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 hemiplegia, severe cognitive impairment, and dependence on staff for transfers had an ADL care plan requiring a two-person stand-pivot assist for all transfers. Despite this, a CNA transferred the resident alone from wheelchair to bed, stating he did not feel a second staff member was needed, even though the Kardex indicated a two-person assist. Around the same time, nursing staff were called to assess bruising on the resident’s upper arm. The facility was unable to produce the Kardex in effect at the time of the incident, and the administrator later acknowledged that CNA Kardexes were not automatically updated when changes were made to the plan of care, creating inconsistency between the documented care plan and the guidance available to CNAs.
The facility failed to ensure comprehensive care plans were reviewed and revised after completion of required MDS assessments for two residents. For one resident, a quarterly MDS was completed, but the care plan meeting and updates occurred before the MDS, and goal dates did not reflect a post-assessment review despite multiple identified issues including cognitive loss, incontinence, mood alterations, skin breakdown risk, and falls risk. For another resident, an annual MDS was completed after the care plan meeting, which had already been documented as updated for multiple conditions such as cognitive loss, hearing deficits, incontinence, behavioral history, nutrition risk, and skin breakdown risk, with goal dates set on the meeting date. The MDS coordinator confirmed that care plan meetings should not occur before MDS completion and that goal dates should have been extended but were not.
A resident with dementia and severe cognitive impairment, fully dependent on staff for care, was found with new bruising on the left forearm. When asked, the resident stated that staff had been rough but would not identify who was involved. The Activity Director reported this to the Unit Manager and ADON, who assessed the resident and speculated the bruising might be from wheelchair self-propulsion, despite the resident having self-propelled for a long time without similar bruising. The DON, ADON, and Unit Manager treated the incident as an injury of unknown origin rather than an abuse allegation, and the internal investigation did not include staff or resident interviews, written witness statements specific to rough care, or efforts to identify any involved staff, contrary to facility policy requiring thorough investigation of all alleged violations.
A resident with moderate cognitive impairment, elopement risk, and a need for supervised ambulation was scheduled for a hospital appointment with an assigned CNA escort. On the day of the appointment, the transport company departed with the resident before the CNA arrived, and an agency nurse unfamiliar with escort procedures allowed the resident to leave unaccompanied. Another nurse recognized the need for an escort and attempted to send the CNA, but the resident had already left. The resident did not present to the scheduled clinic, instead walked to a police station, reported being lost, and was transported by EMS to the hospital ED, while facility leadership later acknowledged the resident should not have left without an escort and that administration was not notified immediately.
A resident with dementia, osteoporosis, CKD, HTN, and a history of falls lost balance while standing in the bathroom and was lowered to the floor by a CNA. An RN assessed the resident, noted stable VS and no initial pain, and assisted the resident back to bed but did not notify the provider or the health care agent, despite facility policy requiring immediate notification after accidents with potential need for physician intervention. Over the next days, the resident was noted as not feeling well and later complained of hip pain, leading to an x-ray that showed an acute intertrochanteric hip fracture. Record review and interviews confirmed there was no documentation that the provider or resident representative were notified at the time of the assisted fall.
A resident with dysphagia, a history of aspiration pneumonia, and NPO orders with all medications to be given via PEG tube received a levothyroxine tablet orally from an RN, who elevated the bed, placed the pill in the resident’s mouth, and gave a sip of water, causing the resident to cough. Later, another nurse found blue medication residue around the resident’s mouth and a cup of water at the bedside, despite documentation and assignment sheets clearly indicating NPO and PEG-only administration. Review of orders and the MAR confirmed that the RN had administered the blue levothyroxine tablet orally in error, constituting a significant medication error.
A resident with COPD, CHF, CVA, non-ambulatory status, incontinence, and dependence on staff for bed mobility was being provided incontinent care on an air mattress by a single CNA, despite the care plan and nursing assessment indicating the need for two-person assistance. The CNA pulled the resident toward her and then rolled the resident onto the opposite side so the resident could use the side rail, but the resident’s heavy, weak legs slipped and the resident fell from the bed to the floor. Nursing staff and the DON confirmed that the resident required two-person assist for bed mobility and that residents should be rolled toward, not away from, staff; the resident was subsequently diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
The facility failed to ensure complete and accurate CNA documentation of ADLs for a resident with COPD, CHF, and a history of CVA. Despite a policy requiring all services to be fully documented, CNA flow sheets for one month contained numerous blanks for bathing, dressing, continence care, personal hygiene, preventative skin care, turning/repositioning, and eating/amount eaten across multiple shifts and meals. A CNA reported that care is supposed to be charted during or by the end of each shift, and the DON confirmed that all care must be documented and that blanks on the flow sheets should not occur.
