Inspection·January 12, 2026

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not isolate me, remove me from my source of agitation, and spend one on one time with me to see what is bothering me dated 09/12/25.R2's progress note dated 08/30/25 at 2:03 PM documents: Resident's roommate (R1) wheeling down the hall and states that this resident (R2) is on the floor. Upon entering room, this resident (R2) was noted to be sitting on his bottom with his back against the wall. Resident (R2) states that he stood up and lost his balance, causing him to fall backwards. Denies hitting his head. During assessment of vitals, this resident (R2) noted to be balling up his fist in a threatening manner and shaking it at his roommate (R1). This resident (R2) noted to be yelling profanities at roommate (R1) as well as this nurse V6 (Registered Nurse), a second nurse and a CNA (V3) that were present. This resident (R2) assisted back to his w/c via two assist.On 01/09/26 at 3:33 PM V3 (Certified Nurse Aide (CNA)) stated, she was working when R1 and R2 had their incident, it was unwitnessed. V3 stated, she went in their room and R2 was on the floor. R1 stated, on her way to their room she passed R1 and he stated, come get your boy she didn't understand what that meant and when she entered the room is when she seen R2 on the floor. V3 stated, R1 stated R2 was trying to was trying to get into his snacks. V3 stated, R1 stated he got mad about it and R2 swung at him. R1 got pulled out of his chair and R2 kicked him. V3 stated, R2 told her that R1 pulled on his shirt and pulled him out of his chair and was starting to swing. V3 stated, R2 stated R1 pulled him by the shirt and he started kicking him (R1). V3 stated, It appeared R1's story lined up closer to what happened than R2's story because R2's shirt was torn and for a time after R1 had a bruise on his leg. V3 stated, she did not remember seeing the bruise on R1's leg prior to the incident but he is on blood thinners so it doesn't take much for him to bruise. V3 stated, they are both smokers and they had never prior to that day or since that day had any concerns with each other. V3 stated, both R1 and R2 are fairly chill so it was surprising that they had the incident, they had been roommates less than 24 hours. V3 stated, they moved R2 to a different room down at the other end of the hall immediately. V3 stated R1 and R2 had never had any concerns with any other residents before that day or since that day either.On 01/09/26 at 3:49 PM R1 stated, he does not have any problems with any residents at the facility including R2. When R1 was specifically asked if R2 kicked him, R1 stated, yes, he kicked me.On 01/09/26 at 3:24 PM R2 stated (when asked about the incident with R1), that was a long time ago, we are fine, we have no problems with each other.On 01/09/26 at 3:45 PM V4 (Registered Nurse) stated, she had never seen R1 or R2 have any concerns with each other or any other resident prior to that day or since that day.On 01/09/26 at 3:53 PM V1 (Administrator) stated, the incident with R1 and R2 was unwitnessed. V1 stated, they had moved R2 into R1's room on 08/29/25 at 10:43 AM and on 08/30/25 she received a call they had a resident to resident involving R1 and R2. V1 stated, she was shocked because they were both fairly laid back, both participated in smoking activity, and she had never seen either have any concerns with anyone. V1 stated, she thought they would get along great. V1 stated, she called the police and she came back to the facility and neither would say very much about it until the police arrived. V1 stated, R1 stated R2 went to grab my mixed nuts and R2 said he did not, he was just going over by the heater. V1 stated, R2 has weakness one his one side due to a stroke and so does R1. R1 also does not see too well. V1 stated, the only concerns they had previously with R2 was he had a few behaviors due to his blood sugar and he had some confusion, he had just been put on insulin on 08/25/25 and started accuchecks shortly after. R2 was sent out for evaluation. R2 returned with no new orders. V1 stated, R1 is on a blood thinner and is anemic, he is susceptible to bruising. V1 stated, at the time of the incident, R1 stated, he did not know if the bruising on his leg was from the kick or from something else. V1 stated, prior to the incident neither resident had had any issues with each other or any other resident.The facility policy dated 09/22 titled, (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 01/12/2026 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 - Minimal harm or potential for actual harm Resident-to-Resident Altercations documents: all altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. 4. if two residents are involved in an altercation, staff: separate the residents, and institute measures to calm the situation; identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145729 If continuation sheet Page 3 of 3