Integrity Hc Of Carbondale
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.
Inspection Findings
bathroom in her room and would urinate in the floor. V20 stated R40 urinated in the corner of her room
different room. V20 stated since R40 was moved to a different room with a working bathroom she
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.
145757 10/09/2025
Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901
Review of the entire Care Plan revealed no Focus area for transfer/discharge and no dates of initiation on the focus areas or interventions. R25's Progress Notes include an entry by V1 (Former Administrator) dated 9/11/25 at 5:15PM documenting that R25's POA was contacted by this administrator to discuss 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 within the geographical area were offered. R25's POA chose (name of sister facility approximately 20 miles east of current location).
Resident was notified of the move.
Psychosocial needs met. No emotional distress noted. A Progress Note entry on 9/12/25 at 1:59PM documents R25 left the facility via facility transportation will (sic) all current medications and belongings.
All questions and concerns were addressed before leaving the facility. On 9/16/25 at 4:15 PM, R25 was observed in the dining room of the new facility. R25 appeared alert to person and was able to recall being transferred to this new facility.
When asked about her move, R25 stated she was just verbally told she was moving the same day she left and didn't 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
145757 10/09/2025
Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901
will be transferred Saturday (9/13/25) 2pm from (this facility) to (sister facility) after scheduled
transfer.
Transfer set for Saturday 2pm.
Nurse on duty notified. On 9/13/25 at 3:01PM: Resident
medical record did not include evidence that a 30-day written notice of transfer was provided to R22 or family members.On 9/16/25 at 12:15 PM, R22 was observed in her room in bed at the new facility.
R22 was interviewable and stated she arrived to this facility recently and thinks she was given maybe a week's notice but she didn't receive anything in writing. R22 stated she is her own responsible party. R22 said she was told she needed to transfer because the facility needed to work on the water pipes. R22 said she understood that she would be able to go back when the repairs are finished. On 9/17/25 at 11:06 AM, V13 (Chief Executive Officer) stated a month or two ago the Local Health Department shut down the facility's kitchen. V13 said they considered doing an emergency closure at that time but didn't want to do that to the residents. V13 said they couldn't find anything in the regulations stating they were doing anything wrong with transferring residents out to other facilities.
V13 thought they were doing what was right with the temporary relocation. V13 said (name of plumbing company) stated it could be catastrophic if the cast iron plumbing collapsed. V13 then stated a different plumbing company (name of company) did the most recent repair work but they need to do a full facility evaluation once the residents are out of the building to see the scope of what they are dealing with. V13 said there are 19 residents still in house at this time. V13 said the plan is not to permanently close the facility and to let residents return once repairs are complete.
When discussing concerns of the rushed nature of the moves, V13 stated, so what you are saying is we basically should have done this as an emergency evacuation. On 9/30/25 at 3:25PM, V3 (ADON) stated she 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.
145757 10/09/2025
Integrity Hc of Carbondale 120 North Tower Road Carbondale, IL 62901
educational needs discussed as needed by the Facility Administrator/Director of Nursing or designee.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.