Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlyle Healthcare & Sr Living during CMS and state inspections, most recent first.
Two cognitively intact residents with stroke histories and mobility impairments, one on anticoagulant therapy and one with a care plan for aggressive behavior, became involved in an unwitnessed altercation after a dispute over snacks. One resident reported that the other attempted to hit him, that he grabbed the other’s shirt, and that the other fell and then kicked him in the lower legs. Staff later observed the residents arguing, with one resident balling his fists and yelling profanities at the other and at staff. Documentation and interviews confirmed a large, tender bruise on one resident’s lower leg and a torn shirt on the other, indicating physical contact. Surveyors determined the facility failed to ensure a resident remained free from abuse during this resident-to-resident incident.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was found with a bruise/skin tear, and an agency nurse suspected possible abuse by a CNA. The DON was informed and began an investigation, but the administrator and State Survey Agency were not notified as required by policy. The facility's procedures mandate immediate reporting of such allegations, but this did not occur.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was found with a bruise/skin tear, and an agency nurse suspected an agency CNA was responsible. The DON began an investigation but did not immediately remove the CNA from resident care, instead reassigning her to a different hall and allowing her to finish her shift, which was not in accordance with facility policy.
The facility experienced staffing shortages in the dietary department, leading to delayed meal service for several residents. One resident with heart failure and diabetes reported receiving her dinner late, while another with Alzheimer's disease received her lunch over an hour late. The delays were due to three dietary employees calling off work, leaving insufficient staff to serve meals on time.
A resident with major depressive disorder and anxiety was mentally abused when a CNA slept in her bed and threatened her not to report it, causing the resident to feel upset and fearful of being kicked out of the facility. The incident was not immediately reported by staff who discovered the CNA sleeping, and the resident later confided in her daughter, leading to an investigation.
The facility failed to store, prepare, and serve food safely, risking foodborne illness for 79 residents. Observations included improper storage of hand sanitizer and insect traps near food, undated and unlabeled food items, and unsafe food temperatures. The Dietary Manager acknowledged these issues, which violated the facility's policies on safe food handling and storage.
The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic use for four residents. Antibiotics were continued without proper justification, as the Infection Control Log lacked causative pathogens for urinary tract infections. The facility's policy was not followed, leading to antibiotics being administered based on symptoms or incomplete documentation.
The facility failed to ensure resident safety in smoking activities and fall prevention. Three residents were observed smoking without required supervision or safety measures, contrary to the facility's smoking policy. Additionally, a high fall-risk resident was left unattended on the toilet, resulting in a fall and fractured ankle. These incidents reflect a lack of adherence to safety protocols, as outlined in the facility's policies.
The facility failed to provide adequate incontinent care for four residents, leading to deficiencies in hygiene and infection prevention. CNAs did not perform hand hygiene or follow proper cleansing procedures, neglecting to clean necessary areas and improperly handling soiled linens. These actions were inconsistent with the facility's Perineal Care Policy, resulting in observed deficiencies.
A facility failed to store medications properly and did not date an open multidose vial, affecting 21 residents in the dementia unit. Ice buildup in the medication refrigerator led to water saturation of medication boxes, and an opened tuberculin vial lacked a date. The RN noted the refrigerator needed defrosting, and both the Administrator and DON expected proper dating and storage of medications.
CNAs in a facility failed to follow proper infection control protocols, including hand hygiene and glove use, during incontinence care for several residents with cognitive impairments. Despite the facility's policy emphasizing hand hygiene, CNAs were observed not washing hands before or after glove use, and improperly handling soiled linens, indicating a systemic issue with infection control practices.
