Inspection·July 2, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the failed to ensure allegations of physical abuse were reported immediately to the administrator of the facility and to the State Survey Agency for 1 of 3 residents (R55) reviewed for reporting of allegation of abuse in a sample of 57. Findings include: R55's Face Sheet, print date of 07/02/25, documented R55 has diagnoses of but not limited to dementia, paranoid schizophrenia, anxiety disorder due to known physiological condition. R55's Minimum Data Set (MDS), dated [DATE], documented R55 is severely cognitively impaired and requires substantial/maximal assistance with bed mobility. V2, Director of Nursing (DON) statement dated 06/22/25, documents V2, Director of Nursing, DON, received a phone call from agency nurse, V35, at 7:43 AM regarding a bruise/skin tear (ST) R55 received. The statement documented V35 stated that she had a gut feeling that the agency Certified Nursing Assistant (CNA), V31 gave resident the bruise/ST. That statement continued that V2 came into the facility and started investigation. The statement documented R55 had a Brief Interview of Mental Status (BIMS) of 99 and was alert to self only. The statement documented V2 assessed R55 and noted the bruise/ST, and R55 did not state she was harmed and did not show any emotional distress at that time. At that time, V2 asked V35 to contact V1, Administrator, and write a statement. The statement documents V35 did not contact V1 or write a statement. R55's Electronic Medical Record (EMR) was reviewed and there was no documentation that the Administrator and/or the State Survey Agency was notified of the allegation of abuse for R55. On 07/02/25 at 9:20 AM, V1, Administrator said with abuse she has to have it turned into the State Survey Agency within two hours and with a fall with major injury she has to have it reported within 24 hours. V1 said had she known about the incident with R55 and V31 she would have reported it immediately to the State Survey Agency. On 07/02/25 at 09:25 AM, V2 said V31 worked on the south hall on the night shift the night of the incident. She said after the incident regarding R55 and V31 the agency nurse, V35 called V2 on the phone while she was driving home and told her she had a gut feeling something happened with V31 and R55. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date (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 07/02/2025 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)