Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 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.
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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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Nursing homes near Framingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Casa De Ramana Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Bethany Skilled Nursing Facility | 1.4 mi | ★★★★★ | 0 | 0 |
| St Patrick's Manor | 1.6 mi | ★★★★★ | 0 | 0 |
| Eliot Center For Health And Rehabilitation | 3.3 mi | ★★★★★ | 1 | 0 |
| Oak Knoll Rehabilitation And Healthcare Center | 3.6 mi | ★★★★★ | 2 | 0 |
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