Failure to Prevent Resident-to-Resident Abuse Resulting in Bruising
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse during a resident-to-resident altercation. One resident (R1), who was cognitively intact and used a walker and wheelchair, had diagnoses including cerebral infarction, hypertensive heart disease with heart failure, asthma, chronic pain, major depressive disorder, gastric ulcer with hemorrhage, and was on anticoagulant therapy with a care plan noting increased risk of bruising and bleeding. Another cognitively intact resident (R2), who used a wheelchair, had diagnoses including cerebral infarction, major depressive disorder, type 2 diabetes with chronic kidney disease, chronic pain, anxiety disorder, and had a care plan focus area for aggressive behavior, including cussing and yelling profanities, with interventions to manage such behavior. On the day of the incident, R1 reported that R2 had been eating his snacks without permission. According to R1’s progress note, when R1 confronted R2, R2 got out of his wheelchair and attempted to hit him. R1 stated he grabbed R2 by the shirt because R2 was attempting to hit him, and R2 then fell to the floor and began kicking R1 in the lower legs. When nursing staff entered the room, they observed the two residents verbally arguing, with R2 balling up his fists and yelling profanities. R2’s progress note documented that he was found sitting on his bottom with his back against the wall and that he stated he had stood up and lost his balance, causing him to fall, while also balling up his fist in a threatening manner and yelling profanities at R1 and staff. Subsequent documentation and interviews confirmed that R1 sustained a large blue/purple bruise around the left lower extremity calf area that was very tender, and that R1 reported being kicked by R2. A CNA (V3) stated the incident was unwitnessed, that R2’s shirt was torn, and that R1 later had a bruise on his leg, noting R1 was on blood thinners and bruised easily. The administrator (V1) stated the altercation occurred less than 24 hours after R2 was moved into R1’s room and that both residents had prior stroke-related weakness, with R1 also having visual impairment and being on a blood thinner and anemic. The facility had a policy on resident-to-resident altercations requiring investigation and identification of what led to aggressive conduct, and the survey finding concluded the facility failed to ensure residents remained free from abuse for one resident reviewed for abuse.
Failure to Timely Report Alleged Abuse to Administrator and State Agency
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident was reported immediately to the facility administrator and the State Survey Agency, as required by policy and federal regulations. The incident involved a resident with diagnoses including dementia, paranoid schizophrenia, and anxiety disorder, who was severely cognitively impaired and required substantial assistance with bed mobility. An agency nurse observed a bruise/skin tear on the resident and expressed suspicion that an agency CNA may have caused the injury. The nurse communicated this suspicion to the Director of Nursing (DON) by phone, who then began an investigation and assessed the resident, noting the injury but no signs of emotional distress or verbalization of harm from the resident. Despite the suspicion of abuse, there was no documentation that the administrator or the State Survey Agency was notified of the allegation as required. The DON instructed the agency nurse to contact the administrator and write a statement, but this was not done. The facility's policies clearly state that all allegations of abuse, including injuries of unknown origin, must be reported immediately to the administrator and appropriate authorities, with "immediately" defined as within two hours for abuse allegations. Interviews confirmed that the administrator was not made aware of the incident in a timely manner and that the required notifications were not completed.
Failure to Immediately Remove Staff After Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from potential further abuse after an allegation was made. A resident with severe cognitive impairment, dementia, paranoid schizophrenia, and anxiety disorder was found with a bruise/skin tear. An agency nurse reported a suspicion that an agency CNA was responsible for the injury. The Director of Nursing (DON) was notified and began an investigation, but the CNA in question was not immediately removed from resident care. Instead, the CNA was reassigned to a different hall and allowed to complete her shift before being removed from the facility until the investigation was completed. Facility policy requires that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete. However, the DON did not follow this policy, as the CNA continued to have resident contact during the shift following the allegation. The facility's own documentation and staff interviews confirmed that the accused CNA was not immediately removed from resident care, contrary to established procedures.
Staffing Shortages Lead to Delayed Meal Service
Penalty
Summary
The facility failed to adequately staff the dietary department, resulting in delayed meal service for several residents. One resident, who was admitted with heart failure and diabetes, reported receiving her dinner late and not as ordered. She expressed that meal service often started later than scheduled. Another resident, with Alzheimer's disease and blindness, received her lunch meal over an hour after it was scheduled to begin. A third resident, with type 2 diabetes and pressure ulcers, also experienced a delay in receiving her lunch meal, which was delivered one hour and twenty-six minutes after the scheduled time. A fourth resident, with chronic kidney disease and type 2 diabetes, received her lunch meal one hour and thirty-five minutes late. The delays in meal service were attributed to staffing shortages in the dietary department. On the day of the survey, three dietary employees called off work, leaving the Environmental Services and Dietary Supervisor to handle much of the work alone. The facility's weekly schedule indicated that five dietary staff were originally scheduled to be present during the lunch hour, but the call-offs led to insufficient staffing. The facility's policy requires meals to be served at scheduled times, but the staffing issues resulted in significant delays, impacting the residents' meal service.