A resident with COPD, CHF, osteoarthritis, and a history of CVA had an ADL care plan that documented dependence or need for assistance with mobility, bed/chair mobility, bathing, dressing, personal hygiene, toileting, and transfers, but the plan did not consistently specify the number of staff required to safely provide this assistance. Although one intervention was updated to indicate two-person assistance for personal hygiene, other ADL interventions only stated "assist/dependent" without clarifying staff numbers. A CNA reported providing care and changing bed linens alone, while the DON stated that total dependence for bed mobility should mean two-person assistance and that CNAs should not determine assistance levels, highlighting that the care plan lacked clear, individualized direction on required staff assistance.
A resident with dementia and behavioral disturbances, who ambulated independently and was required by the care plan to remain in the facility unless supervised, eloped from a secured unit after asking staff how to leave. Staff had observed the resident wandering and inquiring about leaving but had not initiated an elopement risk assessment or related care plan interventions. The resident was last seen at the nurse station, later found missing during clinical rounds, and ultimately located off-site at a former home address. Exit and rear doors were alarmed and code-protected, but staff had shared alarm and elevator codes with visitors, and it was presumed the resident exited by using the elevator with a visitor.
Failure to Follow Care Plan Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently implemented and followed a resident’s care plan interventions for transfers. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, repeated falls, and abnormal posture. A quarterly MDS assessment documented severe cognitive impairment and dependence on staff for transfers from chair to bed. The resident’s ADL care plan, initiated on 12/14/24 with an estimated goal date of 02/27/26, specified a two-person stand-pivot assist for all transfers. The facility’s policy stated that CNAs are to use the ADL Kardex as a complete and updated reference for resident care needs, and that Kardexes are to be reviewed and updated at care plan meetings. On 04/20/26 at about 9:30 P.M., CNA #7 transferred the resident alone from wheelchair to bed, despite acknowledging that the Kardex indicated a two-person assist was required. CNA #7 reported standing the resident, using a walker to pivot, and seating the resident on the bed without incident, and stated he did not obtain a second staff member because he did not feel it was needed. Around the same time, Nurse #2 was called to the resident’s room and observed ecchymosis on the resident’s right upper arm, though she did not know whether the transfer had been done with one or two staff. At the time of survey, the facility could not produce the Kardex in effect on 04/20/26, and the administrator later acknowledged that the CNA Kardexes were not automatically updated when changes were made to the plan of care, resulting in a discrepancy between the resident’s updated plan of care and the information available to CNAs.
Failure to Review and Revise Care Plans After Completion of MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans within seven days of completion of the comprehensive MDS assessment, as required by facility policy and federal regulations. The facility’s Care Plan Policy states that the interdisciplinary team must develop and maintain a comprehensive care plan for each resident within seven days of the completion of the comprehensive MDS, and that care plans must be reviewed and updated with significant changes, unmet outcomes, readmissions, and at least quarterly. For one resident, the quarterly MDS had an Assessment Reference Date (ARD) of 03/11/26, but the care plan meeting occurred on 02/19/26, prior to completion of the MDS, and was documented as updated. This resident’s comprehensive care plan contained multiple problem areas such as cognitive loss and risk of decline in communication, vision impairment, bladder and bowel incontinence, mood alterations, mechanically altered diet, skin breakdown, psychotropic medication use, alterations in ADLs, hearing impairment, and risk of falls, with goal estimated dates listed as 02/27/26, which did not reflect a review and revision following the completed MDS. For a second resident, the annual MDS had an ARD of 03/27/26, but the care plan meeting took place on 03/19/26, again prior to completion of the MDS, and the care plans were marked as updated. This resident’s comprehensive care plan included problem areas such as cognitive loss and risk of decline in communication, hearing deficits, bladder and bowel incontinence, long-term placement, alterations in mood state, history of behaviors, risk for falls, risk for nutrition problems, risk for skin breakdown, and alterations in ADLs, with goal estimated dates listed as 03/19/26. During a telephone interview, the MDS Coordinator acknowledged that care plan meetings should not occur before MDS completion, explained that care plans are reviewed for accuracy, appropriateness of interventions, and realistic goals, and stated that the estimated goal dates for both residents should have been set approximately 90 days from the care plan meeting date but were not.
