Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide documentation by a physician regarding the basis of
a resident's involuntary transfer/discharge, the specific resident needs that cannot be met, facility attempts
to meet the resident needs, the service available at the receiving facility to meet the resident's needs and
failed to allow a resident to return to the facility pending the appeal process for 1 (R8) of 4 residents
reviewed for Involuntary Discharge in a sample of 8.
Findings include:
R8's face sheet documented an admission date of 1/31/23, a discharge date of 7/22/24, and diagnoses
including: Alzheimer's disease, cognitive communication deficit, other specified persistent mood disorders,
altered mental status, unspecified psychosis not due to a substance or know physiological condition.
R8's 7/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6,
indicating R8 has severe cognitive impairment. R8's 7/22/24 MDS Section E documented physical
behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other
behavioral symptoms not directed toward others occurred 1 to 3 days. R8's 7/22/24 MDS also documented
R8 had a behavior of rejecting care occurring 4 to 6 days, but less than daily.
R8's Care Plan documented a 2/7/23 problem start date documenting in part . Category: Behavioral
Symptoms . (R8) has a past history of trauma. He usually understands/ makes others understand him . he
(R8) displays verbal/ physical behaviors during reflection of care (refusing showers, ADLs (Activities of
Daily Living), changing clothes), when others enter his room, when redirecting, while experiencing visual
hallucinations (spiders everywhere), delusional episodes (being bitten by spiders .). He misinterprets
intentions of others . Delusional episodes and potential past history of trauma triggers physical verbal
behaviors with others at times, along with loud behaviors of others . R8's Care Plan documents a Goal of .
Resident will have a reduction in physical, verbal behaviors during rejection of care, delusional episodes,
and providing redirection by next review . with a target date of 3/18/24. Documented Approaches include:
Encourage to go for a walk to help de-escalate and encourage to vent feelings frustrations. Listen with
empathy and offer emotional support dated 8/3/23. If resident becomes agitated during care, stop task and
re-approach at a later time dated 7/8/24. R8's Care Plan documents an additional goal of . Resident will
have a reduction in physical/ threatening behaviors directed toward others by next review . with a target
date of 3/18/24. Documented approaches for this goal include: Encourage him (R8) to let staff assist in
redirecting peers if wandering into his room dated 8/3/23 and Assist as tolerated to quieter area providing
distraction from loud areas/ peers dated 10/24/23. R8's care plan did not document a problem, goals, or
approaches regarding
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
146171
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
R8's diagnosis of Alzheimer's disease or dementia.
Level of Harm - Minimal harm
or potential for actual harm
R8's Behavioral Analysis dated 6/22/24 through 7/22/24 documents physical behavioral symptoms directed
toward others occurred 10 times during this time period. Documented interventions attempted include
redirect, one-on-one, return to room, given food/ fluids, activity, toilet, backrub, and position change. The
section easily altered after each documented behavior and intervention documents and answer of no. The
sections effect on resident and effect on others after each documented behavior and intervention is left
blank.
Residents Affected - Few
On 9/6/24 at 9:20 AM, V19 (Certified Nursing Assistant/ CNA) said she was caring for R8 during the night
shift from 7/5/24 to 7/6/24. V19 said on 7/6/24 around 1:30 AM she entered R8's room to check R8 for
incontinence. V19 said R8 had a bowel movement and R8's bedding and clothing was soiled. V19 said she
woke R8 up and told R8 he needed to get up so staff could clean him up and change his bedding. V19 said
she turned her back and started pulling the sheets off the head of R8's bed when R8 grabbed her around
the neck and started punching V19 in the head and pulling V19's hair. V19 said she jumped over R8's bed
and was able to get out of R8's room. V19 said about 10 minutes later V19 and another staff reentered R8's
room and finished cleaning R8 up and changing his bedding. V19 said R8 would have physical behaviors in
his room with staff, but would have physical behaviors anywhere in the facility. V19 said there was no plan
on what staff should do when R8 became agitated. V19 said she had spoken with V17 (Memory Care Unit
Coordinator) about staff needing a plan on what to do when R8 became agitated or R8 needing his
medications changed.