Failure to Prevent Mental Abuse of Resident
Penalty
Summary
The facility failed to prevent mental abuse for a resident, identified as R2, who was found to be tearful and expressed feelings of being upset and fearful of being kicked out of the facility. R2, who is alert, oriented, and cognitively intact, was admitted with diagnoses of major depressive disorder and anxiety. The incident involved a CNA, V6, who was found sleeping in R2's bed. R2 reported that V6 threatened her not to tell anyone about the incident, stating that if she did, V6 would be fired and R2 would be kicked out of the facility. This threat caused R2 significant emotional distress, as she was afraid of losing her place in the facility. The incident occurred when V6 entered R2's room early in the morning, claiming to be cold and tired, and subsequently fell asleep in R2's bed. R2, who usually sleeps in her recliner, was awake and witnessed the event. Staff members, including V8 and V7, later found V6 sleeping in R2's bed and woke her up. Despite being aware of the situation, V8 and V7 did not report the incident to management immediately. R2 did not initially report the incident due to fear of repercussions, but later confided in her daughter, V5, who then reported it to the facility's administration. The facility's investigation revealed that R2 was tearful and upset during interviews with staff and her family member, V5. The facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised in April 2021, states that residents have the right to be free from abuse, including mental abuse. Despite this policy, the failure to prevent and address the mental abuse experienced by R2 highlights a deficiency in the facility's handling of the situation, as R2 was left feeling unsafe and emotionally distressed.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness, potentially affecting all 79 residents. Observations revealed several issues in the large dry storage room, including hand sanitizer stored next to food items like sugar, and insect bait traps placed near food products such as hot sauce and poppy seed dressing. Mouse droppings were found on the top of the storage rack. In the kitchen, grease and burnt matter were observed on the stovetop and ovens, and the walk-in refrigerator contained undated sweet potatoes and cream cheese removed from original packaging without expiration dates. The walk-in freezer had unlabeled pie crusts, and the standing refrigerator had an opened jar of bouillon without a date of opening. Additional issues were noted in the small dry storage closet, where large tubs of oatmeal, sugar, flour, and thickener were labeled but not dated. The staff and resident refrigerator contained various unlabeled and undated food items, including moldy and expired products. Food temperatures in the second-floor dining room were below safe levels, with green beans at 113°F and salads at 69°F and 56°F, which are within the danger zone as per the facility's policy. The Dietary Manager acknowledged the issues with food storage and temperature management. The facility's policies require food to be stored and handled safely, with specific guidelines for labeling, dating, and maintaining appropriate temperatures, which were not followed in these instances.
Inadequate Antibiotic Stewardship in LTC Facility
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, particularly in antibiotic stewardship, for four residents. The Infection Control Log did not list causative pathogens for urinary tract infections in these residents, leading to inappropriate antibiotic use. For one resident, an antibiotic was continued despite a urine culture showing no microbial growth, based solely on symptoms. Another resident received an antibiotic without a culture to justify its use, and the facility struggled to obtain necessary documentation from the hospital. Similarly, two other residents were administered antibiotics without appropriate culture results to support their use, with one case relying on an elevated white blood cell count from a metabolic panel, which did not justify the antibiotic treatment. The facility's Antibiotic Stewardship Policy, revised in 2016, mandates that antibiotics be prescribed and administered under the guidance of the stewardship program. However, the facility did not adhere to this policy, as evidenced by the lack of proper documentation and justification for antibiotic use. The administrator acknowledged the expectation for staff to follow the policy and educate new hires, but the report highlights a significant gap in the implementation of the program, leading to the continuation of antibiotics without appropriate clinical justification.
Deficiencies in Smoking Safety and Fall Prevention
Penalty
Summary
The facility failed to ensure the safety of residents who engage in cigarette smoking activities by not developing and implementing personalized care plan interventions. Three residents were affected by this deficiency. One resident, who is cognitively intact, was observed smoking without wearing a smoking apron and keeping a lighter in his pocket, which resulted in a burn. Another resident, who is moderately cognitively impaired, was also observed smoking without supervision and not wearing a smoking apron, despite being on oxygen in his room. A third resident, who is cognitively intact, admitted to keeping a lighter in her purse and not wearing a smoking apron. The facility's smoking policy requires supervision and the use of safety measures, which were not adhered to in these cases. The facility also failed to provide adequate supervision to prevent falls for a resident at high risk for falls. This resident, who is severely cognitively impaired, was left unattended on the toilet by a CNA, resulting in an unwitnessed fall and a fractured ankle. The resident's care plan indicated the need for substantial assistance with transfers and the use of a sensor pad, which was not followed. The facility's policy on fall risk management emphasizes the need for supervision in the bathroom for high-risk residents, which was not implemented in this instance. The deficiencies highlight a lack of adherence to established safety protocols for both smoking and fall prevention. The facility's policies clearly outline the need for supervision and specific interventions to ensure resident safety, yet these were not consistently applied, leading to unsafe conditions and injuries for the residents involved.
