Integrity HC of Carbondale: Transfer Notice Failures - IL
Her name is not in the inspection report. She is identified only as R22. She is her own responsible party, meaning no family member makes decisions on her behalf. She was found in her room at the new facility three days after the transfer, able to speak for herself, and that is what she said.
Integrity HC of Carbondale, a nursing home at 120 North Tower Road, transferred R22 and other residents to a sister facility in September 2025 without providing the 30-day written transfer notice her record required. Federal inspectors who reviewed the case found no evidence the notice was ever given. The inspection was completed October 9, 2025.
The building's problems had been mounting for months. The Chief Executive Officer, identified in the inspection report as V13, told inspectors on September 17 that the local health department had shut down the facility's kitchen a month or two before the transfers began. The CEO said the facility had considered an emergency closure at that point but didn't want to do that to the residents.
Then came the plumbing.
A plumbing company told facility management that a collapse of the cast iron pipes could be catastrophic. A second company was brought in to do the most recent repair work, but that company needed all residents out of the building before it could even assess the full scope of what it was dealing with. As of September 17, nineteen residents were still inside.
The facility's own account of how it handled the transfers is, by any reading, a description of decisions made in reverse order. The Assistant Director of Nursing, identified as V3, told inspectors she couldn't remember the exact day, but believed management told staff during a morning meeting that residents needed to transfer due to repairs, maybe a few days to a week before she started making calls to families. She said making those calls was more of the last thing they did before transferring residents out.
R22's transfer was documented in her medical record. On September 10, the ADON noted she had been told about the move and was agreeable. Her power of attorney was also notified and agreeable. The transfer was set for Saturday at 2 p.m. On September 13, she was moved to the sister facility by bus, accompanied by certified nursing assistants. The record showed all of that. What it did not show was any 30-day written notice.
When inspectors raised the rushed nature of the moves with the CEO, his response was direct. "So what you are saying is we basically should have done this as an emergency evacuation," he said.
He also said the facility had searched for regulations that would prohibit what they were doing and found nothing. He said he believed they were doing what was right with the temporary relocation. He said the plan was not to permanently close the facility and that residents would be allowed to return once repairs were complete.
Whether residents were told the same thing is a different question. R22 said she was told she would be able to go back when repairs finished. She said she understood that. But she also said she received nothing in writing, and the inspection record supports her account.
The notice requirement exists for a reason that the situation at Integrity HC of Carbondale makes plain. A resident facing transfer needs time, in writing, to understand what is happening, to contact an advocate, to object, or to make other arrangements. R22 had none of that. She had a verbal explanation about water pipes and a bus that arrived on a Saturday afternoon.
She was in her room at the new facility when inspectors found her, three days after the move. She said she had arrived recently. She thought she had gotten maybe a week's notice.
She was not sure.
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: 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 9, 2026 · Our methodology
INTEGRITY HC OF CARBONDALE in CARBONDALE, IL was cited for violations during a health inspection on October 9, 2025.
Her name is not in the inspection report.
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.