Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Manor Court Of Carbondale during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, prior traumatic subdural hemorrhage, cognitive communication deficit, vascular dementia, major depressive disorder, anxiety, and a documented history of trauma was sharing a room with another cognitively impaired resident. During an argument in their room about a boyfriend, the roommate grabbed the resident’s hand and bit it, causing an immediately visible, crescent-shaped bruise and blood blister on the palmar surface of the hand that resembled a human bite, with lipstick noted around the area. A bystander resident alerted CNAs by yelling that someone was fighting, and staff arrived to find the residents already separated, with the injured resident holding her hand and stating she had been bitten. The facility’s abuse policy stated that abuse is prohibited and that special attention would be given to identifying behaviors that increase the risk of abusing others or being a victim of abuse, yet the resident was not protected from this episode of physical abuse.
The facility failed to follow physician orders and implement ordered pressure-injury prevention and treatment measures for three residents at risk for, or with, pressure ulcers. One resident with diabetes, incontinence, and limited mobility developed three stage II ulcers on the buttocks and intergluteal cleft while reporting that staff did not routinely reposition him in bed or chair; surveyors observed no off-loading boots in use, no heel skin prep applied, and buttock wounds that were not listed on the wound log. A second resident with documented boggy heels and orders for bilateral off-loading boots and heel skin prep was repeatedly seen in bed and in a wheelchair without boots, with very red, boggy heels, and reported that staff did not offer or apply the boots, which were found unused in the closet. A third resident with an unstageable left heel ulcer and orders for an off-loading boot and specific wound care was observed multiple times without the boot, including while the wrapped heel rested on a metal wheelchair foot pedal; this resident stated staff did not put a boot on, and a wound clinic NP confirmed the boot was never in place during clinic visits despite ongoing orders.
A resident with intact cognition but significant mobility limitations, including dependence on staff for transfers and substantial assistance for bed mobility, routinely sat in a wheelchair at the back of the room where the call light could not reach. Staff, including CNAs and the DON, acknowledged that the resident regularly positioned herself by the window and that the call light cord did not extend to that area. The resident reported difficulty propelling forward due to slick shoes and stated she sometimes tried to reach the call light, called her daughter, or went to the doorway to yell for help. The resident’s daughter confirmed these difficulties and frequent calls for assistance, while the care plan required the resident to call for help before transfers and to be oriented to the call light system, resulting in a failure to reasonably accommodate the resident’s need for accessible call light use.
A resident with multiple chronic conditions, intact cognition, and dependence on staff for toileting and transfers received peri and incontinence care during which a CNA repeatedly discarded soiled wipes, a saturated brief, and a urine-soaked pad onto the floor, causing urine to splash, and then carried the soiled pad against his uniform. The CNA left and re-entered the room multiple times wearing the same contaminated gloves, used those gloves to open doors and access the clean linen cart, and changed gloves without performing hand hygiene between glove changes. Another CNA and the DON acknowledged that these practices did not follow facility policy for standard precautions, which requires proper hand hygiene, PPE use, linen handling, and waste disposal.
A resident suffered a nondisplaced spiral fracture of the right tibia when their foot got caught in the rubber strips of a shower chair. The incident occurred during a transfer to the shower room, and the facility's investigation found that the rubber strips were loose and stretched out. The resident, who had impairments in both upper and lower extremities, was dependent on staff for transfers. The maintenance director admitted that bathroom equipment was only checked on an as-needed basis, contributing to the oversight.
The facility failed to provide adequate staffing, resulting in delayed care for residents. Multiple residents reported long wait times for assistance with toileting and incontinence care, leading to discomfort and potential health risks. Staff acknowledged the shortages, particularly on weekends, and the facility could not provide consistent documentation to verify adequate staffing levels.
The facility failed to respond to call lights promptly, affecting four residents' dignity and care. Residents reported long wait times, particularly in the evenings and weekends, leading to inadequate incontinence care and self-transfers. The DON acknowledged the issue, stating call lights should be answered within 15 minutes, but this expectation is not consistently met.
The facility failed to provide adequate ADL assistance and timely incontinence care for four residents, leading to deficiencies in care. One resident received only one shower during a five-day stay, while another reported inconsistent call light responses and delayed toileting assistance. A third resident had previously filed a grievance about delayed care, noting staffing shortages, particularly on weekends. A fourth resident reported delays in incontinence care, resulting in skin issues, with a CNA confirming inadequate night shift care and staffing shortages.
A resident with severe cognitive impairment and behavioral issues was involuntarily discharged from a facility without adequate physician documentation or a clear plan to manage their needs. The facility failed to document the resident's specific needs, attempts to meet those needs, or services available at the receiving facility. Staff interviews revealed a lack of detailed notes on the resident's behaviors and interventions, and the resident was not allowed to return during the appeal process.
A resident, who required substantial assistance for bathing, did not receive scheduled showers as per their care plan. Despite being cognitively intact and needing showers on specific days, the resident reported receiving mostly bed baths, with documentation showing extended periods without a shower. The facility's policy required at least one complete bath weekly, but records indicated non-compliance, leading to inadequate personal hygiene care.
A facility failed to reassess and implement individualized interventions for a resident with dementia, leading to increased combative behaviors. The resident, with severe cognitive impairment, exhibited physical aggression during personal care. Despite having a care plan, it lacked specific strategies for managing the resident's aggressive behaviors. Staff reported multiple incidents of aggression and expressed concerns about the lack of guidance. The facility's policy on proactive interventions was not effectively applied, and documentation was insufficient to update the care plan.
