Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to prevent mental abuse for 1 (R2) of 3 residents
reviewed for abuse in the sample of 3. This failure resulted in R2 being tearful and expressing feelings
including being upset and fearful of being kicked out of the facility.
Findings include:
R2's Minimum Data Set (MDS), dated [DATE] documents, she is alert and oriented, cognitively intact.
R2's Undated Face Sheet, documents she was admitted to the facility on [DATE] with a diagnoses major
depressive disorder and anxiety.
V1, Administrator's typed stated, dated 12/9/2024 documents this is a statement regarding V6, CNA
(Certified Nurse Aide) from 12/8/2024. A resident (R2) came to the ADON's (Assistant Director of Nurse's)
office on 12/9/2024 and stated V6 was sleeping in her bed yesterday (12/8/2024.) The ADON came into the
administrator's office and investigation was initiated immediately. Based on camera footage, V5 went into
(R2's) room on 12/8/2024 at 5:11 AM, she did not leave that room until V7, LPN (Licensed Practical Nurse)
went into resident's room at 6:47 AM to wake her up. Administrator, DON (Director of Nurses), ADON and
HR (Human Resources) spoke to V7 on phone, and she stated that they were unable to find V6. They
entered (R2's) room and found her to be sleeping. V8, LPN stated that V7 asked her to come with her to
wake V6 up. Administrator logged into time clock and noted V6 clocked in at 5:11 AM on 12/8/2024.
On 12/17/2024 at 11:03 AM, R2 was resident sitting up in her wheelchair in her room. R2 recalled CNA
(V6) coming into her room early on Sunday (12/8/2024) and stated she was cold and needed to sleep. R2
stated she always sleeps in her recliner. V6 told R2 not to say a word because if she did, she would be fired
and she would get kicked out of the facility. R2 was upset by this and felt it was a serious threat and she
didn't want to get kicked out of the facility because she didn't have any place to go. R2 stated staff came
into her room about an hour after (V6) had been sleeping and woke her up. She didn't talk to anyone about
the CNA sleeping in her bed because she didn't want to get kicked out of the facility then when she spoke
to her daughter (V5) on 12/9/2024 she was tearful and told her she's afraid she's going to get kicked out of
the facility because a CNA slept in her bed and she was caught by staff but that she didn't tell on the CNA
but she was afraid the CNA thinks she told staff she was sleeping in her bed. R2 stated she hopes that (V6)
doesn't work at the facility anymore because she's afraid of what she will do to her if she thinks she told on
her.
(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
12/18/2024
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 0600
Level of Harm - Actual harm
Residents Affected - Few
On 12/17/2024 at 11:03 AM V8, Licensed Practical Nurse (LPN) stated she got to work on 12/8/2024 at
approximately 5:30 AM and she was told V6 CNA was running late to work that day. At approximately 6:30
AM, V8 hadn't seen V6 and started looking for her. V6 stated she looked in R2's room and observed V6
sleeping in R2's bed. She attempted to wake V6 up, but she told her to get out. V6 then went and reported
V6 was sleeping to another nurse V7, LPN. V8 and V7 went to R2's room and V6 woke up and went to work
at approximately 6:45 AM. R2 was sitting up in her recliner in her room watching at that time and she wasn't
crying or emotionally distressed. V8 stated she didn't report that R2 said not to say anything, or she'd get
fired and R2 would get kicked out of the facility. V8 stated she didn't report the incident to management
because she wasn't assigned to R2 that day.
On 12/17/2024 at 12:23 PM V7, Registered Nurse (RN) she worked on 12/8/2024 day shift and was
assigned to R2. V7 stated she knew V6 was running late but didn't know when she arrived to the facility. V6
stated staff couldn't find V6 and V8 reported to her that she found V6 sleeping in R2's bed. V7 and V8 went
to R2's room and observed V6 was in fact sleeping in R2's bed. V7 stated she woke V6 up and stated she
needed to get to work. V7 didn't report the sleeping incident to management on 12/8/2024. V1 called her on
12/9/2024 and they discussed the incident at that time. R2 wasn't upset on 12/8/2024 when V6 was
sleeping in her bed, R2 actually laughed about it and didn't report that R2 told her not to say anything about
her sleeping in her bed or she'd get fired and R2 would get kicked out of the facility.
