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Home / Illinois / Carbondale

Manor Court of Carbondale

2940 W Westridge Place, Carbondale, IL 62901 · Jackson County · (618) 457-1010

120 certified beds, about 101 residents a day · Non profit - Corporation · Medicare and Medicaid since 2014

CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 146171 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on June 27, 2025, inspectors cited 2 health deficiencies (the Illinois average is 12.6, the national average 9.2).

Of 38 health citations since April 2023, 6 were rated as actual harm or immediate jeopardy to residents.

CMS lists 3 fines totaling $126,274 in the last three years; the largest was $58,656, and the latest is dated February 10, 2026.

Nurses and nurse aides worked 4.42 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.50 of those hours.

52.1% of nursing staff left within the year CMS measured (Illinois average 44.5%).

CMS links it to Unlimited Development, Inc., an affiliated group of 10 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 38 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
6G
0H
0I
Potential for more than minimal harm
20D
7E
5F
Potential for minimal harm
0A
0B
0C
March 6, 2026Complaint inspection · 1 citation
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 7, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe resident environment and protection from physical abuse for 1(R4) of 3 residents reviewed for resident-to-resident abuse in the sample of 9. This failure resulted in R4 being bitten on the hand by R2, leaving a bruise. A reasonable person being bitten would feel fearful, threatened and intimidated. R4's admission Record dated 3/4/26 documents an admission date of 4/20/23 and included diagnoses of dementia, traumatic subdural hemorrhage, cognitive communication deficit, and vascular dementia. R4's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 4, indicating R4 has severe cognitive impairment. [...]
February 10, 2026Complaint inspection · 3 citations
  1. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 25, 2026
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow physicians' orders, provide interventions and monitor residents at risk for pressure ulcers for 3 or 3 residents (R1, R2 and R6) reviewed for pressure ulcers in the sample of 6. This failure resulted in R1 acquiring 3 stage II pressure ulcers.
  2. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 25, 2026
    Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure a call light was within reach for 1 of 3 residents (R2) reviewed for accommodation of needs in a sample of 6.
  3. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 25, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to implement standard precautions when providing resident care for 1 of 3 residents (R2) reviewed for infection control in a sample of 6.
June 27, 2025Standard inspection · 2 citations
  1. D
    Assure that each resident’s assessment is updated at least once every 3 months.
    F638 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 1, 2025
    Inspectors wroteBased on interview and record review, the facility failed to complete timely quarterly Minimum Data Set (MDS) assessments for 2 (R27 and R76) of 19 residents reviewed for quarterly MDS assessments in a sample of 37. The Findings Include: 1. R27's Resident Face Sheet documented an admission date of 10/4/22. The same document does not document when the last qualifying hospital stay was. R27's most recent completed quarterly MDS is documented as being completed on 5/3/25. An MDS 3.0 NH (Nursing Home) Final Validation Report with a submission and print date of 6/27/25 documented a Target Date of 5/3/25 for R27's MDS submission. This same report included a warning message that documented Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). 2. R76's Resident Face Sheet documented an admission date of 1/29/24. [...]
  2. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 1, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain aseptic technique while providing wound care for 1 (R88) of 1 resident reviewed for infection control in a sample of 37.
February 19, 2025Complaint inspection · 1 citation
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review, the facility failed to maintain a shower chair in a safe condition for 1 (R1) of 6 residents reviewed for accidents in the sample of 6. This failure resulted in R1's foot getting caught in the rubber strips of the shower chair causing a nondisplaced spiral fracture of shaft of right tibia. This past non-compliance occurred between 1/24/25 and 1/28/25. R1's face sheet documents R1 was admitted to the facility on [DATE]. The same face sheet list some of R1's diagnoses as nondisplaced spiral fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, Unspecified dementia, unspecified severity, with other behavioral disturbance, squamous cell carcinoma of skin of unspecified upper limb, including shoulder. [...]
September 24, 2024Complaint inspection · 3 citations
  1. F
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) September 30, 2024
    Inspectors wroteBased on interview and record review, the facility failed to provide a sufficient amount of staff to ensure residents receive assistance with care. This has the potential to affect all 111 residents living in the facility.
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) September 30, 2024
    Inspectors wroteBased on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 4 of 9 residents (R3, R6, R10, and R12) reviewed for call light response in a sample of 13.
  3. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) September 27, 2024
    Inspectors wroteBased on interview, observation, and record review, the facility failed to provide dependent residents with showers and timely ADL (Activities of Daily Living) assistance for 4 of 9 residents (R1, R3, R8, R10) reviewed for ADL assistance in the sample of 13.
September 12, 2024Complaint inspection · 3 citations
  1. D
    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.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 25, 2024
    Inspectors wroteBased 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.
  2. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 27, 2024
    Inspectors wroteBased 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.
  3. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 18, 2024
    Inspectors wroteBased 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.
August 22, 2024Complaint inspection · 5 citations
  1. G
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 30, 2024
    Inspectors wroteBased on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 1 of 3 residents (R1) reviewed for dignity in a sample of 7. This failure resulted in R1 having feelings of desertion, fear, frustration and embarrassment.