A resident with Multiple Sclerosis and other conditions experienced a significant delay in receiving assistance after activating the call light, leading to her being left soaked in urine for hours. The delay was attributed to severe staffing shortages, particularly on weekends, which had been a persistent issue at the facility. Staff members, including CNAs and LPNs, confirmed the inadequate care provided due to insufficient staffing, and the facility's administrator acknowledged the grievances received regarding the incident.
A resident with a history of chronic pain and other medical conditions experienced increased pain due to the facility's failure to administer pain medication as ordered. The resident's care plan lacked pain management interventions, and the prescribed Hydrocodone-acetaminophen was unavailable on several occasions. Despite adjustments to medication orders, the facility did not effectively utilize the emergency medication kit, resulting in unmanaged pain and discomfort.
The facility experienced significant staffing shortages, particularly on weekends, leading to inadequate care for residents. On a specific weekend, only 5 CNAs were available instead of the usual 8-10, resulting in prolonged wait times for assistance and unmet care needs. Residents and staff reported delays in care, with some residents left in soiled conditions and call lights going unanswered for extended periods.
Three residents experienced significant delays in receiving toileting assistance due to inadequate staffing, particularly on weekends. One resident, with multiple health issues, was left in a state of incontinence for hours, while another resident, who requires moderate assistance, chose not to use the call light due to known delays. A third resident, with severe cognitive impairment, was found by a family member lying in urine, prompting a grievance. Staff confirmed the staffing shortages and the resulting care delays.
A facility failed to timely acquire medication refills, resulting in missed doses for three residents. One resident did not receive their anxiety medication due to a clerical error with a DEA number. Another resident experienced significant pain due to unavailable pain medication, and a third resident missed a crucial diabetic injection. The facility's medication refill procedures were not followed, leading to these deficiencies.
A resident experienced a significant weight loss of 16.8% over six months due to the facility's failure to follow therapeutic dietary recommendations. The resident, with multiple diagnoses including dementia and dysphagia, did not consistently receive prescribed supplements, and the dietary system had communication issues preventing proper preparation of these supplements. The resident's weight dropped from 125.8 pounds to 96 pounds, and the comprehensive care plan lacked a focus on nutrition or weight loss.
The facility failed to properly label and store foods, affecting all 100 residents. Observations included gnats around ripe bananas, an improperly stored scoop in the powdered milk bin, and opened, unsealed, and undated cookies, bread, and hamburgers. The facility's Food Storage and Labeling procedure was not followed.
The facility failed to provide high calorie high protein supplements as ordered for four residents. Observations and staff interviews confirmed that the residents did not receive the required dietary supplements due to labeling errors in the dietary system.
A resident with multiple diagnoses reported $100 missing, but the facility failed to report the allegation to the state agency within 24 hours. The Director of Nursing confirmed no investigation was completed, and the Administrator admitted to not reporting the incident after local law enforcement could not substantiate the claim.
The facility failed to investigate a resident's allegation of missing money. Despite the resident being cognitively intact and reporting $100 missing, the facility did not conduct a thorough investigation or report the incident to the Illinois Department of Public Health. The Director of Nursing and the Administrator did not follow the facility's policy for handling such allegations.
The facility failed to provide written notification of the reason for transfer or discharge to two cognitively impaired residents, their representatives, and the Long Term Care Ombudsman. Despite verbal notifications and standard procedures, no written documentation was available for these transfers.
The facility failed to provide written notification of the bed hold policy to the representatives of two cognitively impaired residents upon their transfer to a hospital. Despite documentation indicating the policy was sent with the residents, the representatives did not receive any written notifications. The Director of Nursing confirmed that the policy is only provided to the resident, regardless of their cognitive status, and not sent to the family.
A facility failed to coordinate a PASRR Level II Screening for a resident with major depressive disorder, despite the resident being prescribed Aripiprazole. The Admission Coordinator was unaware of the requirement, and the facility lacked a specific PASRR policy, leading to the oversight.
The facility failed to refer a PASRR Level II Screening for a resident diagnosed with bipolar disorder. The Admission Coordinator was unaware of the requirement, and the facility lacks a specific PASRR policy. The Director of Nursing confirmed the absence of a PASRR screening policy, leading to the identified deficiency.
A resident at high risk for falls experienced a fall while attempting to use the restroom without assistance. Despite the care plan requiring visual cues to remind the resident to use the call light, these cues were not present in the resident's room or bathroom. Staff confirmed the absence of visual cues and were unaware of the requirement, indicating a failure to follow the care plan and implement necessary safety interventions.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and protection from physical abuse for one resident with severe cognitive impairment and a history of trauma, including sexual and other forms of abuse. The resident had diagnoses of dementia, traumatic subdural hemorrhage, cognitive communication deficit, and vascular dementia, and a care plan problem category of mood state documenting major depressive disorder and anxiety. The resident’s Minimum Data Set showed a BIMS score of 4, indicating severe cognitive impairment. Despite this vulnerability and documented history of trauma, the resident remained in a shared room with another cognitively impaired resident who later became physically aggressive. On the date of the incident, the cognitively impaired roommate approached the resident while she was going through her closet and accused her of taking her boyfriend. A verbal argument ensued, during which the resident yelled that she did not want the boyfriend. The roommate then grabbed the resident’s hand and bit it, causing an immediately visible bruise. A bystander resident yelled that someone was fighting, prompting CNAs to run to the room. When staff arrived, the residents were already separated, with the injured resident holding her hand and stating that the roommate had bitten her. Staff observed a crescent-shaped, dark purple to almost black bruise on the palmar surface of the resident’s right hand below the fifth finger, resembling a human bite mark, with a blood blister and lipstick noted around the area; the skin was closed and not broken. Interviews and documentation showed that the incident was characterized as a resident-to-resident altercation and physical assault, with both residents marked as interviewable but unable to make informed decisions. The injured resident repeatedly reported that her right hand was hurting, and staff confirmed the presence of a bruise in the shape of a human bite or crescent moon. The facility’s abuse policy stated that the facility actively prohibits resident abuse and that special attention will be given to identifying behavior that increases a resident’s potential for abusing others or being a victim of abuse. Despite this policy and the resident’s known history of trauma and severe cognitive impairment, the facility failed to prevent the physical abuse that occurred when the roommate bit the resident’s hand, resulting in a bruise.
