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Complaint Investigation

Integrity Hc Of Carbondale

October 9, 2025 · Carbondale, IL · 120 North Tower Road
Citations 4
CMS Rating 1/5
Beds 131
Provider ID 145757
Healthcare Facility
Integrity Hc Of Carbondale
Carbondale, IL  ·  View full profile →
Inspection Summary

INTEGRITY HC OF CARBONDALE in CARBONDALE, IL — inspection on October 9, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0558
Resident Rights Deficiencies
Potential for More Than Minimal Harm

V6 stated he plans to have the plumbing company look at it when they come to address the plumbing issues in the kitchen. On 9/25/25 at 12:09 PM, V20 (CNA) stated when she started working at this facility, which was in the beginning of August of 2025, R40 already had a bedside commode in her room. V20 stated R40 would get confused because she couldn't use the bathroom in her room and would urinate in the floor. V20 stated R40 urinated in the corner of her room one time and R40 used her wig to mop it up.

V20 stated R40's bathroom was locked due to not functioning properly from the time she started working at this facility until R40 was moved to a different room. V20 stated since R40 was moved to a different room with a working bathroom she uses the bathroom in her room without any issues and has not urinated or defecated in the floor. On 9/25/25 at 12:13 PM, V26 (CNA) stated R40 was admitted to the room with the nonfunctioning toilet when she first came to the facility. V26 stated R40 had a bedside commode in her room because the bathroom in her room was not functioning properly, and the door was padlocked so R40 could not get into it. V26 said R40's room was connected to the room next door via a shared bathroom. V26 stated the bathroom door on R40's side was locked so she could not enter it from there, but it was not locked on the adjoining side so it could be entered from that room. V26 stated at one point, R40 got confused trying to find a bathroom so she went to the room next to hers that shared the adjoining bathroom, went into the bathroom and defecated and urinated onto a plastic cover that was covering the toilet due to it not being operational. V26 stated R40 also defecated in her closet at one point. V26 stated since R40 has been moved to the North Hall with a properly functioning bathroom, R40 is using her bathroom properly and has not urinated or defecated on the floor or in a closet. R40's Progress Note dated 8/12/25 at 7:42 PM documented under Required Daily Note: Resident (R40) compliant with meds today. Up ambulating and redirected back to her w/c (wheelchair).

Memory deficit keeps her from complying at time.

Incontinent of stool and deficated [sic] in her closet this afternoon.

Area cleaned.

Appetite remains poor and fluid intake is encouraged. POC (Plan of Care) continues. R40's Progress Note dated 8/31/25 at 6:15 PM documented under Required Daily Note: Resident up ambulating independently and redirected numerous times to her w/c .

Vision is poor and is unable to determine distance and objects until they are up close.

Appetite is good today.

Fluids encouraged.

Assisted to the bathroom as she gets lost finding it and unable to see where she is going. No s/sx (signs or symptoms) of pain or discomfort.

She has been continent of B&B (Bowel and Bladder) today. No signs of distress noted.

Assisted with all adls (activities of daily living).

POC (Plan of Care) continues. R40's Progress Note dated 9/12/25 at 12:55 PM documented under Required Daily Note: Resident is alert and confused.

Redirected multiple times today from other residents rooms.

Noted resident pilfering through others belongings.

Redirected back to her room for snacks.

Was incontinent of urine x 1 on the floor.

Poor eyesight and needs assist with toileting as she does not always see the toilet. No signs of pain. BG (Blood Glucose) readings wnl (within normal limits).

Staff continues to redirect as needed.

Staff assist with all adls (activities of daily living). POC (Plan of Care) continues. On 9/22/25 at 10:00 AM, V1 (Former Administrator) stated she wasn't aware of R40 urinating in the floor and not being able to find the bathroom in the hallway. V1 stated R40 should have probably been moved to a room with a properly functioning bathroom. V1 stated there were other open rooms that had a properly functioning toilet that she could have been moved to.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Integrity Hc of Carbondale

120 North Tower Road Carbondale, IL 62901

SUMMARY STATEMENT OF DEFICIENCIES

get a 30-day notice or anything in writing. R25 stated they packed my bags and away we went. R25 said they told her it was because the building needed work, but no one told her it was an emergency. R25 said she doesn't remember having any kind of meeting for discharge planning. 8. R24's admission Record documented admission to the facility on 2/23/22 and included diagnoses of generalized anxiety disorder and unspecified intellectual disabilities.

This admission Record also lists V30 (Family Member) as R24's guardian/responsible party. R24's MDS dated [DATE] documented a BIMS score of 2, indicating severe cognitive impairment. R24's Care Plan includes a Focus area of R24 doesn't have plans for discharge and will reside at the facility for long term care, with an intervention documenting as necessary, meet with the resident/representative on a regular basis to discuss discharge plans.

Provide the resident with an opportunity to express any thoughts or feelings.

Address concerns as they arise.

This focus area and intervention were initiated on 3/18/25 with no updates or revisions to indicate the interdisciplinary team did any planning for transfer or discharge to another facility.

Another Focus area initiated on 3/9/22 documents R24 has impaired cognitive function and impaired thought processes r/t (related to) dx (diagnosis) MR (mental retardation) with interventions of discuss concerns about confusion, disease process, NH placement with the resident/family/caregivers, R24 needs assistance with all decision making, and keep his routine consistent to try and provide consistent caregivers as much as possible in order to decrease confusion. R24's Progress Notes include an entry on Sunday 9/14/25 at 9:00AM authored by V31 (MDS/Care Plan Coordinator) documenting spoke with POA (V30) and discussed the need to move residents to another facility temporarily in order to complete the needed extensive sewer repairs within the facility.

Choices of available facilities

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Integrity Hc of Carbondale

120 North Tower Road Carbondale, IL 62901

SUMMARY STATEMENT OF DEFICIENCIES

can't remember the exact day, but thinks V1 told staff that the residents needed to transfer out of the facility due to repairs during a morning meeting maybe a few days to a week before she started making calls to families. V3 said that making the calls was more of the last thing they did before transferring residents out.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Integrity Hc of Carbondale

120 North Tower Road Carbondale, IL 62901

SUMMARY STATEMENT OF DEFICIENCIES

measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Facility nurse immediately educated staff on duty to ensure fall interventions are in place for R42, including fall mats and bed in lowest position.

Facility immediately conducted a fall investigation with risk management and R42's care plan was updated.

Inservice documentation noted staff education was completed on 9/1/25. 4.

How will you monitor the corrective actions to ensure the deficient practice will not recur i.e., what quality assurance program will be put into place: Administrator, Director of Nursing, and or designees will do random observations of fall interventions in place a minimum of 5 times per week for 4 weeks.

Results of the observations will be discussed in the Quarterly Quality Assurance meeting times 2 with educational needs discussed as needed by the Facility Administrator/Director of Nursing or designee.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CARBONDALE, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from INTEGRITY HC OF CARBONDALE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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