Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared,
and served in a manner which prevents potential contamination and food-borne illness. This has the
potential to affect all 87 residents living in the facility.
Findings include:
1. On 5/30/23 at 9:51 AM, the ice scoop was inside the ice machine in the second-floor dining room. There
was a cooler on top of the ice machine that also had a scoop inside on the ice.
On 5/30/23 at 11:34 AM, on the kitchen preparation counter, there was a clear container holding
approximately 16 ounces of a white powdery substance that was labeled (Thickener) and was not dated.
On 5/30/23 at 11:38 AM in the beverage refrigerator next to the prep counter, there was a 32-ounce bag of
walnuts that had been opened and resealed but was not dated. There was a pitcher containing a red liquid
that was labeled 4/23 and cranberry. There was a plastic gallon storage bag with a light tan colored creamy
substance inside with no label or date. V5 (Dietary Aide) stated, I'm not even sure what that is.
On 5/30/23 at 11:42 AM in the small storage closet there were four large, clear bins that were
approximately three feet tall each. One contained a white powder and was not labeled or dated. The other
three were labeled instant food thickener, oats, and sugar and were not dated. There was a plastic storage
bag containing banana cake mix that had been opened but was not dated.
On 5/30/23 at 11:45 AM in the walk-in refrigerator there was a container labeled chicken gravy dated 5/20 5/26. V4 (Dietary Manager) stated 5/26 is the date it should have been thrown out. I'll throw it out now.
There was a container of an unknown substance that was not labeled or dated. V4 stated, That is pea
salad, and it can come out since it's not labeled. There was a shallow pan containing a red liquid covered
with plastic wrap labeled SB (gelatin) that was not dated.
On 5/30/23 at 11:47 AM in the walk-in freezer, there was a pan with 3.5 pies that were covered with plastic
wrap. None were labeled or dated. V4 (Dietary Manager) told V5 (Dietary Aide) to throw it out. There was a
banana split in a container from a fast-food restaurant that was not labeled or dated. There was a plastic
bag labeled diced potatoes that was not dated, and another plastic bag labeled salmon patties that was not
dated.
On 5/30/23 at 11:55 AM, V6 (Dietary Aide) was washing dishes in the three-compartment sink. V4 (Dietary
Manager) stated, (Testing) is not done as often as we should. You probably know that since I
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145729
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145729
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carlyle Healthcare & Sr Living
501 Clinton Street
Carlyle, IL 62231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
had to go look for the strips. V4 placed the test strip into third part of the sink with the sanitizing solution. V4
pulled out the strip and compared it to the chart on the test strip tube. V4 stated, It looks like 10 ppm (parts
per million) but should be in the 50-100 ppm range. I'm going to say I have the wrong strips or it's not right
and I need to call the (maintenance) company about the chemicals.
On 5/30/23 at 12:00 PM in the first-floor dining room V7 (Cook) pointed to the refrigerator, and stated, I
don't feel like this is cold enough. V4 (Dietary Manager) read the dial on the thermometer inside and stated,
It's not. It's 50 (degrees Fahrenheit). Everything in there is going to have to go.
On 5/30/23 at 12:40 PM, V8 (Dietary Aide) took a can of cream of mushroom soup out of the cupboard on
the first-floor dining room. V8 opened the can, poured contents in a bowl, and placed bowl in the microwave
for 60 seconds. V8 began working on other tasks, then stopped microwave with 19 seconds remaining. V8
removed the bowl and gave to V4 (Dietary Manager) who served the bowl to R77. V4 or V8 did not check
the temperature before serving to resident.
2. On 5/30/23 at 1:11 PM, obtained temperatures of food from the steam table using a metal calibrated
thermometer on the first-floor dining room after the last resident tray was served. The pureed pork
measured 98 degrees (º) Fahrenheit (F). The mechanically altered pork measured 100º F. The
pureed vegetables measured 99ºF. The French fries measured 87º F.
The Facility's Modified Diet List documents three residents were on Dental Soft (Mechanical Soft) Diets
(R7, R43, R79) and 3 residents on Pureed Diets (R5, R11, R56).
3. On 6/1/23 at 12:08 PM V6 (Dietary Aide) was serving residents in the second-floor dining room. V6
pulled a dish towel out from her cleavage underneath her shirt with gloved hands and placed it on the side
of her neck. V6 then placed the same towel in her pant pocket. V6 did not change gloves but resumed
plating food at the steam table and delivered a plate to R79.
On 6/1/23 at 9:58 AM, V1 (Administrator) stated she expects staff to follow food service policies.
The Facility's Food Storage (Dry/Refrigerated/Frozen) Policy, 2011 Edition, documents, Food shall be
stored at appropriate temperatures and using appropriate methods to ensure the highest level of food
safety. All food items will be labeled. The label must include the name of the food and the date by which it
should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food
that has been prepared in the facility after seven days of storing under proper refrigeration. Keep potentially
hazardous foods out of the temperature danger zone (41ºF - 135ºF, or per state specific
regulations). Leftover contents of cans and prepared food will be stored in covered, labeled and dated
containers in refrigerators and/or freezers. Refrigerated storage guidelines to be followed: Set refrigerators
to the proper temperature. The setting must ensure the internal temperature of the food is 41ºF or
lower. Wrap food properly. Never leave any food item uncovered and not labeled. Any food item at greater
than 41º for an unknown duration of time, such as during opening of the kitchen, will be discarded
immediately.
The Facility's Steam Table Serving Temperatures for Hot and Cold Foods Policy, 2011 Edition, documents,
Staff will follow the guidelines below when serving hot and cold beverages and food Foods will be served at
the following temperatures to ensure a safe and appetizing experience. Meat, Casseroles: 135 ºF to
170 ºF. Vegetables, Potatoes: 135 ºF to 170 ºF.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145729
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145729
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Carlyle Healthcare & Sr Living
501 Clinton Street
Carlyle, IL 62231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
The Resident Census and Condition of Residents Form, (CMS 672), dated 5/30/2023 documents there are
87 residents living in the Facility.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145729
If continuation sheet
Page 3 of 3
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
FAQ · About this visit
Common questions about this visit
What happened during the June 2, 2023 survey of CARLYLE HEALTHCARE & SR LIVING?
This was a inspection survey of CARLYLE HEALTHCARE & SR LIVING on June 2, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARLYLE HEALTHCARE & SR LIVING on June 2, 2023?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordanc..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.