Failure to Follow Pressure Ulcer Orders and Implement Off-Loading Interventions
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and implement ordered pressure-injury prevention and treatment interventions for multiple residents at risk for, or with, pressure ulcers. One resident with intact cognition, decreased mobility, diabetes, incontinence, and a documented risk for pressure sores had care plan interventions for pressure reduction devices, turning and repositioning assistance, incontinence care after each episode, and ordered treatments including skin prep to bilateral heels, Triad cream and dressings to shearing on the buttocks and coccyx, antifungal powder to moisture-associated skin damage of the genital area, and off-loading boots. Despite these orders, the resident reported that staff did not reposition him in the recliner and only sometimes repositioned him in bed, especially at night only when he asked. Surveyors observed that off-loading boots were not in place on multiple occasions, and no skin prep was applied to the heels during a treatment observation. The resident was found with three open, bleeding areas on the buttocks and intergluteal cleft, consistent with stage II pressure ulcers, and with extensive redness and flaky skin over the buttocks. During observed peri care and wound treatment for this resident, CNAs and nursing staff did not have dressings in place on the buttock wounds prior to care, and the wounds were not listed on the facility’s Wound Summary Report. The DON stated that she believed these areas were “shears” and therefore not measured or included on the wound log, and that such areas were monitored only through weekly skin notes. Weekly skin assessments documented ongoing bilateral shearing to the buttocks with bleeding at times and boggy heels with treatment applied, but the wounds were not formally entered into the wound management system until after surveyor identification. The DON also acknowledged there was no facility policy for turning and repositioning and that staff did not document turning and repositioning, instead stating they “just follow the standard” of every two hours. The resident reported not receiving showers due to the sores on his buttocks and stated he could not reposition himself in bed or chair, and that staff did not routinely reposition him in the recliner. A second resident, cognitively intact and dependent or requiring substantial assistance for transfers and bed mobility, had documented risk for pressure ulcers, boggy heels, and physician orders and care plan interventions for skin prep to bilateral heels twice daily and off-loading boots to both lower extremities twice daily. The Wound Summary did not list this resident’s boggy heels, although progress notes documented bilateral boggy heels on several dates with sure-prep applied and no open areas. Surveyors repeatedly observed the resident without off-loading boots while in a wheelchair and in bed, with very red heels and one heel described by an RN as very soft, boggy, and non-blanchable. The resident stated that staff did not offer or attempt to apply the boots, that she could not put them on herself, and that she had only ever seen one boot, which was found in her closet; staff and the resident’s daughter reported not seeing boots in use. A third resident with dementia, diabetes, decreased mobility, and documented unstageable pressure injuries to the left heel and buttocks had care plan and physician orders for off-loading boots twice daily, pressure-reducing devices in bed and wheelchair, and specific wound treatments to the left heel and buttocks. The facility’s Wound Summary showed an unstageable pressure ulcer to the left heel that was not present on admission and was improving in size. However, surveyors observed this resident multiple times in bed and in a wheelchair without an off-loading boot on the affected foot; at one point, the wrapped left heel was resting directly on the metal wheelchair foot pedal. The resident reported that she sat in the wheelchair all day on some days, was not repositioned in the wheelchair, and that staff did not apply a large boot to her foot. The wound clinic NP later stated that the resident had never had the off-loading boot on during clinic visits and that the resident reported staff told her she did not need it anymore, despite the NP’s belief that the boot was needed to aid healing and prevention. Across these residents, the facility did not consistently implement or document ordered off-loading boots, heel protection, and turning/repositioning for residents at risk for or with existing pressure injuries. The DON confirmed that staff were expected to apply off-loading boots and follow physician orders but acknowledged that some residents refused and that nurses had “a lot to learn.” The physician and NP both stated they expected staff to follow orders and that off-loading boots help prevent and heal heel wounds. The facility’s Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol required assessment of high- and moderate-risk residents for heel protectors and bridging of heels, yet residents with boggy heels and pressure injuries were observed without ordered off-loading devices in place, and some wounds were not entered into the wound summary for ongoing monitoring.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s need for access to a call light. The resident had chronic atrial fibrillation, osteoarthritis, anemia, essential hypertension, a history of TIA, and sleep apnea, and was assessed with a BIMS score of 15 indicating intact cognition. The MDS documented that the resident was dependent on staff for sit-to-stand, chair/bed-chair transfers, and toilet transfers, and required substantial/maximal assistance for bed mobility. The care plan identified the resident as at risk for falls and included interventions to instruct the resident to call for assistance before getting out of bed or transferring, and to orient the resident to the room and use of the call light system. On multiple observations, the resident was seen sitting in a wheelchair at the back of the room, several feet away from the call light, which was tied to the left bed rail and could not reach the resident’s preferred seating location. CNAs confirmed that the resident routinely sat in that spot, that the call light did not reach there, and that the resident pushed herself backward in the wheelchair but had difficulty moving forward. The DON acknowledged the resident sat in that location and was unsure if the call light would reach. The resident reported that she could push herself back but had trouble moving forward due to slick shoes, and that when she needed help she would try to get to the call light, call her daughter, or go to the doorway and yell for staff. The resident’s daughter confirmed the resident frequently sat by the window, struggled to propel herself forward, and often called her when she could not reach the call light, and stated she was concerned that the call light did not reach where the resident sat.
