Cycle 1
Health 2025-07-29 · Fire 2025-07-29
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Framingham, MA
Carlyle House
1-star overall rating with 1-star inspections with $16,153 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
342 Winter Street, Framingham, MA
(508) 879-6100
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
55
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.63
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
4.34
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,916
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9951
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.25
Baseline 21.12% · Performance 19.00% · Measure score 5.25 · Achievement 5.25 · Improvement 4.69
Healthcare-associated infections
2.28
Baseline 6.45% · Performance 7.15% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Total nurse turnover
4.79
Baseline 44.64% · Performance 44.12% · Measure score 4.79 · Achievement 4.79 · Improvement 0
Adjusted total nurse staffing
4.54
Baseline 3.82 hours · Performance 4.37 hours · Measure score 4.54 · Achievement 4.54 · Improvement 2.30
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 10.94% · Lower 95% interval 7.26% |
| Discharge to community | 56.14% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 44.74% · Lower 95% interval 45.7% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 83 · Denominator 83 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 83 |
| Discharge self-care score | 53.45% |
53.69%
0.2 pts worse
|
Numerator 31 · Denominator 58 |
| Discharge mobility score | 37.93% |
50.94%
13 pts worse
|
Numerator 22 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 2.41% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 83 · Adjusted rate 1.82% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 78 · Observed rate 8.97% · Lower 95% interval 4.65% |
| Staff COVID-19 vaccination coverage | 15.38% |
8.2%
7.2 pts better
|
Numerator 10 · Denominator 65 |
| Staff flu vaccination coverage | 30.49% |
42%
11.5 pts worse
|
Numerator 25 · Denominator 82 |
| Discharge function score | 56.9% |
56.45%
0.4 pts better
|
Numerator 33 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 47.06% |
25.2%
21.9 pts better
|
Numerator 24 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.9
0.5 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
92.2%
6.2 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 100.0% · Q3 100.0% · Q4 97.8% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
94.8%
1 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.5%
2.4 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
12.0%
9 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 2.4% · Q4 4.5% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 16.3% |
5.2%
11.1 pts worse
|
5.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 23.5% · Q3 15.6% · Q4 10.5% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
19.2%
0.5 pts better
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 19.4% · Q3 14.3% · Q4 15.4% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.1% |
22.5%
1.6 pts worse
|
16.7%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 20.8% · Q3 18.5% · Q4 26.5% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
17.7%
5 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
17.6%
5.5 pts better
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 23.3% · Q3 3.6% · Q4 9.4% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
1.0%
2.2 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 6.0% · Q3 1.6% · Q4 3.3% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
2.0%
2 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 7.1% · Q3 4.9% · Q4 2.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.0% |
21.7%
14.7 pts better
|
19.8%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 11.1% · Q3 10.5% · Q4 4.7% · 4Q avg 7.0% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.6%
0.2 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 10.1% · Q3 3.2% · Q4 1.5% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
77.1%
0.1 pts better
|
81.7%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.4% · Q2 78.3% · Q3 82.2% · Q4 73.0% · 4Q avg 77.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
11.8%
9.4 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 20.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.5% |
77.7%
3.2 pts worse
|
79.7%
5.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
25.8%
1.3 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 26.9% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-07 · Fire 2022-11-07
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-07-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-12
E · Potential for more than minimal harm
2022-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-16
Inspection history
Recent health citations
G · Actual harm
2026-01-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-02-25
G · Actual harm
2026-01-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-25
D · Potential for more than minimal harm
2025-07-29
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-07-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-07-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-07-29
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-07-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-12
J · Immediate jeopardy
2025-03-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-14
J · Immediate jeopardy
2025-03-03
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-03-14
D · Potential for more than minimal harm
2025-03-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-14
F · Potential for more than minimal harm
2024-05-01
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-01
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-10
B · Minimal harm
2024-05-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-10
D · Potential for more than minimal harm
2022-11-07
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-07
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-12-06
D · Potential for more than minimal harm
2022-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-06
Penalties and ownership
What sits behind the stars
$16,153
2025-03-03
Fine
Fine · fine $16,153
Fine
Ownership
Morgan, Joseph
5% Or Greater Direct Ownership Interest · Individual
Morgan, Christopher
5% Or Greater Direct Ownership Interest · Individual
Morgan, Michael
5% Or Greater Direct Ownership Interest · Individual
Morgan, Joseph
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Casa De Ramana Rehabilitation Center
Framingham, MA
4-star overall rating with 4-star inspections with $8,512 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Bethany Skilled Nursing Facility
Framingham, MA
5-star overall rating with 5-star inspections with $9,318 in total fines with 4 fire-safety deficiencies in the latest cycle
#3
St Patrick's Manor
Framingham, MA
2-star overall rating with 2-star inspections with $33,157 in total fines with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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