Failure to Investigate Resident’s Allegation of Rough Care and Unexplained Bruising as Potential Abuse
Penalty
Summary
The deficiency involves the facility’s failure to respond appropriately to an allegation of rough handling and associated bruising in a resident with severe cognitive impairment. The resident, admitted in December 2022 with diagnoses including dementia, depression, and anxiety, was dependent on staff for care. A Quarterly MDS dated 03/19/26 documented severe cognitive impairment. On 04/07/26, a skin assessment identified new bruising on the resident’s left inner and outer forearm. The facility submitted a report through the Health Care Facility Reporting System noting small bruises on the resident’s left forearm and completed an internal investigation that characterized the bruising as an injury of unknown origin, suggesting it might have been caused by wheelchair self-propulsion. According to the Activity Director’s written statement and interview, during lunch on 04/07/26 she observed bruises on the resident’s left forearm and asked how they occurred. The resident responded that “they were rough with me” and stated not wanting to get anyone in trouble, and would not identify which staff member was involved. The Activity Director immediately informed the Unit Manager and the ADON. The Unit Manager confirmed that she was told the resident had said someone had been rough with care and that she and the ADON assessed the resident. The Unit Manager reported that the resident was unable to tell them what happened, and although they considered self-propulsion of the wheelchair as a possible cause, she acknowledged the resident had been self-propelling for a long time without similar bruising. The ADON acknowledged that on 04/07/26 she was aware the resident had alleged staff had been rough with care and that rough handling could have caused the bruising. The DON stated she was notified of the new bruising and, together with the ADON and Unit Manager, concluded the bruises were from self-propulsion, and she did not investigate the matter as an allegation of abuse by staff. The facility’s internal investigation contained no documentation that staff were interviewed or asked for written statements specific to the allegation of rough care, and no efforts were documented to identify an accused staff member or to interview other residents on the unit. The Administrator later stated she had not been informed of the resident’s allegation of rough care at the time and that the incident had been handled only as an injury of unknown origin rather than as an abuse allegation, resulting in the absence of a thorough abuse investigation as required by the facility’s policy on incident and reportable event management.
Resident at Elopement Risk Sent to Hospital Without Required Escort and Later Found Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents for a resident assessed as being at increased risk for elopement, with moderate cognitive impairment and a legal guardian in place. The resident’s MDS documented a need for supervision with ambulation, and an elopement care plan identified elopement risk with a Wandergard bracelet initiated. Despite these assessments and care plans, the resident was scheduled for an out‑patient hospital appointment that required an escort, and a CNA was assigned as the escort on the facility’s appointment calendar. On the day of the incident, a transportation company arrived to take the resident to the hospital appointment. The resident was transported from the facility without the assigned escort, as the transport company left before the CNA arrived downstairs. An agency nurse assigned to the resident was not aware of the facility’s escort procedures and allowed the resident to leave with the transport company, believing the appointment transport was routine. Another nurse observed the resident leaving with the driver, confirmed the appointment on the schedule, and attempted to send the CNA as an escort, but by the time the CNA reached the pickup area, the resident had already departed without supervision. Subsequently, the resident did not arrive at the scheduled clinic appointment. The resident instead walked to a police station, reported being lost and needing to go to the hospital, and was then transported by EMS to the hospital’s emergency department. Facility staff, including the unit manager, ADON, DON, and administrator, later acknowledged that the resident always required an escort for appointments based on cognitive status and safety needs, and that the resident had gone out without an escort and was found wandering in the community. The administrator also stated that nursing staff did not notify him immediately when they realized the resident had left without an escort.