Inadequate Incontinent Care and Hygiene Practices
Penalty
Summary
The facility failed to provide complete incontinent care for four residents, leading to deficiencies in maintaining hygiene and preventing infections. Resident R17, who is severely cognitively impaired and always incontinent of urine, was observed being transferred into bed by two CNAs who did not perform hand hygiene before or after the procedure. The CNAs used the same disposable cloth to cleanse different areas of R17's body without changing gloves or cloths, and they did not cleanse all necessary areas, such as the outer labia and inner thighs. After completing the care, the CNAs left the room without performing hand hygiene. Resident R3, who is moderately cognitively impaired and dependent on staff for toileting hygiene, was also subjected to inadequate care. The CNAs did not perform hand hygiene before or after handling R3, and they failed to cleanse the entire length of R3's penis, inner thighs, scrotum, and buttock. Additionally, they did not retract R3's uncircumcised penis to cleanse the area properly. Similar issues were observed with Resident R38, who is severely cognitively impaired. The CNAs did not use perineal cleanser or soap and failed to cleanse R38's frontal labia region after a bowel movement. Soiled linens were improperly handled, and hand hygiene was neglected. Resident R59, who requires substantial assistance with toileting, was also inadequately cared for. The CNAs did not cleanse R59's frontal region, including the inner labia and thighs, and failed to perform hand hygiene before and after the procedure. The facility's Perineal Care Policy outlines specific steps for maintaining cleanliness and preventing infections, but these were not followed, leading to the observed deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medications in a sanitary manner and did not date an open multidose medication vial, which could potentially affect all 21 residents in the dementia unit. During an inspection of the dementia unit's medication storage room, a large block of ice buildup was observed in and around the freezer section of the medication refrigerator. This ice was dripping onto the bottom of the refrigerator, causing water saturation of a box containing a vial of abrysvo vaccine and another box containing bisacodyl suppositories. Additionally, an opened multidose vial of tuberculin solution was found without a date indicating when it was opened. The Registered Nurse (RN) acknowledged that the medications, including the suppositories, abrysvo vial, and tuberculin solution, were used as needed for all residents in the unit and noted that the refrigerator required defrosting. Both the Administrator and the Director of Nursing (DON) expressed that they expected medications to be dated when opened and stored in a clean manner. The facility's Storage of Medications Policy, revised in November 2020, mandates that drugs and biologicals be stored safely, securely, and orderly, with proper temperature, light, and humidity controls, and that medication storage areas be maintained in a clean, safe, and sanitary manner.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the areas of hand hygiene and glove use, during the care of five residents. Certified Nurse Assistants (CNAs) were observed not performing hand hygiene before donning gloves, between glove changes, or after removing gloves. This was noted during the provision of incontinence care for residents who were cognitively impaired and dependent on staff for activities of daily living (ADLs). The CNAs involved did not follow the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent the spread of infections. For instance, one resident with Alzheimer's disease and severe cognitive impairment was transferred to bed by CNAs who donned gloves without hand hygiene, changed the resident's soiled brief, and performed incontinence care without changing gloves or washing hands. Another resident, also with Alzheimer's and dependent on staff for toileting, was similarly handled by CNAs who failed to perform hand hygiene before and after care, and improperly disposed of soiled linens. These actions were repeated across multiple residents, indicating a systemic issue with infection control practices. The facility's policy, revised in August 2019, clearly states that glove use does not replace hand hygiene and that all personnel should be trained and regularly in-serviced on these procedures. Despite this, CNAs were observed not adhering to these guidelines, as evidenced by their actions during the care of residents. Interviews with staff, including the Administrator and Director of Nursing, confirmed that the expectation was for CNAs to perform hand hygiene before, during, and after providing care, which was not met in these instances.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carlyle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evercare Of Breese | 8.4 mi | ★★★★★ | 3 | 0 |
| Aviston Countryside Manor | 12.8 mi | ★★★★★ | 9 | 0 |
| Centralia Manor | 13.5 mi | ★★★★★ | 19 | 1 |
| Fireside House Of Centralia | 13.5 mi | ★★★★★ | 0 | 0 |
| Odin Health And Rehab Center | 16.9 mi | ★★★★★ | 2 | 1 |
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