  2. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 11, 2024
    Inspectors wroteBased on interview and record review the facility failed to administer pain medication as ordered and develop interventions to manage pain for 1 of 5 residents (R2) reviewed for medication administration in the sample of 7. This failure resulted in R2 experiencing increased pain due to missing 4 doses of ordered pain medication on 8/10/24, 8/11/24, and 8/12/24.
  3. F
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) September 30, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure has the potential to effect all 102 residents residing in the facility.
  4. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 27, 2024
    Inspectors wroteBased on interview, and record review the facility failed provide timely toileting assistance to 3 of 7 residents (R1, R3, and R5) reviewed for ADL (Activities of Daily Living) care in the sample of 7.
  5. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 11, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to acquire medication refills timely resulting in missed doses of medications for 3 of 5 residents (R1, R2, and R3) reviewed for medication administration in a sample of 7.
June 14, 2024Standard inspection · 10 citations
  1. G
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) July 2, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to follow therapeutic dietary recommendations for residents at risk for weight loss for 1 of 1 (R64) resident reviewed for nutrition in a sample of 38. This failure resulted in R64 having a significant weight loss of 16.8% over a period of 6 months. The Findings Include: R64's Resident Face Sheet documents an admission date of 8/7/21 and a date of birth of [DATE]. This same document includes the following diagnoses: unspecified dementia, dysphagia, anxiety disorder, and cognitive communication deficit. R64's 06/2024 Physician Order Sheet documents a diet order for mechanical soft, high calorie/high protein (HCHP) diet. R64's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that she is cognitively intact. [...]
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) July 1, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to properly label and store foods. This has the potential to affect all 100 residents residing in the facility. The Findings Include: On 6/11/24 at 9:30 AM during the initial tour of the kitchen, the following items were observed: 1. A case of bananas in the dry storeroom were on a stainless cart with multiple gnats swarming around over the ripe fruit. 2. The bulk powdered milk bin was found with a scoop in it and the handle touching the food source. 3. A bag of cookies were found opened, unsealed, and not dated in the dry store room. 4. A loaf of bread was found opened, unsealed, and not dated in the dry store room. 5. Hamburgers were opened, unsealed, and not dated in the freezer. The facility's Food Storage and Labeling procedure with a revision date of 9/22 documents Food Storage: [...]
  3. E
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    F808 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 2, 2024
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide high calorie high protein supplements as ordered for 4 (R14, R23, R26, and R246) of 4 residents reviewed for therapeutic diets in the sample of 38. Findings Include: 1. R246's Face Sheet documents an admission date of 1/9/24 with a diagnosis of End Stage Renal Disease. R246's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R246 is cognitively intact. R246's current Physician Orders documents Regular solids and High Calorie Supplement (HCS). R246's Progress Notes dated 6/7/24 at 11:29 AM by V10 (Registered Dietitian/RD) documents Dietary to emphasize K+ (potassium) in diet: NO high K+ foods. Continue SF HCS (Sugar Free High Calorie Supplement) for additional protein/cals. Include HS (evening) snack (High) protein per MD . [...]
  4. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 28, 2024
    Inspectors wroteBased on interview and record review, the facility failed to report an allegation of misappropriation of resident property to the state agency within 24 hours for 1 of 20 (R78) residents reviewed for abuse in the sample of 38.
  5. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 28, 2024
    Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of an allegation of misappropriation of resident property for 1 (R78) of 20 residents in a sample of 38.
  6. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 1, 2024
    Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for transfer/dishcharge to residents, resident representitives and the Long Term Care Ombudsman office for 2 (R39 and R93) of 2 cognitively impaired residents reviewed for notice requirements of transfer/discharge in a sample of 38.
  7. D
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 1, 2024
    Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the bed hold policy to resident representatives for 2 (R93 and R39) of 2 cognitively impaired residents reviewed for notice of bed hold policy upon transfer in a sample of 38. The Findings Include: 1. R39's Face Sheet documents an admission date of 2/15/2022 and includes diagnoses of heart failure, cerebral infarction, chronic kidney disease stage 3, ischemic cardiomyopathy, rheumatoid arthritis, hypertension, chronic systolic heart failure, diarrhea, constipation, GERD (gastroesophageal refulx disease), fatigue, benign prostatic hyperplasia, weakness, paroxysmal atrial fibrillation, anemia, chronic pain, insomnia, vitamin deficiency, hyperlipidemia, gout, and unspecified dementia. [...]
  8. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 1, 2024
    Inspectors wroteBased on interview and record review, the facility failed to coordinate a PASRR (Preadmission Screening and Resident Review) Level II Screening for 1 (R53) of 1 resident reviewed for PASRR Screening in the sample of 38. Findings Include: R53's Face Sheet documented an initial admission date to the facility as 7/31/2023. Diagnoses listed on this form included but were not limited to: major depressive disorder, recurrent, unspecified. R53's current physician orders documents Aripirazole 5mg (milligram) tablet by mouth daily for Major depressive disorder, recurrent, unspecified with a start date of 9/01/2023. R53's Notice of PASRR Level I Screen Outcome dated 4/12/2019 in section PART I states based upon all information and data available to me for this person there is a reasonable basis for suspecting DD (Developmental Disability) or MI (Mental Illness) and is checked No. [...]
  9. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 1, 2024
