Carlyle House

In the surveyor’s words

From the most serious findings on record at Carlyle House, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF700Mar 3, 2025

  Based 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. […]

• Actual harm, isolatedF656Jan 27, 2026

  Based 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.Findings include:The Facility Policy, titled Resident Assessment, dated 09/01/20, indicated an individualized interdisciplinary plan of care, treatment and services would be developed by the interdisciplinary team that… […]

• Actual harm, isolatedF689Jan 27, 2026

  Based 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. […]

• Actual harm, isolatedF626May 23, 2022

  Based on interviews and records reviewed for one of four sampled residents (Resident #1), whose Health Care Proxy was activated, the Facility failed to permit Resident #1 to return to the Facility following an evaluation in the Hospital Emergency Department (ED) on 4/19/22 due to a change in mental status. As a result of the facility not permitting Resident #1 to return to the facility, he/she remained in the Hospital ED for three weeks, while the Hospital searched for alternative placement for him/her. Findings include: Review of the Admission Agreement, undated, indicated that before the Facility sought to involuntarily discharge a resident, the Facility shall give the resident and their representative written notice of the proposed discharge. […]