R8's Behavior and Mood Event dated 7/6/24 documented R8 had a physical behavior toward staff with
possible contributing factors of ADL (Activities of Daily Living) care. R8's 7/6/24 Behavior and Mood Event
documented a 2:00 AM progress note documenting in part . Resident displayed physical behavior towards
staff member while performing care. Resident has been redirected and is currently in his bed resting .
R8's Behavior and Mood Events dated 7/8/24 documented a physical behavior directed toward staff with
possible contributing factors of ADL care documenting in part . punched staff in abdomen during shower
assistance .
On 9/6/24 at 10:10 AM, V21 (CNA) said she was caring for R8 on 7/21/24. V21 said R8 was wearing an
incontinent brief and jogging pants. V21 said it was apparent R8 needed incontinence care. V21 said she
assisted R8 back to R8's room for care and as soon as V21 shut the door R8 physically attacked her. V21
said R8 would get physically aggressive with staff with providing personal care since R8 was admitted to
the facility. V21 said R8's physically aggressive behaviors had gotten worse and more intense toward the
end of R8's stay. V21 said R8 was able to be redirected when he was in the common areas but was not
able to be redirected when staff were providing care in his room or in the shower room. V21 said the only
thing staff could do when R8 became aggressive during care was to stop the task, leave, and return later to
try to finish care.
R8's Behavior and Mood Event dated 7/21/24 documented a physical behavior directed towards others and
rejection of care with a 1:50 AM progress note documenting in part . resident became agitated and had a
physical behavior toward staff when staff was attempting to assist resident with changing soiled (disposable
undergarment) and soiled clothing resident was redirected safety of peers and staff secured resident is
resting in bed at this time [sic] .
R8's 7/22/24 Progress Note at 8:30 AM documented in part . Resident refusing care from staff d/t
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
Level of Harm - Minimal harm
or potential for actual harm
(due to) delusional behaviors (believing that they just want to see him naked). Multipule attempts were
made. Still unsuccessful .
R8's 7/22/24 Progress Note at 10:16 AM documented in part . Resident displayed physical behaviors during
episodes of rejection of care. Task was stopped at this time and will re-approach .
Residents Affected - Few
On 9/6/24 at 10:38 AM, V22 (CNA) said R8's mood would change quickly and if R8 could not understand
what you were telling him R8 would get upset. V22 said R8 would wander into other resident's room and
urinate in the floor. V22 said R8 was able to be redirected when in the common areas but could not be
redirected when assisting R8 with personal care. V22 said R8 would become very upset with staff and
become agitated when staff would remove soiled clothing or linens from R8's room. V22 said R8 had less
behaviors with female staff and R8's behaviors were worse at night.
On 9/5/24 at 11:59 AM, V17 (Memory Care Unit Director) said R8 was very difficult. V17 said when R8 was
first admitted to the facility R8 was seen by the psychiatric provider and had less behaviors and suddenly
had an increase in severity of physical behaviors. V17 said R8 would get mad if anyone went into his room
because he thought people were trying to steal from him. V17 said R8 would become violently aggressive
very quickly when staff were trying to assist him with care. V17 said R8's Electronic Medical Record (EMR)
documented when R8 had physical behaviors toward others but did not contain details of the physical
behaviors in the progress notes because other facilities are unlikely to accept the resident if the facility
wanted to transfer the resident.
On 9/5/24 at 12:30 PM, V2 (Director of Nursing) said he would expect there to be detailed notes in the
resident's progress notes pertaining to a resident's behavior. V2 said if there were no details in the
resident's progress notes about what behaviors are being exhibited or if the interventions are effective, he
was unsure how the resident's care plan would be updated.
On 9/4/24 at 10:26 AM, V14 (Hospital Social Worker) said R8 had been discharged to the hospital from the
facility due to R8 being combative and the facility not being able to meet R8's needs. V14 said during R8's
hospital stay R8 did not exhibit any combative behaviors.