    Inspectors wroteBased on interview and record review, the facility failed to refer a PASRR (Preadmission Screening and Resident Review) Level II Screening for 1 (R19) of 1 resident reviewed for PASRR Screening in the sample of 38. Findings Included: R19's Face Sheet documented an initial admission date to the facility of 4/16/24. Diagnoses listed on this form included but were not limited to: bipolar disorder, current episode hypomanic. [...]
  10. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 24, 2024
    Inspectors wroteBased on interview, observation and record review, the facility failed to implement new interventions to prevent falls for 1 (R56) of 2 residents reviewed for falls in the sample of 38 .
February 1, 2024Complaint inspection · 5 citations
  1. F
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) February 13, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staff were available to provide needed care in a timely manner. This failure affected (R2, R3, R7, and R8 ) and has the potential to affect all 104 residents residing in the facility. Findings Include: 1. R2's Face sheet, undated, documents R2 was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus with unspecified complications, Nontraumatic subdural hemorrhage, Constipation, Dysuria, Anxiety disorder, Unspecified fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing, Weakness, Muscle weakness (generalized), Unspecified dementia with other behavioral disturbance, Unsteadiness on feet, and Cerebral infarction. R2's Care Plan, dated 10/31/23, documents Resident Care Information and Interventions of: Bowel and bladder: [...]
  2. F
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) February 20, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed ensure a functioning or equivalent notification call system was available for resident use. This failure has the potential to affect all 104 residents residing in the facility.
  3. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 19, 2024
    Inspectors wroteBased on interview and record review, the facility failed to maintain a resident's right to receive timely care and be treated with dignity for 6 of 17 residents (R1, R2, R7, R8, R9, R10) reviewed for resident rights in a sample of 17.
  4. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 19, 2024
    Inspectors wroteBased on interview and record review, the facility failed to provide assistance with activities of daily living (ADL) for residents requiring assistance with toileting hygiene for 4 of 17 residents (R1, R2, R7, and R8) reviewed for ADL care in a sample of 17.
  5. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 20, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents with an effective means to request assistance in the absence of a functioning call light system for 2 of 17 residents (R1 and R2) reviewed for accommodation of needs in a sample of 17.
November 22, 2023Complaint inspection · 1 citation
  1. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 6, 2023
    Inspectors wroteBased on interview and record review, the facility failed to treat residents with respect and dignity by ensuring timely responses to requests for assistance for 3 (R1, R7 and R8) of 8 residents reviewed for Resident Rights in the sample of 8. R1's Resident Face Sheet documents an admission date of 10/22/23 and includes diagnoses of Cognitive Communication deficit, Difficulty in walking, not elsewhere specified; Weakness; Unsteadiness on feet. R1's Minimum Data Set (MDS) dated [DATE] documents R1 requires substantial/maximal assist for toilet transfers. This same MDS documents R1 is always incontinent of bowel and bladder. R1's Care Plan lists a problem start date of 10/22/23 documenting that R1 requires dependent assistance of x(times)2 staff with stand-aid for transfers. [...]
April 13, 2023Standard inspection · 4 citations
  1. E
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    F808 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on interview, observation, and record review, the facility failed to provide nutritional supplements as ordered for 15 of 20 (R10, R44, R8, R28, R36, R66, R53, R17, R4, R4, R38, R27, R56, R67, and R1) residents reviewed for nutritional supplements in a sample of 44.
  2. E
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    F810 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adaptive equipment was provided for 1 of 22 (R134) residents reviewed for nutrition in the sample of 44. Findings Include: R134's facility Face Sheet with a print date of 4/13/23 documents R134 was admitted to the facility on [DATE] with diagnoses that include diabetes, need for assistance with personal care, glaucomatous flecks left eye, hypertension, and heart disease. R134's MDS (Minimum Data Set) dated 3/27/23 documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R134 is cognitively intact. R134's current Care Plan documents an intervention under Resident Care Information of, Approach Start Date: 3/23/23 Eye Sight Device: Partially Blind. This same care plan documents, Problem Start Date: [...]
  3. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received assistance with meals for 1 of 2 (R134) residents reviewed for activities of daily living in the sample of 44. Findings Include: R134's facility Face Sheet with a print date of 4/13/23 documents R134 was admitted to the facility on [DATE] with diagnoses that include diabetes, need for assistance with personal care, glaucomatous flecks left eye, hypertension, and heart disease. R134's MDS (Minimum Data Set) dated 3/27/23 documents a BIMS (Brief Interview for Mental Status) score of 13, which indicates R134 is cognitively intact. R134's current Care plan documents an intervention under Resident Care Information of, Approach Start Date: 3/23/23 Eye Sight Device: Partially Blind. This same care plan documents, Problem Start Date: [...]
  4. D
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 14, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure diets met the nutritional needs for 5 of 9 (R15, R17, R53, R62, R67) residents reviewed for nutrition in the sample of 44. Findings Include: 1. R62's facility Face Sheet with a print date of 4/13/23 documents R62 was admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, anorexia, anemia, nausea, edema, and morbid obesity. R62's MDS (Minimum Data Set) dated 2/8/23 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R62 is cognitively intact. R62's current Care Plan documents a Problem Area with a start date of 6/8/22, (R62) is a vegetarian. Interventions are documented as Serve diet and supplements as MD (physician) order. R62's Progress Notes dated 3/5/23 documents, DIETITIAN ASSESSMENT: On a Regular diet. High Calorie High Protein Supplement. [...]