Failure to Follow Standard Precautions During Peri and Incontinence Care
Penalty
Summary
The deficiency involves failure to implement standard precautions during incontinence and peri care for one resident. The resident had intact cognition, multiple chronic conditions including chronic atrial fibrillation, osteoarthritis, anemia, essential hypertension, history of TIA, and sleep apnea, and was dependent on staff for transfers and toileting, with occasional bladder and bowel incontinence and a history of UTIs. During early morning care, a CNA provided peri care while the resident was side-lying, removed a urine-soaked brief and pad with strong urine odor, and began cleaning the buttocks with disposable wipes. After each use, the CNA threw the soiled wipes onto the floor. The CNA left the room to obtain a clean pad without removing gloves or performing hand hygiene, used the same contaminated gloves to open the door and access the clean linen cart, then returned and changed gloves without hand hygiene between glove changes. The CNA again left the room wearing gloves to obtain assistance, returned with another CNA, and continued care. Soiled wipes, the saturated brief, and the soiled bed pad were repeatedly thrown onto the floor, causing urine to splash onto the floor when the brief landed. After completing peri care and repositioning the resident, the CNA gathered the soiled items from the floor, bundled the used wipes and brief together, folded the soiled bed pad, and carried it under his arm with the contaminated surface touching his uniform. He then left the room still wearing the same gloves, disposed of the trash and linen, and handled the lids of the trash and soiled linen containers before finally removing his gloves and washing his hands at the end of the hall. Another CNA and the DON both confirmed that placing soiled items on the floor and wearing the same gloves from resident care into the hall and to the clean linen cart were not consistent with facility policy, which requires standard precautions including hand hygiene, proper PPE use, environmental care, linen handling, and waste disposal.
Shower Chair Deficiency Leads to Resident Injury
Penalty
Summary
The facility failed to maintain a shower chair in a safe condition, resulting in a resident's foot getting caught in the rubber strips of the chair, causing a nondisplaced spiral fracture of the right tibia. The resident, who was unable to complete a mental status interview and had impairments in both upper and lower extremities, was dependent on staff for showering and transfers. During a transfer to the shower room, the resident's foot slipped through the slats of the footrest, and a CNA heard a pop in the resident's ankle, leading to the injury. The incident occurred when two CNAs were pushing the resident in a shower chair to the shower room. The resident screamed in pain, and upon inspection, it was found that the foot had slipped through the rubber strips of the chair. Despite attempts to free the foot, a pop was heard, indicating a fracture. The resident was subsequently sent to the emergency room for evaluation and treatment of the fracture and a skin tear on the shin. The facility's investigation revealed that the rubber strips on the shower chair were stretched out and loose, which contributed to the incident. The maintenance director confirmed that the rubber strips were loose and stretched out, and the chair was taken out of use until it could be repaired. The facility's policy required regular equipment checks, but the maintenance director admitted that bathroom equipment was only checked on an as-needed basis, which may have contributed to the oversight.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, affecting all 111 residents. Multiple residents reported delays in receiving assistance with toileting and incontinence care, which are critical for their health and well-being. For instance, one resident, R3, who is cognitively intact and requires assistance due to cerebral infarction and hemiplegia, reported frequent incontinence and delays in receiving care, leading to discomfort and potential health risks. Another resident, R8, also cognitively intact, experienced similar issues, noting that timely incontinence care was not provided, contributing to ongoing skin issues. The report highlights several instances where residents had to wait extended periods for assistance, as evidenced by call light response times. R10, who is moderately cognitively impaired and requires assistance for various activities, reported waiting over an hour for help, resulting in a sore bottom due to delayed incontinence care. Similarly, R6 and R12 expressed frustration with the call light system, indicating that they often had to wait too long for assistance, sometimes resorting to self-care, which could lead to falls or other injuries. Staff interviews corroborated the residents' complaints, with CNAs and the Director of Nursing acknowledging staffing shortages, particularly on weekends. The facility was unable to provide consistent documentation to verify adequate staffing levels during the reported period. This lack of sufficient staffing and the inability to provide timely care and assistance to residents constitute a significant deficiency in the facility's operations.
Delayed Call Light Response Affects Resident Care
Penalty
Summary
The facility failed to respond to call lights in a timely manner, affecting the dignity and care of four residents. Resident R10, who is moderately cognitively impaired and requires assistance for various activities, reported long wait times for call light responses, particularly in the evenings. Documentation showed multiple instances where R10's call light was not answered for extended periods, including one instance where the response time was over an hour. R10 expressed that the delay in response led to inadequate incontinence care, resulting in a sore bottom. Resident R6, who is cognitively intact but requires assistance with daily activities, also reported difficulties in getting timely help. R6 mentioned being left in the bathroom for extended periods and experiencing inconsistent response times to call lights. The incident list confirmed delays in response times, with one instance lasting over thirty minutes. R6's care plan emphasizes the need for assistance to prevent falls, yet the delays in response compromise this intervention. Resident R3, who is cognitively intact and has a history of cerebrovascular accident, reported that there are times when no CNA is assigned to their hallway, especially on weekends. R3 stated that call light response times are inconsistent, and sometimes staff turn off the call light without returning. R12, who is also cognitively intact and recently admitted, echoed similar concerns, stating that call lights are often not answered promptly, leading her to take herself to the bathroom. The Director of Nursing acknowledged the issue, stating that call lights should be answered within 15 minutes, but this expectation is not consistently met.