On 9/10/24 at 2:43 PM, V14 said she had spoken with V2 at the facility on 7/24/24 and was told R8 would
not be allowed to return to the facility.
On 9/10/24 at 2:15 PM, V15 (Ombudsman) said she had spoken with V14 when V14 was told R8 would not
be allowed to return to the facility. V15 said she had contacted V16 (Family Member) to ask if V16 would like
to appeal the involuntary discharge of R8 from the facility. V14 said she had filed for an appeal of the
involuntary discharge. V14 said the facility had not let R8 return to the facility during the involuntary
discharge appeal process.
On 9/12/24 at 10:30 AM, V1 (Administrator) said R8 had an incident of violent physical behaviors on 7/6/24,
7/7/24, and 7/21/24. V1 said R8 was involuntarily discharged to the hospital acute psychiatric unit with the
intention that R8 was not going to be permitted to return to the facility.
On 9/12/24 at 10:37 AM, V2 (Director of Nursing) said when he called to give the hospital report on R8 V2
had expressed to the hospital R8 would not be permitted to return to the facility and would be arriving with
the involuntary discharge documents. V2 said if the hospital acute psychiatric unit had called the facility
after R8 had been treated and report R8 was not having any behaviors R8 would not have been permitted
to return to the facility.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R8's 7/22/24 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home
Residents documented R8 had been emergency transferred or discharged from the facility due to the safety
of individuals in the facility being endangered.
R8's Illinois Department of Public Health State of Illinois Proof of Service documented in part . The
undersigned certifies that true and correct copies of the attached Notice of prehearing conference and
hearing were sent via email and/or Certified mail to: (R8), (V16), (V14), (V15), and (the facility's attorney).
That said documents were sent from the Illinois Department of Public Health Office in [NAME], Illinois on
the (8th) day of August 2024 .
On 9/10/24 at 9:59 AM, V24 (Psychiatric Nurse Practitioner) said R8's physically aggressive behaviors had
worsened and R8 needed an inpatient acute psychiatric care stay. V24 said she had adjusted R8's
psychiatric medications to the best of her abilities but increasing R8's medications would have been
worrisome of chemical restraint. V24 said she was aware of R8 being involuntarily discharged from the
facility. V24 said it was the responsibility of the Medical Director to document why the facility was not able to
meet the resident's needs and what the receiving facility would need to meet the resident's needs.
On 9/10/24 at 10:46 AM and 9/12/24 at 2:35 PM, messages were left with V25's (Physician) office with no
return phone call from V25.
On 9/10/24 at 10:32 AM, V2 said R8's EMR did not contain any documentation by V25 (Physician)
pertaining to why the facility could not meet R8's needs and what the receiving facility would need to do to
meet R8's needs.
R8's 7/1/24 through 7/31/24 Physician Order Report documented the following medication orders: 7/17/24 7/20/24 Depakote Sprinkles 125 mg (milligrams) 2 capsules by mouth 3 times daily, 7/21/24 - open ended
Depakote Sprinkles 125 mg 1 capsule by mouth 3 times daily, 7/10/24 clonazepam 0.5 mg 1 tablet by
mouth at bedtime, 5/2/24 Risperdal 12.5 mg intramuscular once a day on Wednesday every other week.
R8's Physician Order Report did not document an order from V25 or V24 to discharge R8 or to refer R8 to
inpatient psychiatric treatment.
R8's hospital Medication Administration Record (MAR) documented an 8/8/24 order to start Remeron 15
mg by mouth at bedtime and an 8/11/24 order to start Zoloft 50 mg by mouth daily.
R8's hospital record documented an 8/3/24 progress note documenting in part . (R8) is going to medical
due to low response with spoken with, lack of caloric intake and hydration. (R8) appears to be experiencing
failure to thrive. Poor (oral) intake staff is encouraging (R8) to sip water, juice, ice chips through straw with
no success. (R8's) vital signs are within normal limits. (R8) skin tents on back of hand and lips and gums
are furled. (R8's) hue is a pale ashen hue .
The facility policy titled Skilled Special Care Unit Care and Treatment (revised 4/7/21) documents in part .