Fire safety inspections

19 fire safety citations on file: 8 on June 27, 2025, 5 on June 14, 2024, 6 on April 13, 2023.

Every fire safety citation19 citations
  1. F
    Implement emergency and standby power systems.
    E 41 · June 27, 2025 · Corrected (the home has a date of correction)
  2. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · June 27, 2025 · Corrected (the home has a date of correction)
  3. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 27, 2025 · Corrected (the home has a date of correction)
  4. E
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · June 27, 2025 · Corrected (the home has a date of correction)
  5. E
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · June 27, 2025 · Corrected (the home has a date of correction)
  6. E
    Install corridor and hallway doors that block smoke.
    K 363 · June 27, 2025 · Corrected (the home has a date of correction)
  7. E
    Ensure proper usage of power strips and extension cords.
    K 920 · June 27, 2025 · Corrected (the home has a date of correction)
  8. E
    Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
    K 927 · June 27, 2025 · Corrected (the home has a date of correction)
  9. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · June 14, 2024 · Corrected (the home has a date of correction)
  10. F
    Follow proper procedures when the fire alarm was out of service for more than 4 hours.
    K 346 · June 14, 2024 · Corrected (the home has a date of correction)
  11. F
    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
    K 354 · June 14, 2024 · Corrected (the home has a date of correction)
  12. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · June 14, 2024 · Corrected (the home has a date of correction)
  13. E
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · June 14, 2024 · Corrected (the home has a date of correction)
  14. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · April 13, 2023 · Corrected (the home has a date of correction)
  15. F
    Establish staff and initial training requirements.
    E 37 · April 13, 2023 · Corrected (the home has a date of correction)
  16. F
    Follow proper procedures when the fire alarm was out of service for more than 4 hours.
    K 346 · April 13, 2023 · Corrected (the home has a date of correction)
  17. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · April 13, 2023 · Corrected (the home has a date of correction)
  18. F
    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
    K 354 · April 13, 2023 · Corrected (the home has a date of correction)
  19. E
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · April 13, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
February 10, 2026Fine $52,855
February 19, 2025Fine $14,763
August 22, 2024Fine $58,656
August 22, 2024Payment Denial 10 days from September 20, 2024