Deficiencies in ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for four residents, leading to deficiencies in care. Resident 1, who was admitted for a short stay, was noted to have received only one shower during her five-day stay, despite her care plan indicating she should have showers on specific days. Concerns were raised by her power of attorney about her appearance, but staff assured that her needs were being met. However, there was a discrepancy in staff accounts regarding the provision of showers. Resident 3, who is cognitively intact and requires assistance due to hemiplegia and other mobility issues, reported not receiving timely assistance for toileting and incontinence care. She expressed frustration with inconsistent call light response times, which sometimes resulted in her being left incontinent for extended periods. Her care plan indicated she should be checked every two hours, but this was not consistently happening. Resident 8, who is also cognitively intact, had previously filed a grievance about delayed incontinence care and personal hygiene assistance. He noted that while care had improved slightly, staffing shortages, particularly on weekends, continued to impact the timeliness of care. Resident 10, with moderate cognitive impairment, also reported delays in receiving incontinence care, leading to skin issues. A CNA confirmed that night shift care was lacking, and staffing shortages were a recurring issue, especially on weekends and Fridays.
Inadequate Documentation and Involuntary Discharge of Resident
Penalty
Summary
The facility failed to provide adequate documentation by a physician regarding the involuntary transfer or discharge of a resident, identified as R8, who had severe cognitive impairment and a history of behavioral issues. The report highlights that the facility did not document the specific needs of R8 that could not be met, the attempts made by the facility to meet those needs, or the services available at the receiving facility to address R8's needs. Additionally, the facility did not allow R8 to return during the appeal process of the involuntary discharge. R8 had a history of Alzheimer's disease, cognitive communication deficit, and other mental health issues, which contributed to physical and verbal behavioral symptoms. The care plan for R8 included strategies to manage these behaviors, such as encouraging walks and providing emotional support. However, the care plan lacked specific goals or approaches related to R8's Alzheimer's or dementia diagnosis. Staff interviews revealed that there was no clear plan for managing R8's agitation, and the facility's electronic medical records did not contain detailed notes on R8's behaviors or the effectiveness of interventions. The facility's actions led to R8 being discharged to a hospital's acute psychiatric unit without proper documentation or a physician's order for discharge. The facility's Director of Nursing and other staff members acknowledged the lack of detailed documentation and the decision not to allow R8 to return during the appeal process. The facility's policies on memory care and resident transfer were not adequately followed, contributing to the deficiency identified in the report.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate bathing care for a resident, identified as R2, who was dependent on staff for assistance with activities of daily living. R2, who was cognitively intact with a BIMS score of 15, required substantial assistance for bathing as documented in the Minimum Data Set. The care plan specified that R2 should receive showers or whirlpool baths on Mondays, Wednesdays, and Fridays. However, observations and interviews revealed that R2 had not received a shower in over a week, with her hair appearing greasy and unwashed. R2 reported receiving mostly bed baths with moistened wipes instead of the scheduled showers. The facility's policy required at least one complete bath and hair wash weekly, with additional baths as necessary for personal hygiene. Despite this, documentation showed that R2 went 14 days without a shower or bath at one point, and another period of 9 days without a shower or bath. The Director of Nurses stated that the facility's policy was for residents to receive one shower or bath a week, with attempts to reschedule if a resident refused. However, the records indicated a failure to adhere to the care plan and facility policy, resulting in inadequate personal hygiene care for R2.
Failure to Implement Individualized Dementia Care Interventions
Penalty
Summary
The facility failed to reassess and implement individualized interventions for a resident diagnosed with dementia, leading to increased occurrences of combative behaviors. The resident, identified as R8, had a history of Alzheimer's disease, cognitive communication deficit, and other mood disorders. Despite having a care plan in place, the plan did not address R8's diagnosis of Alzheimer's disease or dementia, nor did it provide specific strategies for managing R8's aggressive behaviors. The care plan included general approaches such as encouraging walks and stopping tasks when the resident became agitated, but these were not tailored to R8's specific needs or effective in preventing aggressive incidents. R8 exhibited severe cognitive impairment with a BIMS score of 6 and displayed physical and verbal behaviors towards others, particularly during personal care activities. Staff members reported multiple incidents where R8 became physically aggressive, such as grabbing and punching a CNA during incontinence care. These behaviors were documented in the resident's records, but the interventions attempted, such as redirection and one-on-one attention, were not effective. The facility's documentation lacked detailed notes on the effectiveness of these interventions, making it difficult to update the care plan appropriately. Interviews with staff revealed that there was no clear plan for managing R8's agitation, and staff expressed concerns about the lack of guidance and the need for medication adjustments. The facility's policy emphasized proactive interventions and recognizing stress signs in residents, but these were not effectively implemented for R8. The Director of Nursing acknowledged the absence of detailed behavior notes, which hindered the ability to update the care plan and address R8's needs adequately.
