F 0802
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition
service.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the Facility failed to adequately staff the dietary department to
ensure meals are served in a timely manner for 4 of 5 residents (R1, R2, R4, R5) reviewed for food and
nutrition services in the sample of 5.
Findings include:
1. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including heart
failure and diabetes.
R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, required supervision
with eating, and ambulated via wheelchair.
R1's Physician Order dated 9/28/24 documents R1 is on a regular diet with no added sodium.
R1's Grievance Form dated 12/27/24 documented, (R1) came to me about issues with not getting her
dinner last night until late.
On 1/7/25 at 11:43 AM, R1 stated everyone else was eating dinner, but she did not get served. She was
supposed to get grilled cheese and soup, but they brought her something different which she did not like.
She stated she then went back to her room and did not receive her grilled cheese and soup until around
7:00 PM. She stated, It is always late. It's supposed to start at 5:00 PM, and we are lucky if they start at
5:30 PM or a quarter 'til (6:00 PM).
2.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including
Alzheimer's disease and blindness in right eye.
R2's MDS dated [DATE] documented R2 was severely cognitively impaired and required substantial
assistance with eating, bed mobility, and transfer.
R2's Physician Order dated 7/27/16 documents R2 is on a regular diet.
On 1/7/25 at 12:46 PM, V14, Licensed Practical Nurse (LPN), obtained a meal tray from the cart on the 200
Hall and delivered it to R2 in her room. This was one hour sixteen minutes after the lunch meal was
scheduled to begin.
3.R4's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including type
(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 2
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
01/08/2025
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 0802
2 diabetes mellitus and pressure ulcers.
Level of Harm - Minimal harm
or potential for actual harm
R4's MDS dated [DATE] documented R4 was cognitively intact, required setup with eating, and was
dependent with bed mobility and transfer.
Residents Affected - Some
R4's Physician Order dated 10/25/24 documents R4 is on a mechanical soft diet.
On 1/7/25 at 12:56 PM, V13, Certified Nursing Assistant (CNA), took a meal tray from the cart on the 200
Hall and delivered it to R4 in her room. V13 stated, We have good days (with timing) and bad days, but
there usually aren't so many hall trays. There have been more (hall trays) with Covid, and it takes longer (to
pass them). R4's tray was passed one hour and twenty-six minutes after the lunch meal was scheduled to
begin.
4.R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including chronic
kidney disease and type 2 diabetes mellitus.
R5's MDS dated [DATE] documented R5 was cognitively intact, required supervision with eating, and was
dependent with bed mobility and transfer.
R5's Physician Order dated 10/10/24 documents R5 is on a low concentrated sweets diet.
On 1/7/25 at 1:05 PM, V13 took a meal tray from the cart on the 200 Hall and delivered it to R5 in her room.
R5's tray was delivered one hour and thirty-five minutes after the lunch meal was scheduled to begin.
On 1/7/25 at 8:55 AM, V4, Environmental Services and Dietary Supervisor, stated occasionally meals run
late at supper. V1, Administrator, stated they have had some delays in meals with the recent snowfall and
staff calling off work.
On 1/7/25 at 9:20 AM, V11, Licensed Practical Nurse (LPN), stated sometimes there are delays in meals at
the Facility.
On 1/7/25 at 1:49 PM, V1 stated lunch was late today because three dietary employees that were
scheduled to work called off. There was no cook or prep cook, so V4 had to do a lot of the work herself.
On 1/7/25 at 2:40 PM, V1 stated she will be working with V4 to correct the issue.
The Facility's Weekly Schedule for 1/5/25-1/11/25 documents five dietary staff were originally scheduled to
be present during the lunch hour on 1/7/25 before the reported three call offs.
The Facility's Mealtimes Posting documents lunch is served at 11:30 AM.
The Facility's Frequency of Meals Policy revised 7/2017 documents, Each resident shall receive at least
three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with
resident needs preferences, requests and the plan of care. The facility will serve at least three (3) meals or
their equivalent daily at scheduled times.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145729
If continuation sheet
Page 2 of 2