Failure to Notify Provider and Health Care Agent After Staff-Assisted Fall and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s provider and health care agent of a staff-assisted fall and subsequent change in condition. The resident, admitted with dementia, osteoporosis, hypertension, chronic kidney disease, and a history of falls, experienced a loss of balance while standing in the bathroom and was lowered to the floor by a CNA. The facility’s policy on Changes in Resident’s Condition or Status required immediate physician notification for any accident with potential need for physician intervention. Nurse #1 was informed by the CNA that the resident became weak in the bathroom and had to be lowered to the floor. Nurse #1 assessed the resident, found stable vital signs and no reported pain at that time, and assisted the resident back to bed but did not notify the provider or the health care agent of the staff-assisted fall, and there was no documentation of such notification in the medical record. In the days following the incident, the resident was noted by another CNA as not feeling well and not being his/her usual self, and the decision was made to keep the resident in bed, though this CNA was not informed of the prior fall. Later, the Unit Manager became aware that the resident had been lowered to the floor when the resident complained of left hip pain, at which point the provider was contacted and an x-ray was ordered, revealing a left acute femoral intertrochanteric fracture with mild osteoporosis. Review of the facility’s report to the Health Care Facility Reporting System documented the staff-assisted fall and subsequent hip pain and fracture diagnosis, but interviews with the DON and record review confirmed there was no documentation that the provider or health care agent had been notified at the time of the fall, contrary to facility policy and expectations.
Oral Administration of Medication to NPO PEG-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error when a nurse administered an oral medication contrary to NPO and PEG tube orders. The facility’s medication administration policy required medications to be administered safely and appropriately per physician orders. For the resident in question, physician orders specified NPO status with all nutrition, fluids, and medications to be given via PEG tube, including a levothyroxine 137 mcg tablet ordered via PEG tube once daily. The resident had been admitted with diagnoses including dysphagia, pneumonitis due to inhalation of food and vomit, hypothyroidism, a history of aspiration pneumonia, was non-verbal, and developmentally delayed. On the morning in question, the nurse assigned to the 11:00 P.M. – 7:00 A.M. shift reported that she entered the resident’s room, informed the resident she had thyroid medication, elevated the head of the bed, and placed the levothyroxine pill directly into the resident’s open mouth, followed by a sip of water. The resident began to cough, and the nurse further elevated the head of the bed until the coughing stopped, after which she left the room believing the resident appeared comfortable. Later that morning, the nurse on the 7:00 A.M. – 3:00 P.M. shift observed a blue crushed substance in and around the resident’s mouth and a cup of water on the bedside table. This nurse stated he was concerned because the resident’s record and assignment sheet clearly indicated NPO status and that the resident could not have anything by mouth. Subsequent review by the unit manager and DON confirmed that the resident’s orders specified NPO with all medications via PEG tube, that the levothyroxine tablet was blue in color, and that the administering nurse had signed off on giving the medication. The administering nurse later acknowledged that, despite having been told at shift start that the resident was NPO, she had given the medication orally in error, constituting a significant medication error.
Failure to Provide Required Two-Person Assist During In-Bed Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent for bed mobility and used an air mattress received the necessary level of staff assistance during in-bed care, resulting in a fall. The resident had diagnoses including COPD, CHF, and CVA, was non-ambulatory, always incontinent, and required maximum staff assistance for bed mobility per the MDS. The ADL care plan, reviewed with the January 2026 MDS, documented that the resident was totally dependent on staff for positioning and turning in bed and required assistance for toileting and personal hygiene. The DON, nursing staff, and PT confirmed that from a nursing standpoint the resident was dependent for bed mobility, which meant assistance of two staff members was required. On the date of the incident, CNA #1 entered the resident’s room, noted a soiled brief, and decided to provide incontinent care alone. CNA #1 reported that she had previously changed the resident’s bed linens by herself and believed the resident could hold onto the side rail during care. She pulled the resident toward her using the incontinent pad and then rolled the resident onto the left side, away from herself, so the resident could hold the side rail. The resident reported that the side rail was not in use (up) that day, that his/her legs were very heavy, and that when placed on the side away from the CNA, the legs began to slip, leading to a fall from the bed to the floor. The facility’s post-fall investigation identified that the resident, who required two-person assistance, had been changed by one staff member on an air mattress. Nursing staff and supervisors stated that the resident was well known to require two-person assistance for bed mobility and care due to size, immobility, and use of a mechanical lift for transfers. Nurse #1 and Nursing Supervisor #1 both indicated that CNA #1 should have had another staff member present to provide care. Nurse #1 also stated that staff should always roll residents toward themselves in bed, not away. The DON confirmed that the resident’s dependent status for bed mobility meant two-person assistance was required and acknowledged that the air mattress contributed to instability. Following the fall, the resident was transferred to the hospital ED and diagnosed with bilateral displaced distal femur fractures with lipohemarthrosis.