Resident's Dignity Compromised Due to Delayed Call Light Response
Penalty
Summary
The facility failed to respond to call lights in a timely manner, compromising the dignity and care of a resident, R1, who was part of a sample of seven residents reviewed for dignity. R1, who was admitted with multiple diagnoses including Multiple Sclerosis and anxiety disorder, required substantial assistance with daily activities such as toileting and transfers. On the morning of August 11, 2024, R1 activated the call light for assistance to use the bathroom but was left waiting for hours, resulting in her being soaked in urine and experiencing feelings of desertion, fear, frustration, and embarrassment. Interviews with staff and review of call light logs confirmed that R1's call light was activated for over an hour before assistance was provided. The Occupational Therapist Assistant, who eventually helped R1, reported that the resident was found crying and soaked through her clothes and bedding. The facility's call light log corroborated the delay, showing a duration of over an hour for R1's call light on the day in question. Staff members, including CNAs and LPNs, acknowledged the severe staffing shortages on that day, which contributed to the delayed response to call lights and inadequate care. The facility's administrator and other staff members admitted awareness of the staffing issues, particularly on weekends, which had been ongoing for several months. Despite receiving grievances about the care provided on August 11, 2024, the facility struggled to maintain adequate staffing levels, resulting in compromised care for residents like R1. The administrator confirmed that the staffing on that day was not preferred and acknowledged the grievances received regarding the care issues.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered and develop interventions to manage pain for a resident, resulting in increased pain due to missing four doses of ordered pain medication. The resident, who was cognitively intact, had a history of encephalopathy, end-stage renal disease, low back pain, and other conditions. Despite being on a scheduled pain medication regimen, the resident experienced significant pain, particularly after a fall, and reported that the pain medication was not administered timely, causing prolonged periods of severe pain. The resident's care plan did not address pain management, and the facility's Medication Administration Record indicated that the prescribed Hydrocodone-acetaminophen was unavailable on several occasions. The resident's pain was documented as severe, with scores ranging from 6 to 9 on a 10-point scale, and the resident expressed that the pain was not adequately controlled with the available medications. The facility's Director of Nursing acknowledged that the resident ran out of pain medications and was only given Tylenol, which was insufficient for managing the resident's chronic back pain. The Nurse Practitioner involved was aware of the resident's increased pain and had adjusted the medication orders accordingly. However, there were instances when the facility ran out of the prescribed medication, and the emergency medication kit was not utilized effectively to provide alternative pain relief. The facility's policy on pain management emphasized the importance of individualized care plans, which was not implemented in this case, leading to the resident's unmanaged pain and discomfort.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to meet the needs of its residents, particularly on the weekend of 8/11/2024. Multiple residents reported inadequate care due to staffing shortages, with some residents experiencing prolonged wait times for assistance. For instance, one resident was left in a soiled state for an extended period, and another resident's call light went unanswered for over an hour. These incidents were corroborated by family members and staff, who noted that the facility was significantly understaffed, especially on weekends. Staff interviews revealed that the facility typically operates with 8-10 CNAs on weekends, but on 8/11/2024, only 5 CNAs were present. This shortage was exacerbated by call-ins and no-shows, leaving some halls with only one CNA to care for numerous residents. The Director of Nursing acknowledged the staffing issues and the resulting delays in care, admitting that the situation was not acceptable and that residents were not adequately tended to. The facility's call light log confirmed extended wait times, with one resident's call light remaining active for over an hour. Staff members, including CNAs and LPNs, reported struggling to provide timely care due to the insufficient number of staff. The facility's administrator and other management personnel were aware of the staffing issues but were unable to rectify the situation promptly, leading to substandard care for the residents on that day.
Inadequate Staffing Leads to Delayed Care and Resident Distress
Penalty
Summary
The facility failed to provide timely toileting assistance to three residents, leading to significant distress and discomfort. Resident 1, who has multiple diagnoses including Multiple Sclerosis and requires substantial assistance with toileting, reported being left in a state of incontinence for several hours due to unresponsive call lights. The resident expressed distress over the situation, noting that the staffing was particularly low on weekends, which contributed to the delay in receiving care. An Occupational Therapist Assistant confirmed the prolonged wait time and the resident's condition upon finally receiving assistance. Resident 3, who is cognitively intact but requires moderate assistance for toileting, also experienced delays in care. The resident reported that the care is generally adequate but noted that the past weekend was particularly challenging due to staffing shortages. The resident chose not to use the call light, aware of the existing delays, and instead waited for the staff to assist him as part of the routine morning care. This indicates a systemic issue with staffing levels, particularly on weekends, affecting the timeliness of care. Resident 5, who has severe cognitive impairment and is dependent on staff for toileting, was found by a family member to be lying in urine, prompting a grievance. The family member expressed frustration over the persistent staffing issues and had to hire a private sitter to ensure adequate care. The CNA Supervisor and other staff members corroborated the reports of inadequate staffing, particularly on the day in question, which led to delayed care and unmet needs for the residents. The facility administrator acknowledged the staffing issues and the grievances received regarding the care provided.
Medication Refill Delays Lead to Missed Doses for Residents
Penalty
Summary
The facility failed to acquire medication refills in a timely manner, resulting in missed doses for three residents. Resident 1, who has multiple diagnoses including generalized anxiety disorder, did not receive their prescribed Dextroamphetamine-amphetamine (Adderall) on two occasions due to the medication being unavailable. The Director of Nursing acknowledged the issue, citing a clerical error with the Nurse Practitioner's DEA number as a contributing factor. The resident expressed distress over not receiving their anxiety medication and other necessary prescriptions. Resident 2, who suffers from chronic back pain among other conditions, experienced delays in receiving their prescribed Hydrocodone-acetaminophen. The resident reported significant pain due to the unavailability of the medication, which was documented as being out of stock on several occasions. The Director of Nursing confirmed that the resident had to be given Tylenol instead, as the facility ran out of the prescribed pain medication. Resident 3, diagnosed with type 2 diabetes mellitus, did not receive their scheduled Trulicity injection due to the medication being unavailable. The resident expressed concern over missing their diabetic medication, which is crucial for their condition. The pharmacist confirmed that the refill request was received late, and the medication was not available at the time it was due. The facility's policy and procedural manual outlines the process for medication refills, which was not adhered to, leading to these deficiencies.