Our Memory Care program is a Skilled Special Care Unit designated to meet the physical needs, emotional
needs, and psychosocial well-being of individuals related to Alzheimer's disease/ dementia diagnosis . Staff
are trained to expect the unexpected with emphasis on using proactive interventions designed to prevent
behaviors from occurring and to recognize individual signs that a resident is in stress. Emphasis is placed
on perceiving any behaviors as a means of communication by a resident and determining the trigger . The
resident will be assessed through observations geared toward analysis of the resident's activity interests,
cognitive and behavioral status . The care plan is
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
accessible to all (Memory Care Unit) staff and shall be utilized as a directive for all cares provided . As a
resident requires more assistance, staff will communicate these needs with the Director of Memory Care to
ensure changes are made to the resident's plan of care as needed
The facility policy titled Transfer of a Resident (revised 1/11/23) documents in part . 5. Involuntary Discharge
. Involuntary transfers will be initiated for reasons as specified by the Resident Contract.
R8's admission Agreement dated 1/31/23 documents in section Q. Discharge The Facility may terminate
the contract and discharge the Resident with a 30 day notice for any of the following reasons: The
discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility .The
safety of individuals in the Facility is endangered. The health of individuals in the Facility would otherwise
be endangered .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation, and record review the facility failed to provide showers for dependent residents for 1
(R2) of 3 residents reviewed for Activities of Daily Living in a sample of 8.
Residents Affected - Few
The findings include:
R2's Resident Face Sheet documents an admission date of 6/17/24 with diagnoses including acute
respiratory failure with hypoxia, acute myocardial infarction, unspecified, Chronic Obstructive Pulmonary
Disease, unspecified, unspecified open wound, left knee, initial encounter, systemic lupus erythematosus,
unspecified, and Rheumatoid arthritis, unspecified.
R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of
15 which indicates R2 is cognitively intact. The same MDS documents that for shower/baths, R2 requires
substantial/maximum assistance-helper lifts or holds trunk or limbs and provides more than half the effort.
R2's Care Plan documents a problem area of Resident Care Information dated 6/17/24. Documented
approaches include bathing type: shower/whirlpool and bath days of Monday, Wednesday and Friday.
On 9/5/24 at 10:00 am, R2's hair appeared to be greasy and to have not been washed. R2 said her hair
had not been washed in a week or so and it really needs it. R2 said she has not had a shower in a while,
said she has received mostly bed baths with moistened bath wipes. R2 said she would really like her hair
washed.
On 9/10/24 at 10:45 am, V1 (Administrator) said the CNA's (Certified Nurse Assistants) does the whirlpools
baths.
On 9/5/24 at 11:00 am, V2 (DON/Director of Nurses) said that the facility policy is that a resident receives
one shower/bath a week, and they do schedule residents for 2 a week. V2 said it is his expectation that if a
resident refuses a shower/bath, staff will go back and attempt again.
R2's document labeled CNA Duties List dated 8/13/24 document that R2 received a shower on 8/27/24 and
notes BB which indicates a bed bath. R2's Point of Care History in the electronic Health Record document
that R2 refused a shower on 8/17/24. This indicates that R2 went 14 days without a shower/ bath. R2's
Point of Care History documents R2's next shower/bath as 9/4/24 which indicates R2 went from 8/25/24 to
9/4/24 which indicates 9 days without a shower/bath.
The facility's Personal Care of Residents policy (revised 12/02) documents Each Resident shall have at
least one (1) complete bath and hair wash weekly and as many additional baths and hair washes as
necessary for satisfactory personal hygiene.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to re-assess and implement progressive
individualized interventions for increased occurrences of combative behaviors for 1 (R8) of 3 residents
reviewed for dementia care in the sample of 8.
Residents Affected - Few
Findings include:
R8's face sheet documented an admission date of 1/31/23, a discharge date of 7/22/24, and diagnoses
including: Alzheimer's disease, cognitive communication deficit, other specified persistent mood disorders,
altered mental status, unspecified psychosis not due to a substance or known physiological condition.
