Integrity HC of Carbondale: Discharge Planning Failures - IL
That is how a resident identified in inspection records as R25 described her transfer out of Integrity HC of Carbondale, a nursing home on North Tower Road that federal inspectors visited on October 9, 2025, following a complaint. What they found was rated as causing actual harm to residents.
The facility had been dealing with what staff described as extensive sewer repairs. The solution, according to inspection records, was to move residents to other facilities while the work was completed. What the facility did not do, inspectors found, was plan those moves in any meaningful way, notify residents in writing, or hold discharge planning meetings before sending people out the door.
R25 said she was told the building needed work. She was not told it was an emergency. She did not remember any kind of meeting.
The second resident identified in the inspection report, R24, had been living at the facility since February 2023. His diagnoses included generalized anxiety disorder and unspecified intellectual disabilities. A cognitive assessment documented in his records gave him a score of 2 on the Brief Interview for Mental Status, a result that indicates severe cognitive impairment. His care plan noted that he needed assistance with all decision making, that staff should keep his routine consistent and try to provide consistent caregivers in order to decrease his confusion.
R24's care plan also contained a section devoted specifically to discharge. It was direct about his situation: he had no plans for discharge and would reside at the facility for long-term care. The intervention attached to that section called for regular meetings with R24 or his representative to discuss discharge planning and for staff to give him the opportunity to express any thoughts or feelings. That section had been in place since March 2025. Inspectors found no updates to it, no revisions, nothing to indicate the interdisciplinary team had done any planning for a transfer to another facility.
The first documented sign that a transfer was coming appeared in a progress note entered on a Sunday morning, September 14, 2025, at 9:00 a.m. The note was written by the facility's MDS and care plan coordinator, who recorded a conversation with R24's guardian, identified as a family member, about the need to move residents temporarily because of the sewer repairs. The note referenced choices of available facilities.
That was it. A Sunday morning phone call to a guardian, logged in a progress note, for a man whose own care plan said he needed help with every decision, required consistent routines to function, and was not supposed to be going anywhere.
The inspection report rated the violation under F0627, which covers the right to return to a facility and discharge planning requirements, at a level of actual harm affecting some residents.
What the records do not contain is any evidence that the facility held a discharge planning meeting before moving R24. His care plan, which had been in place for months and explicitly addressed his long-term placement at the facility, was never updated to reflect that a transfer was being planned. The intervention calling for regular meetings to discuss discharge went unexercised. The instruction to give him an opportunity to express his thoughts and feelings, written into his own plan of care, went unmet.
R25 described the experience plainly. They told her the building needed work. Nobody told her it was an emergency. She doesn't remember any meeting. They packed her bags.
For a man with a BIMS score of 2, severe cognitive impairment, anxiety, and a care plan built around the premise that consistency was essential to his wellbeing, the question of what he understood about what was happening to him, and whether anyone sat down with him or his guardian before it happened, is left unanswered in the inspection record.
The facility's plan of correction was not included in the documents reviewed for this article.
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: July 21, 2026 · Our methodology
INTEGRITY HC OF CARBONDALE in CARBONDALE, IL was cited for violations during a health inspection on October 9, 2025.
What they found was rated as causing actual harm to residents.
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.