Carlyle House

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), whose comprehensive plan of care indicated he/she required two staff member assistance with use of the Hoyer (mechanical) lift for all transfers, the Facility failed to ensure staff consistently implemented and followed his/her care plan interventions, when on 12/30/25 Certified Nurse Aide (CNA) #1 transferred him/her without the assistance of another staff member, and Resident #1 sustained injuries including a right head laceration, and multiple fractures during the transfer.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required two staff member assistance with the use of a Hoyer (mechanical) lift for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, in accordance with facility policies and assessed level of care needs, to maintain his/her safety to prevent an incident/accident resulting in significant injuries. On 12/30/25, Certified Nurse Aide (CNA) #1 attempted to transfer Resident #1 without another staff member present to assist her, which resulted in an unsafe transfer. Resident #1 sustained a laceration to the right side of his/her head, was transferred to the Hospital Emergency Department (ED) for an evaluation, where he/she was also diagnosed with multiple fractures.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that the appropriate individual had the authority to make decisions regarding Advance Directives (legal documents that provide instructions for medical care when an individual is incapacitated) for one Resident (#26) out of a total sample of 13 residents. Specifically, for Resident #26, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) Form was completed by a Legal Guardian (person assigned by the court to make decisions for an individual who is incapacitated) who had an expansion for the authority to make decisions about the Resident's Advance Directives relative to his/her wishes for life-sustaining treatments.

Inspectors wroteBased on record review, and interview, the facility failed to accurately code Minimum Data Set (MDS) Assessments as the clinical basis for care planning and care delivery for four Residents (#4, #20, #7 and #36) out of a total sample of 13 residents. Specifically: 1. For Resident #4, the facility failed to accurately code an intravenous line (IV) access when the Resident had an IV access in place. 2. For Resident #20, the facility failed to accurately code antidepressant and antipsychotic medications when the Resident was ordered for and being administered an antidepressant medication daily but was coded as receiving an antipsychotic medication when the Resident was not ordered for antipsychotic medication. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the Resident was provided the right to participate in the care plan process for one Resident (#26), out of a total sample of 13 residents. Specifically, the facility failed to ensure that quarterly care plan meetings were conducted as required for Resident #26, and that the Resident and/or Resident Representative were encouraged to participate in the care plan meetings.

Inspectors wroteBased on observation, and interview, the facility failed to ensure that drugs and biologicals were stored in accordance with currently accepted professional principles of practice on one Unit (Front Unit) and one (Medication Cart A) of two medication carts reviewed. Specifically, the facility failed to ensure that multi-dose vials of eye medications were dated once opened according to manufacturer's guidelines in the Front Unit medication storage room, and for Medication Cart A located on the Front Unit.

Inspectors wroteBased on interview, and record review, the facility failed to administer Pneumococcal Vaccinations for one Resident (#9) out of five applicable residents, out of a total sample of 13 residents. Specifically, for Resident #9, the facility failed to administer Pneumococcal Vaccines when the Resident was eligible to receive, and the Responsible Party consented to the Pneumococcal immunization, putting the Resident at risk of acquiring pneumococcal illnesses.

Inspectors wroteBased on observation, records reviewed and interviews, for one of six sampled residents (Resident #1), who had limited mobility due to a cylinder (plaster type) cast on his/her right leg from his/her mid thigh down to his/her ankle, required physical assistance from staff with rolling and moving in bed, and had requested the use of bed rails for bed mobility, the Facility failed to ensure he/she was adequately supervised for safety and potential hazards related to the use of bed rails as an assistive device, in order to prevent an incident and/or accident resulting in serious injury or death. On [DATE] around 6:00 A.M., Resident #1 was found unresponsive, without a pulse, his/her lower body was hanging off the mattress with his/her feet touching the floor, and his/her head/neck area was hyperextended and caught between the mattress and the bed rail. [...]

Inspectors wroteBased on observation, records reviewed and interviews for one of six sampled residents (Resident #1) who had limited mobility in his/her right leg related the need for a hinge brace which was changed to a long leg cylinder cast (both of which kept his/her right leg fully extended) for treatment of a fractured patella (knee cap), and had requested bed rails to aide in bed mobility, the Facility failed to ensure nursing completed bed rail assessment on Resident #1, attempted the use of an appropriate alternative to bed rails and obtained informed consent prior to installing two quarter bed rails on his/her bed. [...]

Inspectors wroteBased on records reviewed and interviews, for two of six sampled residents (Resident #1 and Resident #5), who both had bed rails on their beds, the Facility failed to ensure they developed and implemented individualized comprehensive plans of cares that included interventions, treatment goals and measurable outcomes, when Resident #1 and Resident #5, Plans of Care did not include or address the installation and use of bed rails.