R8's 7/22/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6,
indicating R8 has severe cognitive impairment. R8's 7/22/24 MDS Section E documented physical
behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other
behavioral symptoms not directed toward others occurred 1 to 3 days. R8's 7/22/24 MDS also documented
R8 had a behavior of rejecting care occurring 4 to 6 days, but less than daily.
R8's Care Plan documented a 2/7/23 problem start date documenting in part . Category: Behavioral
Symptoms . (R8) has a past history of trauma. He usually understands/ makes others understand him . he
(R8) displays verbal/ physical behaviors during refection of care (refusing showers, ADLs (Activities of Daily
Living), changing clothes), when others enter his room, when redirecting, while experiencing visual
hallucinations (spiders everywhere), delusional episodes (being bitten by spiders .). He misinterprets
intentions of others . Delusional episodes and potential past history of trauma triggers physical verbal
behaviors with others at times, along with loud behaviors of others . R8's Care Plan documents a Goal of .
Resident will have a reduction in physical, verbal behaviors during rejection of care, delusional episodes,
and providing redirection by next review . with a target date of 3/18/24. Documented Approaches include:
Encourage to go for a walk to help de-escalate and encourage to vent feelings frustrations. Listen with
empathy and offer emotional support dated 8/3/23. If resident becomes agitated during care, stop task and
re-approach at a later time dated 7/8/24. R8's Care Plan documents an additional goal of . Resident will
have a reduction in physical/ threatening behaviors directed toward others by next review . with a target
date of 3/18/24. Documented approaches for this goal include: Encourage him (R8) to let staff assist in
redirecting peers if wandering into his room dated 8/3/23 and Assist as tolerated to quieter area providing
distraction from loud areas/ peers dated 10/24/23. R8's care plan did not document a problem, goals, or
approaches regarding R8's diagnosis of Alzheimer's disease or dementia.
R8's Behavioral Analysis dated 6/22/24 through 7/22/24 documents physical behavioral symptoms directed
toward others occurred 10 times during this time period. Documented interventions attempted include
redirect, one-on-one, return to room, given food/ fluids, activity, toilet, backrub, and position change. The
section easily altered after each documented behavior and intervention documents and answer of no. The
sections effect on resident and effect on others after each documented behavior and intervention is left
blank.
On 9/6/24 at 9:20 AM, V19 (Certified Nursing Assistant/ CNA) said she was caring for R8 during the night
shift from 7/5/24 to 7/6/24. V19 said on 7/6/24 around 1:30 AM she entered R8's room to check R8 for
incontinence. V19 said R8 had a bowel movement and R8's bedding and clothing was soiled. V19
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
said she woke R8 up and told R8 he needed to get up so staff could clean him up and change his bedding.
V19 said she turned her back and started pulling the sheets off the head of R8's bed when R8 grabbed her
around the neck and started punching V19 in the head and pulling V19's hair. V19 said she jumped over
R8's bed and was able to get out of R8's room. V19 said about 10 minutes later V19 and another staff
reentered R8's room and finished cleaning R8 up and changing his bedding. V19 said R8 would have
physical behaviors in his room with staff, but would have physical behaviors anywhere in the facility. V19
said there was no plan on what staff should do when R8 became agitated. V19 said she had spoken with
V17 (Memory Care Unit Coordinator) about staff needing a plan on what to do when R8 became agitated
or R8 needing his medications changed.
R8's 7/6/24 Behavior and Mood Event documented R8 had a physical behavior toward staff with possible
contributing factors of ADL care. R8's 7/6/24 Behavior and Mood Event documented a 2:00 AM progress
note documenting in part . Resident displayed physical behavior towards staff member while preforming
care. Resident has been redirected and is currently in his bed resting .
R8's 7/8/24 Behavior and Mood Event documented a physical behavior directed toward staff with possible
contributing factors of ADL care documenting in part . punched staff in abdomen during shower assistance .