On 12/17/2024 at 12:45 PM V4, Social Services Assistant stated it was reported to her on 12/9/2024 that
on 12/8/2024 V6 was found sleeping in R2's bed. V4 and V1 spoke to R2 about the incident on 12/9/2024
and V4 stated the resident got tearful during the interview and stated she didn't want anyone to get in
trouble. V4 stated R2 didn't mention fear of being kicked out of the facility and V4 wasn't aware that R2 was
fearful of being kicked out of the facility. V4 let R2 know V6 was terminated for sleeping in her bed and R2
understood she was safe at the facility.
On 12/17/2024 at 1:30 PM V5, (family member) stated she went to see R2 in the afternoon on 12/9/2024
and as soon as she walked in the door R2 started to cry and shake and she told her that a CNA slept in her
bed the day before and told her if she told anyone she would get fired and R2 would get kicked out of the
facility. V5 stated R2 was very upset and shaking when she told her, and she could tell R2 was scared of
the sleeping CNA V6. V5 spoke to the ADON and reported the incident immediately then she showered R2
in an attempt to calm her down. The Administrator spoke to her and R2 after the shower and that's when R2
told the Administrator that the CNA V6 slept in her bed the morning before, and she told her she'd get fired
and R2 would be kicked out of the facility if she told on her for sleeping. V5 stated R2 told her that V6
threatened her, and she didn't feel safe at that time.
On 12/17/2024 at 12:33 PM V6, CNA stated she worked at the facility day shift on 12/8/2024 and she had a
rough night and that she was really cold and tired. V6 assisted R2 to the bathroom and R2 told her to lay in
her bed and rest. V6 stated she thought she'd sit on R2's bed for a few minutes but she fell fast asleep. V7
and V8 woke her up, she didn't know how long she slept for. V6 went straight to work after being woke up
and R2 was her usual cheerful self, she wasn't tearful or emotionally upset that day at all. V6 denied telling
R2 not to tell staff she slept in her bed because she'd get fired and R2 would get kicked out of the facility.
V6 stated she'd worked at the facility for over a year and R2 was like family to her, and she'd never say that
to her.
On 12/17/2024 at 10:30 AM, V3 stated she was aware a CNA was found sleeping in R2's on 12/9/2024
when R2's family member R5 reported it to her. An investigation was started immediately. V3 stated when
she spoke to R5 on 12/9/2024 she stated R2 told her that if she said anything about R2 sleeping in
(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
12/18/2024
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 0600
Level of Harm - Actual harm
Residents Affected - Few
her bed the CNA would be fired and she would be kicked out of the facility. When V3 spoke to R2 she was
very upset and tearful stating she didn't want V6 to get in trouble and didn't mention the possibility of being
kicked out of the facility.
On 12/17/2024 at 2:11 PM V2 stated on 12/9/2024 sometime after morning meeting the R2, the ADON and
V5, R2's family member entered V1, Administrator's office and stated V6 slept in R2's bed the morning
before and that R2 didn't say anything because she didn't want to get V6 in trouble. V2 didn't recall who told
her that R2 stated that V6 stated to her not to tell anyone that she was asleep in her room because she
would get fired and R2 would get kicked out of the facility. R2 was tearful when she entered V1's office to
speak to them. R2 has depression and her antidepressant medication was discontinued on 11/18/2024 due
to swelling and was restarted due to being tearful and having more signs and symptoms of depression on
12/12/2024.
On 12/17/2024 at 10:35 AM V1 stated R2, V3 and V5 entered her office on 12/9/2024 and R2 was tearful at
that time and R2 stated V6 slept in her bed the morning before and that if she told anyone V6 would be
fired, and she would be kicked out of the facility. R2 was visibly upset when she told V1 this but R2 had
recently had some medication changes so that could have something to do with her being emotional.
The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021
documents residents have the right to be free from abuse, this includes but is not limited to mental abuse.
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
1 citation 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.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
FAQ · About this visit
Common questions about this visit
What happened during the December 18, 2024 survey of CARLYLE HEALTHCARE & SR LIVING?
This was a inspection survey of CARLYLE HEALTHCARE & SR LIVING on December 18, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CARLYLE HEALTHCARE & SR LIVING on December 18, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
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
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.