Integrity HC of Carbondale: Transfer Notice Failures - IL
The resident, identified in inspection records as R25, was transferred from Integrity HC of Carbondale to a sister facility roughly 20 miles away in September 2025, after management determined sewer repairs required moving residents out of the building. A progress note from the former administrator, dated September 11, documented that R25's power of attorney was called that day to discuss the move. R25 left the next morning.
When an inspector observed R25 in the dining room of the new facility on September 16, she was alert and remembered the transfer. She said she was told verbally that she was moving, on the day she left. "They packed my bags and away we went," she said. She said no one told her it was an emergency. She said she didn't remember any kind of discharge planning meeting.
R25's care plan had no transfer or discharge focus area, and the existing focus areas had no initiation dates.
A second resident, R24, had been admitted to the facility in February 2022 with generalized anxiety disorder and an intellectual disability. His most recent cognitive assessment gave him a score of 2 out of 15, indicating severe impairment. His care plan, last updated in March 2025, documented that he had no plans for discharge and would remain at the facility long-term. Nothing in the care plan was revised before his transfer. A note entered Sunday, September 14, by the facility's MDS and care plan coordinator, documented that R24's guardian was called that morning to discuss the move.
The inspection, completed October 9, 2025, cited the transfers as causing actual harm. R25's care plan had identified her cognitive impairment and noted the importance of keeping her routine consistent, with familiar caregivers, to reduce confusion. The facility moved her anyway, the same day her family was called, with her bags packed and no paperwork in hand.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
INTEGRITY HC OF CARBONDALE in CARBONDALE, IL was cited for violations during a health inspection on October 9, 2025.
A progress note from the former administrator, dated September 11, documented that R25's power of attorney was called that day to discuss the move.
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.