Failure to Follow Dietary Recommendations Leads to Significant Weight Loss
Penalty
Summary
The facility failed to follow therapeutic dietary recommendations for a resident at risk for weight loss, resulting in a significant weight loss of 16.8% over six months. The resident, who has diagnoses including unspecified dementia, dysphagia, anxiety disorder, and cognitive communication deficit, was on a mechanical soft, high calorie/high protein (HCHP) diet. Despite this, the resident reported not consistently receiving the prescribed fortified milk, egg/tuna salad, or hard-boiled eggs. Observations confirmed that the resident's meal did not include fortified milk, and the resident's comprehensive care plan lacked a focus area for nutrition or weight loss. The facility's dietary system had issues with communication between two computer programs, leading to the failure of generating labels for dietary staff to prepare the necessary supplements. The Registered Dietitian (RD) noted significant weight loss and recommended additional supplements, but these were not consistently provided. The dietary supervisor acknowledged the system issue, and the RD confirmed that residents with HCHP supplements should receive them at all meals. The physician also expected that supplements would be provided to prevent weight loss. The resident's weight records showed a decline from 125.8 pounds to 96 pounds over the specified period, and the resident had a history of poor meal intake and pressure ulcers.
Improper Food Labeling and Storage
Penalty
Summary
The facility failed to properly label and store foods, which has the potential to affect all 100 residents residing in the facility. During an initial tour of the kitchen, multiple deficiencies were observed: a case of bananas in the dry storeroom had multiple gnats swarming around the ripe fruit; the bulk powdered milk bin had a scoop with the handle touching the food source; a bag of cookies and a loaf of bread were found opened, unsealed, and not dated in the dry storeroom; and hamburgers were found opened, unsealed, and not dated in the freezer. The facility's Food Storage and Labeling procedure, revised in 9/22, requires all food to be covered in a resealable bag or container, or the original container if applicable, and labeled with the product name, date, and discard date.
Failure to Provide Prescribed Dietary Supplements
Penalty
Summary
The facility failed to provide high calorie high protein supplements as ordered for four residents (R14, R23, R26, and R246) reviewed for therapeutic diets. For R246, who has a diagnosis of End Stage Renal Disease and is cognitively intact, the facility did not provide the prescribed high calorie supplement and high protein snack. Despite the dietary card indicating specific dietary restrictions and supplements, R246 was served regular meals without the required supplements. Interviews with dietary staff and CNAs confirmed that R246 did not receive the high calorie supplement or high protein snack due to a labeling error in the dietary system. R26, who has severe cognitive impairment and a diagnosis of unspecified protein-calorie malnutrition, was also not provided with the prescribed high calorie high protein supplement and extra gravy. Observations during meal times showed that R26 was served regular mechanical soft diets without the extra gravy or supplements. Family members and CNAs confirmed that R26 did not receive the required dietary supplements, and the dietary supervisor acknowledged a labeling error that prevented the supplements from being provided. R14, who is cognitively intact and has diagnoses including chronic kidney disease, did not receive the prescribed high calorie high protein supplement and extra protein at meals. Despite the meal ticket indicating the need for extra protein, R14 was served regular meals without the additional protein. Similarly, R23, who has moderate cognitive impairment and diagnoses including Alzheimer's Disease and chronic kidney disease, did not receive the fortified whole milk and fortified pudding as prescribed. Observations and staff interviews confirmed that R23 was not provided with the required supplements due to a failure in the dietary labeling system.
Failure to Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency within 24 hours. A resident with diagnoses including dementia, insomnia, bipolar disorder, anxiety disorder, depression, and hypothyroidism reported $100 missing from her belongings. The resident's Minimum Data Set (MDS) indicated she was cognitively intact, but her care plan noted she often misinterprets staff's intentions and has delusional episodes. The incident was documented in a Loss Control/Damage Report, but the money was never found, and no formal investigation was completed by the facility. Interviews revealed that the resident had informed the Activities Director about her missing money, but the Director was unaware of the allegation. The Director of Nursing confirmed that no investigation was completed and that the Administrator was responsible for reporting such incidents to the Illinois Department of Public Health (IDPH). The Administrator admitted to being aware of the allegation but did not report it to IDPH after local law enforcement could not substantiate the claim. This failure to report was acknowledged as a lapse in protocol by the Administrator.
Failure to Investigate Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of misappropriation of resident property for one resident. The resident, who was cognitively intact with a BIMS score of 15, reported $100 missing from her belongings. The facility's documentation indicated that the money was last observed on 5/19/24 and discovered missing on 5/21/24. Despite the resident's report, the facility did not conduct a comprehensive investigation as required by their Abuse Prohibition and Reporting policy. The Director of Nursing confirmed that no investigation was completed, and the Administrator admitted that the allegation was reported to local law enforcement but not to the Illinois Department of Public Health (IDPH) due to insufficient evidence. Additionally, the Social Services Director noted that staff had not seen the resident with money, and the Activities Director was unaware of the missing money allegation. The facility's policy mandates interviews with all involved parties, obtaining signed statements, and maintaining documentation of the investigation. However, these steps were not followed. The Director of Nursing and the Administrator failed to produce any investigation documentation, and the Administrator did not supervise the investigation or report the results to IDPH. The lack of a thorough investigation and proper reporting constitutes a deficiency in the facility's handling of the resident's allegation of missing money.