On 9/6/24 at 10:10 AM, V21 (CNA) said she was caring for R8 on 7/21/24. V21 said R8 was wearing an
incontinent brief and jogging pants. V21 said it was apparent R8 needed incontinence care. V21 said she
assisted R8 back to R8's room for care and as soon as V21 shut the door R8 physically attacked her. V21
said R8 would get physically aggressive with staff with providing personal care since R8 was admitted to
the facility. V21 said R8's physically aggressive behaviors had gotten worse and more intense toward the
end of R8's stay. V21 said R8 was able to be redirected when he was in the common areas but was not
able to be redirected when staff were providing care in his room or in the shower room. V21 said the only
thing staff could do when R8 became aggressive during care was to stop the task, leave, and return later to
try to finish care.
R8's 7/21/24 Behavior and Mood Event documented a physical behavior directed towards others and
rejection of care with a 1:50 AM progress note documenting in part . resident became agitated and had a
physical behavior toward staff when staff was attempting to assist resident with changing soiled depends
and soiled clothing resident was redirected safety of peers and staff secured resident is resting in bed at
this time [sic] .
R8's 7/22/24 progress note at 8:30 AM documented in part . Resident refusing care from staff d/t (due to)
delusional behaviors (believing that they just want to see him naked). Multipule attempts were made. Still
unsuccessful .
R8's 7/22/24 progress note at 10:16 AM documented in part . Resident displayed physical behaviors during
episodes of rejection of care. Task was stopped at this time and will re-approach .
On 9/6/24 at 10:38 AM, V22 (CNA) said R8's mood would change quickly and if R8 could not understand
what you were telling him R8 would get upset. V22 said R8 would wander into other resident's room and
urinate in the floor. V22 said R8 was able to be redirected when in the common areas but could not be
redirected when assisting R8 with personal care. V22 said R8 would become very upset with staff and
become agitated when staff would remove soiled clothing or linens from R8's room. V22 said R8 had less
behaviors with female staff and R8's behaviors were worse at night.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146171
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Manor Court of Carbondale
2940 W Westridge Place
Carbondale, IL 62901
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 9/5/24 at 11:59 AM, V17 said R8 was very difficult. V17 said when R8 was first admitted to the facility
R8 was seen by psychiatric provider and had less behaviors and suddenly had an increase in severity of
physical behaviors. V17 said R8 would get mad if anyone went into his room because he thought people
were trying to steal from him. V17 said R8 would become violently aggressive very quickly when staff were
trying to assist him with care. V17 said that R8's Electronic Medical Record (EMR) documented when R8
had physical behaviors toward others but did not contain details of the physical behaviors in the progress
notes because other facilities are unlikely to accept the resident if the facility wanted to transfer the
resident.
On 9/5/24 at 12:30 PM, V2 (Director of Nursing) said he would expect there to be detailed notes in the
resident's progress notes pertaining to a resident's behavior. V2 said if there were no details in the
resident's progress notes about what behaviors are being exhibited or if the interventions are effective, he
was unsure how the resident's care plan would be updated.
The facility's revised 4/7/21 Skilled Special Care Unit Care and Treatment policy documented in part . Our
Memory Care program is a Skilled Special Care Unit designated to meet the physical needs, emotional
needs, and psychosocial well-being of individuals related to Alzheimer's disease/ dementia diagnosis . Staff
are trained to expect the unexpected with emphasis on using proactive interventions designed to prevent
behaviors from occurring and to recognize individual signs that a resident is in stress. Emphasis is placed
on perceiving any behaviors as a means of communication be a resident and determining the trigger . The
resident will be assessed through observations geared toward analysis of the residents activity interests,
cognitive and behavioral status . The care plan is accessible to all (Memory Care Unit) staff and shall be
utilized as a directive for all cares provided . As a resident requires more assistance, staff will communicate
these needs with the Director of Memory Care to ensure changes are made to the resident's plan of care
as needed
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146171
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
FAQ · About this visit
Common questions about this visit
What happened during the September 12, 2024 survey of MANOR COURT OF CARBONDALE?
This was a inspection survey of MANOR COURT OF CARBONDALE on September 12, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MANOR COURT OF CARBONDALE on September 12, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific info..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.