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🔎 Carlyle House

Inspection Results


Inspection Overview

Carlyle House has been cited for a total of 22 deficiencies since we began saving each survey.

In Massachusetts, the average facility has **46.34 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-03-03
Correction Date: 2025-03-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2025-03-03
Correction Date: 2025-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Survey Date: 2025-03-03
Correction Date: 2025-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2024-05-01
Correction Date: 2024-06-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Ensure each resident receives an accurate assessment.

Survey Date: 2024-05-01
Correction Date: 2024-06-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care or services that was trauma informed and/or culturally competent.

Survey Date: 2024-05-01
Correction Date: 2024-06-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2024-05-01
Correction Date: 2024-06-10
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-05-01
Correction Date: 2024-06-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Survey Date: 2024-05-01
Correction Date: 2024-06-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Survey Date: 2022-11-07
Correction Date: 2022-12-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

PASARR screening for Mental disorders or Intellectual Disabilities

Survey Date: 2022-11-07
Correction Date: 2022-12-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-11-07
Correction Date: 2022-12-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-11-07
Correction Date: 2022-12-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2022-11-07
Correction Date: 2022-12-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-11-07
Correction Date: 2022-12-06
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-05-23
Correction Date: 2022-07-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2022-05-23
Correction Date: 2022-07-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2021-11-02
Correction Date: 2021-12-17
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2021-11-02
Correction Date: 2021-12-17
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-06-19
Correction Date: 2019-07-19
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-06-19
Correction Date: 2019-07-19
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2019-06-19
Correction Date: 2019-07-19
Category: Pharmacy Service Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**