Integrity HC of Carbondale: Broken Toilet Left Resident - IL
The resident, identified in inspection records only as R40, was placed in a room at Integrity HC of Carbondale where the toilet had not functioned properly since at least the beginning of August 2025. The bathroom door on her side was secured with a padlock. Staff gave her a bedside commode instead.
The commode was not enough.
A nursing assistant who started at the facility in early August told inspectors she witnessed R40's confusion from her first days there. R40 couldn't reliably find or use the commode, and would end up urinating on the floor. Once, the aide said, R40 urinated in the corner of her room and used her wig to clean it up.
A second nursing assistant described a night R40 wandered into the adjoining room searching for a bathroom. The two rooms shared a connected bathroom, and while the door was padlocked on R40's side, it was accessible from the neighboring room. R40 found her way in from that direction and defecated and urinated onto a plastic cover that had been placed over the non-functioning toilet. The same aide said R40 also defecated in her own closet on a separate occasion.
The facility's own progress notes confirmed what staff described. A note from August 12 recorded that R40 had "deficated in her closet this afternoon. Area cleaned." A note from August 31 documented staff assisting R40 to the bathroom because "she gets lost finding it and unable to see where she is going." A note from September 12 recorded that R40 had been "incontinent of urine x 1 on the floor," adding that her "poor eyesight" meant she didn't always see the toilet and needed assistance with toileting.
None of those notes prompted a room change.
R40 was not moved to a room with a working bathroom until sometime before the inspection. Both nursing assistants told inspectors that once she was relocated to the North Hall, where the bathroom functioned properly, she used it without incident and had not urinated or defecated on the floor or in a closet since.
The facility's maintenance supervisor told inspectors the broken plumbing would be addressed when the plumbing company came to deal with kitchen issues.
The former administrator, interviewed on September 22, said she wasn't aware R40 had been urinating on the floor or couldn't find the bathroom. She acknowledged R40 probably should have been moved sooner and that other rooms with working toilets had been available.
The inspection was completed October 9, 2025, following a complaint. The deficiency was cited at a level of minimal harm or potential for actual harm.
R40's condition made the situation harder for her to escape on her own. Progress notes describe a woman who was alert but confused, frequently redirected away from other residents' rooms, and struggling with vision so poor she couldn't identify objects until they were directly in front of her. She needed staff assistance with nearly all daily activities. She was not someone who could advocate her way into a different room.
For at least six weeks, documented in the facility's own records, she lived in a room with a padlocked bathroom and managed as best she could.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Integrity Hc of Carbondale from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
INTEGRITY HC OF CARBONDALE in CARBONDALE, IL was cited for violations during a health inspection on October 9, 2025.
The bathroom door on her side was secured with a padlock.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.