Failure to Provide Written Notification for Transfers
Penalty
Summary
The facility failed to provide written notification of the reason for transfer or discharge to residents, their representatives, and the Long Term Care Ombudsman office for two cognitively impaired residents. Resident 39, who had severe cognitive impairment and multiple medical conditions, was transferred to the hospital on two occasions without written notification being provided to the resident or their Power of Attorney (POA). Despite requests for documentation, the Director of Nursing (DON) was unable to present any written notifications for these transfers, and the POA confirmed that no written notifications were received. Similarly, Resident 93, who was alert only to person and had a family member as their responsible party, was transferred to the hospital for shortness of breath. Although the family member was notified via phone, there was no documentation to show that written notification was provided. The DON and Medical Records staff confirmed that while the bed hold policy is typically sent with the resident's paperwork to the hospital, there were no records available to show that written notifications were sent to the family or the Ombudsman for this hospitalization.
Failure to Provide Written Notification of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to the resident representatives for two cognitively impaired residents, R39 and R93, upon their transfer to a hospital. R39, who has severe cognitive impairment and multiple diagnoses including heart failure and dementia, was transferred to the hospital on two occasions. Despite the facility's documentation that the bed hold policy was sent with the resident, R39's POA stated she did not receive any written notifications regarding the bed hold policy. The Director of Nursing confirmed that the facility only provides the bed hold policy to the resident upon transfer, regardless of their cognitive status, and does not send written documentation to the family. Additionally, the facility was unable to present evidence of the requested documents for R39's transfers when asked by the surveyor. This indicates a failure to comply with the requirement to notify the resident's representative in writing about the bed hold policy during transfers to the hospital. R93, who is alert only to person, was transferred to the hospital for shortness of breath, and the responsible party was notified via phone. However, the Director of Nursing again confirmed that the bed hold policy is only provided to the resident upon transfer and not sent to the family. The Medical Records staff stated that the form is filled out and mailed to the family, but no records were available to show that this occurred for R93's hospitalization. This further demonstrates the facility's failure to provide the required written notification of the bed hold policy to the resident's representative.
Failure to Coordinate PASRR Level II Screening
Penalty
Summary
The facility failed to coordinate a PASRR Level II Screening for a resident (R53) who was admitted on 7/31/2023 with a diagnosis of major depressive disorder. Despite the resident being prescribed Aripiprazole for major depressive disorder starting on 9/01/2023, the facility did not complete the necessary PASRR Level II Screening. The resident's PASRR Level I Screen Outcome dated 4/12/2019 indicated no suspicion of developmental disability or mental illness, and the Minimum Data Set (MDS) admission assessment did not consider the resident to have serious mental illness or intellectual disability. However, the resident's condition and medication indicated otherwise, necessitating a Level II Screening which was not performed. The Admission Coordinator (V4) admitted to not being aware that the resident required a PASRR Level II Screening and stated that the electronic PASRR system did not notify her of this requirement. The resident's stay, initially intended for respite care, extended beyond a few days, but the necessary screening was not initiated. Both the Admission Coordinator and the Director of Nursing (V2) confirmed that the facility lacked a specific PASRR policy. The facility's existing policy on Pre-Admission, Admission, and Orientation of Residents, revised on 6/1/2022, mandates pre-screening by the Department of Aging or other State Agency, but this was not adhered to in this case.
Failure to Refer PASRR Level II Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to refer a PASRR Level II Screening for a resident diagnosed with bipolar disorder, current episode hypomanic. The resident's initial admission to the facility was documented on 4/16/24, and the PASRR Level I Screen Outcome dated 3/22/2023 indicated that no Level II was required. However, the Minimum Data Set (MDS) Admission assessment documented the resident's active diagnosis of bipolar disorder, which should have triggered a Level II PASRR screening. The Admission Coordinator was unaware that the resident needed a PASRR Level II and stated that the electronic PASRR system did not notify her of this requirement. Additionally, the facility does not have a specific PASRR policy in place. The Director of Nursing confirmed that the facility lacks a specific PASRR screening policy. The facility's Pre-Admission, Admission, and Orientation of Residents policy, revised on 6/1/2022, states that all residents should be pre-screened by the Department of Aging or other State Agency, and the Admissions Director should ensure that the screening form is placed in the electronic medical record. Despite this policy, the facility failed to complete the necessary PASRR Level II screening for the resident with a serious mental illness diagnosis, leading to the identified deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident identified as high risk for falls. The resident, who is cognitively intact and requires partial assistance for toilet transfer, experienced a fall while attempting to use the restroom without assistance. Despite the care plan including visual cues to remind the resident to use the call light, these cues were not present in the resident's room or bathroom. Staff members, including CNAs and an LPN, confirmed the absence of visual cues and were unaware that such interventions were required for the resident. The resident's care plan documented the need for visual cues after a fall incident, but these were not implemented. The resident confirmed the absence of reminders to use the call light, and staff verified that visual cue cards, which should say 'Stop. Press Call Button' in red letters, were not placed as required. This oversight indicates a failure to follow the care plan and implement necessary safety interventions for a high-risk resident, leading to a deficiency in accident prevention and supervision.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 177 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carbondale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Integrity Hc Of Carbondale | 0.4 mi | ★★★★★ | 13 | 0 |
| Helia Healthcare Of Energy | 12.9 mi | ★★★★★ | 32 | 1 |
| Integrity Hc Of Herrin | 13.8 mi | ★★★★★ | 2 | 0 |
| Shawnee Senior Living | 13.9 mi | ★★★★★ | 5 | 0 |
| Integrity Hc Of Cobden | 14.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.