering the plate and placing it on the tray. On the day in question, the dietary aide assigned to the food truck stated that the lunch meal was chicken parmesan with spaghetti noodles and acknowledged that the resident was on a ground diet. He reported that he must have read the wrong resident’s diet order for a regular diet to the cook and then placed the regular diet plate on this resident’s tray without checking the plate against the meal ticket as required. Nursing staff were also responsible for checking residents’ meal trays against the meal tickets before meals were passed. On the day of the incident, a nurse sitting at the nurses’ station near the dining room heard another resident ask if the affected resident was choking. The nurse observed the resident performing the universal choking sign, confirmed the resident was choking, and performed the Heimlich maneuver, after which a piece of chicken was expelled from the resident’s mouth. The nurse then checked the resident’s diet order and discovered that the resident had an order for a ground diet but had been given a regular texture diet. The facility’s own report through the Health Care Facility Reporting System documented that the lunch meal was not prepared according to the resident’s diet, that nursing staff had not checked the meal tray for accuracy against the meal ticket, and that the resident was served the incorrect meal texture.
Failure to Obtain Nursing Assessment After Resident Lowered to Floor
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received care and treatment consistent with professional standards and the facility’s fall assessment policy after being lowered to the floor in the bathroom. The resident, admitted with diagnoses including non-Hodgkin lymphoma, a left femur fracture, and a pelvic fracture, was cognitively intact and dependent on staff for care. On the date of the incident, the resident reported standing in the bathroom holding a grab bar while a CNA provided care, then telling the CNA that the resident’s knee was giving out and that they could not continue standing. The resident stated the CNA told them to hold on, but because the resident could not stand any longer, the CNA had to lower the resident to the floor, after which the resident cried due to right knee pain. According to the incident report and staff interviews, CNA #1 confirmed lowering the resident to the floor, then independently lifting the resident, placing them in a wheelchair, and transferring them back to bed before notifying any nurse. The facility’s policy on assessing falls requires that when a resident has fallen or is found on the floor, staff must evaluate for possible injuries to the head, neck, spine, and extremities before moving the resident. Multiple nurses and the nursing supervisor reported that CNA #1 did not inform them of the resident being lowered to the floor until after the resident had been moved back to bed, and some were only told about a skin tear sustained during a transfer, not that the resident had been on the floor. The DON and nursing supervisor both stated that being lowered to the floor is considered a fall and that a nurse should have assessed the resident for potential injury before the resident was moved, which did not occur in this case.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation and Maintain Current Abuse Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely internal and external reporting of an allegation of resident-to-resident sexual abuse, and failure to maintain an abuse policy aligned with current reporting requirements. The facility’s written policy, dated June 2022, stated that any complaint, observation, or suspicion of abuse, neglect, mistreatment, or misappropriation of resident property would be reported to the Massachusetts Department of Public Health, Division of Health Care Quality and other appropriate agencies in accordance with state and federal law. The policy further indicated that the Unit Manager/Supervisor would notify the DON and Administrator within two hours after an allegation if there was abuse or bodily harm, and that the Administrator and DON would be notified immediately based on CMS and State time frames, with a report to the Department of Public Health within 24 hours if abuse was suspected or confirmed. However, the Administrator later acknowledged that the policy had not been fully updated to accurately reflect current requirements that allegations of abuse be reported immediately to administration and to the State Agency within two hours. The incident involved two severely cognitively impaired residents. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, with an MDS showing he/she rarely/never made him/herself understood or understood others and had severely impaired cognitive skills for daily decision making. Resident #2’s care plan indicated wandering behavior with potential intrusion on others’ privacy, with interventions to distract with pleasant diversions and structured activities. Resident #3 had vascular dementia, with an MDS indicating he/she usually made him/herself understood and usually understood others, but had severely impaired cognitive patterns, and a care plan noting impaired cognitive function or thought processes due to dementia, with interventions to cue, reorient, and supervise as needed. On the evening in question, CNA #2 observed Resident #2, known to wander, in the dining room and later found Resident #2 in Resident #3’s room, seated on Resident #3’s bed, although Resident #2 did not reside there. CNA #2 entered and saw Resident #3 lying in bed with no clothing covering the genital area, while Resident #2 was touching Resident #3’s genital area with one hand; one of Resident #3’s hands was over Resident #2’s hand and the other was touching Resident #2’s chest under the shirt. CNA #2 removed Resident #2 from the room and immediately reported the incident to Nurse #1. Nurse #1 stated she reported the incident to the ADON (who did not recall being informed) and texted the DON sometime after 11:00 P.M., approximately four hours after the incident, acknowledging she should have called immediately but was distracted by other tasks. The DON did not see the text until about 5:00 A.M. the following morning, nearly 11 hours after the incident, and the Administrator was not notified until around 8:00 A.M., almost 14 hours after the incident. The facility’s report to the State Agency via the Health Care Facility Reporting System was created the following afternoon, and the Administrator later stated that allegations of abuse were expected to be reported immediately to administration and to the State Agency within two hours, which was not reflected in the written policy or in the staff’s actions.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to administrative staff so it could be reported to the State Survey Agency within the required two-hour timeframe. Facility policy dated June 2022 required that any complaint, observation, or suspicion of resident abuse, neglect, mistreatment, or misappropriation of resident property be reported to the Massachusetts Department of Public Health, Division of Health Care Quality, and other appropriate agencies in accordance with state and federal law. On the evening of 03/04/26, CNA #2 observed Resident #2, who did not reside in Resident #3’s room, seated on Resident #3’s bed while Resident #3 lay in bed with no clothing covering the genital area. CNA #2 saw Resident #2 touching Resident #3’s genital area with one hand, while Resident #3’s hand covered Resident #2’s hand and the other hand touched Resident #2’s chest under the shirt. CNA #2 immediately removed Resident #2 from the room and reported the incident to Nurse #1. Resident #2 had diagnoses including dementia, aphasia, conversion disorder, and post-traumatic stress disorder, and an annual MDS dated 02/25/26 showed severely impaired cognitive skills and that the resident rarely or never made self understood or understood others. Resident #3 had vascular dementia, and a quarterly MDS dated 02/17/26 indicated severely impaired cognitive patterns despite usually being able to make self understood and understand others. After CNA #2’s report, Nurse #1 acknowledged that around 6:15 P.M. on 03/04/26 she was informed of the residents’ sexual activity and stated she contacted the ADON by telephone or email and later texted the DON sometime after 11:00 P.M., approximately four hours after the incident. The ADON did not recall being informed, and the DON reported she did not become aware of the incident until seeing Nurse #1’s text at about 5:00 A.M. on 03/05/26, nearly 11 hours after the event, at which time she notified the Administrator. The Administrator stated he first learned of the allegation when the DON texted him the morning of 03/05/26 as he arrived at 8:00 A.M., and confirmed the incident was not reported to the State Agency within two hours, with the Health Care Facility Reporting System submission created on 03/05/26 at 1:29 P.M., more than 18 hours after the alleged incident occurred.
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