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIllinoisUnited States
All nursing staff (RN, LPN and aides)4.423.453.86
Registered nurses0.500.720.69
All nursing staff on weekends3.763.073.42
Nurse aides3.00
Licensed practical nurses0.92
Nursing staff turnover (share who left in a year)52.1%44.5%45.8%
Registered nurse turnover57.1%41.8%42.9%
Administrators who left0

CMS expects 4.58 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.69 on weekdays and 3.76 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.34 in April to June 2025 to 4.42 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20264.420.504.693.76 0.0%0 of 90101
Oct to Dec 20254.350.474.663.58 0.0%0 of 92105
Jul to Sep 20254.280.524.593.49 0.0%0 of 92102
Apr to Jun 20254.340.564.643.59 0.0%0 of 9199
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Illinois, Jan to Mar 20263.260.653.402.925.4%0.6% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Illinois

JobMedianMiddle halfEmployed
Illinois, all employers
CNAs (nursing assistants)$22.10$18.95 to $23.2668,640
LPNs and LVNs$36.06$30.57 to $38.2517,440
Registered nurses$46.15$38.47 to $50.94138,910
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Manor Court of Carbondale. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

Your job
Employed by
Usual shift
Do you get a shift differential?
Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIllinoisUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
24.913.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.50.90.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.01.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
7.53.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
2.02.21.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
19.814.314.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
2.84.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
15.021.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
24.426.123.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
25.913.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.32.01.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.42.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Manor Court of Carbondale's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (49.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

49.8% this home

No different from the national rate

US median of homes 51.5% · Illinois: 106 better, 85 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 243 eligible stays.

Potentially preventable readmissions

11.1% this home

No different from the national rate

US median of homes 10.7% · Illinois: 2 better, 14 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 218 eligible stays.

Infections that led to a hospital stay

10.5% this home

Worse than the national rate

US median of homes 7.1% · Illinois: 3 better, 10 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 159 eligible stays.

Self-care and mobility at discharge

42.7% this home

Median of homes: Illinois50.0% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 124 residents counted.

Falls with major injury

0.0% this home

Median of homes: Illinois0.3% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 165 residents counted.

New or worsened pressure ulcers

3.3% this home

Median of homes: Illinois1.5% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 165 residents counted.

Medication list given at discharge

96.8% this home

Median of homes: Illinois100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 94 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: UNLIMITED DEVELOPMENT, INC. CMS links this home to Unlimited Development, Inc., a group of 10 nursing homes averaging 2.2 stars overall.

NameRoleTypeShareSince
Neitzel, MelissaW-2 managing employeeIndividual07/05/2019
Finke, AudreyCorporate directorIndividual07/25/2014
Gilmore, JerryCorporate directorIndividual07/25/2014
Haney, DavidCorporate directorIndividual07/25/2014
Wagner, RobertCorporate directorIndividual07/25/2014
Finke, AudreyCorporate officerIndividual07/05/2019
Wagner, RobertCorporate officerIndividual07/25/2014
Wilson, RonaldCorporate officerIndividual05/25/2022

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 11 problems in this area, most recently on February 10, 2026: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 9 problems in this area, most recently on February 10, 2026: "Reasonably accommodate the needs and preferences of each resident."
  3. Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 5 problems in this area, most recently on June 14, 2024: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
  4. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 3 problems in this area, most recently on March 6, 2026: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."

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Common questions

What is Manor Court of Carbondale's Medicare star rating?
CMS rates Manor Court of Carbondale 2 out of 5 stars overall, with 2 for health inspections, 2 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Manor Court of Carbondale get at its last inspection?
2 health deficiencies at the standard inspection on June 27, 2025. The Illinois average is 12.6.
Has Manor Court of Carbondale been fined?
Yes. CMS lists 3 fines totaling $126,274 in the last three years.
Does Manor Court of Carbondale accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Manor Court of Carbondale?
CMS lists 8 owners and managers, and links the home to Unlimited Development, Inc.. Legal business name: UNLIMITED DEVELOPMENT, INC.

Sources

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