Incomplete CNA ADL Documentation for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident when Certified Nurse Aide (CNA) documentation of Activities of Daily Living (ADLs) was left incomplete on multiple shifts. The facility’s undated policy on Charting and Documentation required that all services provided to residents be documented in the medical record and that documentation be complete and accurate. Resident #1, admitted in July 2025 with diagnoses including COPD, CHF, and CVA, had CNA ADL flow sheets for April 2026 with numerous blanks where care should have been recorded. For bathing, dressing, bladder/bowel continence, personal hygiene, and preventative skin care, entries were left blank and not coded as provided on 15 of 21 applicable shifts across day, evening, and night shifts. The same resident’s flow sheets showed that turning and repositioning every two hours was left blank and not coded as provided on 13 of 21 applicable shifts, and eating and amount eaten were left blank and not coded as provided for 11 of 21 applicable meals. These omissions occurred over multiple consecutive days and shifts. During interviews, CNA #2 stated that CNAs are supposed to chart all resident care either immediately after providing it or by the end of the shift, and the DON confirmed that CNAs are expected to document all resident care by the end of their shifts and that there should not be blanks on this resident’s CNA flow sheet.
Failure to Specify Required Staff Assistance in ADL Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized ADL care plan that clearly specified the number of staff required to safely assist a resident with limited mobility and total dependence for certain tasks. Facility policies required comprehensive, person-centered care plans with measurable objectives and timetables, and specified that residents unable to perform ADLs independently must receive appropriate support in accordance with the plan of care. Resident #1, admitted with COPD, CHF, and a history of CVA, had an ADL care plan noting an ADL self-care performance deficit related to activity intolerance, limited mobility, CHF, osteoarthritis, and CVA. The care plan documented that the resident was dependent or required assistance for mobility, bathing/showering, bed/chair mobility, dressing, personal hygiene, toileting, and transfers, including being totally dependent on staff for positioning and turning in bed. However, the plan of care did not identify the specific number of staff required to safely provide assistance for these ADL tasks, despite the resident’s dependence and need for turning and repositioning. The personal hygiene intervention was later updated to require two-person assistance, but other interventions remained non-specific, listing only "assist/dependent" without clarifying staff numbers. During interviews, a CNA reported that she believed she could provide care to this resident by herself and had previously changed the resident’s bed linens alone. The DON stated that a notation of total dependence for bed mobility should be interpreted as requiring assistance of two staff members and that CNAs should not determine the resident’s level of staff assistance, emphasizing that the care plan should explicitly state the level and number of staff required for each intervention.
Failure to Supervise Resident and Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent elopement for a resident on a secured unit who had a legal guardian and a care plan requiring that he/she remain in the facility unless supervised. The resident, admitted with dementia with behavioral disturbances, anxiety, major depressive disorder, and frontotemporal neurocognitive disorder, ambulated independently and required physical assistance with ADLs. The facility’s elopement policy required that residents at risk for wandering or elopement have care plan strategies and interventions to maintain safety. Despite this, the DON acknowledged that no elopement assessment or care plan interventions had been initiated for this resident prior to the incident, even after staff observed the resident asking how to leave the facility. On the day of the incident, a CNA observed the resident at the nurse station around 2:30 P.M. asking how to leave the facility. The CNA reported that the resident routinely wandered the unit but was not known to exhibit exit-seeking behavior and therefore did not believe the resident would leave. Around 2:40 P.M., a nurse saw the resident at the nursing station interacting with staff, and by approximately 3:00 P.M., during final clinical rounds, the nurse noted the resident was missing and activated an elopement code. Staff searched the interior and exterior of the facility without success, and about 45 minutes later, staff and local police located the resident at his/her former home approximately two miles away. The administrator reported that exit doors and rear doors were alarmed and required codes, and presumed the resident may have exited by entering an elevator with a visitor who had access to the code, but staff had previously shared alarm/elevator codes with visitors or outside consultants.
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