Inspectors wroteBased on record review and interview, 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 failed to have an RN working at least eight consecutive hours for 16 days between 10/1/23 and 2/11/24, placing 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 provision of resident care.

Inspectors wroteBased on interview, record and policy review, the facility failed to provide privacy and confidentiality for one Resident (#50) out of a total sample of 13 residents. Specifically, for Resident #50, the facility staff failed to provide privacy while assisting with personal care in the facility shower room, when an unauthorized CNA (Certified Nurses Aide #1) entered the shower room to utilize their personal cell phone, and CNA #2 who was providing personal care did not cover or drape the Resident to prevent exposure of body parts.

Inspectors wroteBased on interview, record and policy review, the facility failed to perform a trauma assessment on admission to the facility for two Residents (#7 and #45) out of a total sample of 13 residents. Specifically, the facility failed to assess whether Resident's #7 and #45 had any history of trauma, and/or any triggers which may cause re-traumatization to the Residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff adhered to infection control standards for one Resident (#25) out of a total sample of 13 residents. Specifically, the facility staff failed to perform appropriate hand washing/hygiene for four opportunities, during a wound care procedure to prevent contamination and the spread of infection.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that the Pneumococcal (any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus that can range from ear and sinus infections to pneumonia and blood stream infections) Vaccination was administered to two Residents (#42 and #36) for five applicable residents, out of a total sample of 13 residents, increasing the Residents' risk for facility acquired Pneumococcal infections. Specifically, the facility staff failed to: -identify whether Residents #42 and #36 were up to date with their Pneumococcal Vaccinations. -administer the Pneumococcal Vaccine to Residents #42 and #36 when the Residents were not up to date with their Pneumococcal Vaccinations and were eligible to receive the Pneumococcal Vaccine.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) Assessments were accurately coded for two Residents (#45 and #55), out of a total sample of 13 residents. Specifically, the facility failed to ensure that: 1. Two consecutive MDS Assessments for Resident #45 were accurately coded relative to the use of psychotropic (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications. 2. One MDS Assessment for Resident #55 was accurately coded relative to the Resident's discharge status.

Inspectors wroteBased on record review and interview the facility failed to ensure that its staff honored the wishes for one Resident (#45) out of 13 total sampled residents for advanced directives (a person's wishes regarding medical treatment). Specifically, the staff failed to accurately document and execute a Medical Orders for Life-Sustaining Treatment (MOLST - a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders) form for Resident #45.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff completed a timely Level One Preadmission Screening and Resident Review (PASRR) for one Resident (#6) before the Resident was admitted to the facility. Specifically, the facility failed to ensure that its staff completed a Level One PASRR for Resident #6 prior to him/her being admitted to the facility when the Resident had documented mental illness and was likely to require more than 30 days of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that 1) for Resident #1, the facility followed a Physician's order for a pressure wound to the left heel, and, 2) for Resident #37, failed to implement a care plan intervention for the use of a seat cushion as part of the skin integrity care plan when the Resident had been identified as being at risk, in a total sample of 13 Residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its staff provided care and services to maintain an indwelling urinary catheter (tube inserted into the body used to drain urine from the bladder) for one Resident (#26), according to the Resident's plan of care. Specifically, facility staff failed to provide documented evidence that Resident #26 was provided with monthly follow-up visits to the Urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system), status post hospitalization for a urinary tract infection (UTI), to have his/her indwelling urinary catheter tube changed, when it was indicated in the Resident's Indwelling Suprapubic (SP; area of the stomach, between the pubic bone and the navel) Catheter care plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure that its staff maintained a complete and accurate medical record for one Resident (#1) relative to the care of a pressure ulcer (PU; injury to the skin and underlying tissue resulting from prolonged pressure on the skin). Specifically, the facility failed to ensure that its staff 1.)transcribed a verbal order provided by the Physician to continue treatment for a stage three (full thickness skin loss) PU on the Resident's left heel, and 2.) documented the treatment that was provided for the care of the Resident's stage three left heel PU, which increased the Resident's risk of not receiving care for, and/or deterioration of, the PU.

Inspectors wroteBased on observation, policy review and record review, the facility failed to 1) ensure its staff implemented the policy for Clean Dressing Change during a dressing change related to hand hygiene between handling contaminated and clean dressing materials for one Resident (#1), in a total sample of 13 Residents, and, 2) failed to ensure its staff implemented infection control practices related to the following: Hand hygiene during staff self Covid-19 testing Disinfection of shared equipment (temporal thermometer) between use by staff Disinfection of a contaminated surface after staff self Covid-19 testing