Manor Court of Carbondale
2940 W Westridge Place, Carbondale, IL 62901 · Jackson County · 120 certified beds · avg 101 residents/day · certified since Sep 29, 2014
Abuse citation flag (CMS)
Part of chain: UNLIMITED DEVELOPMENT, INC. (10 facilities, chain avg rating 2.5★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 6, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 7, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 10, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 25, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 19, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 28, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Aug 22, 2024 · F-0550 · triggered by a complaint
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 30, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 22, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 11, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 14, 2024 · F-0692
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 2, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (38)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 6, 2026 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Feb 10, 2026 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 10, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Feb 10, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Jun 27, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 19, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 24, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Sep 24, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Sep 24, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Aug 22, 2024 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Aug 22, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Aug 22, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 22, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 14, 2024 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 14, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 14, 2024 | E · Potential for harm, repeated | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jun 14, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 1, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Feb 1, 2024 | F · Potential for harm, facility-wide | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Feb 1, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 1, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Feb 1, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Nov 22, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Apr 13, 2023 | E · Potential for harm, repeated | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| Apr 13, 2023 | E · Potential for harm, repeated | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
| Apr 13, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 13, 2023 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | E |
| 2024 | 26 | 3 | G ▲ |
| 2025 | 3 | 1 | G ▲ |
| 2026 | 4 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $126,274, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Feb 10, 2026 | Fine | $52,855 |
| Feb 19, 2025 | Fine | $14,763 |
| Aug 22, 2024 | Fine | $58,656 |
| Aug 22, 2024 | Payment Denial | 10 days from Sep 20, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.70 | 2.99 | 3.95 | top 20% in Illinois; bottom 47% in the U.S. |
| Registered Nurse hours | 0.42 | 0.63 | 0.69 | bottom 35% in Illinois; bottom 25% in the U.S. |
| Weekend total nurse staffing | 3.15 | 2.67 | 3.50 | top 22% in Illinois; bottom 39% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.35 | 0.56 | 0.48 | bottom 31% in Illinois; bottom 43% in the U.S. |
| Total nursing staff turnover (%) | 52.1 | 44.5 | 45.8 | bottom 29% in Illinois; bottom 32% in the U.S. |
| RN turnover (%) | 57.1 | 41.8 | 42.9 | bottom 25% in Illinois; bottom 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.42, RN 0.50, weekend 3.76. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 3/5 · short-stay residents: 1/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Finke, Audrey | Individual | Corporate Director | NOT APPLICABLE | 07/25/2014 |
| Finke, Audrey | Individual | Corporate Officer | NOT APPLICABLE | 07/05/2019 |
| Gilmore, Jerry | Individual | Corporate Director | NOT APPLICABLE | 07/25/2014 |
| Haney, David | Individual | Corporate Director | NOT APPLICABLE | 07/25/2014 |
| Neitzel, Melissa | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/05/2019 |
| Wagner, Robert | Individual | Corporate Director | NOT APPLICABLE | 07/25/2014 |
| Wagner, Robert | Individual | Corporate Officer | NOT APPLICABLE | 07/25/2014 |
| Wilson, Ronald | Individual | Corporate Officer | NOT APPLICABLE | 05/25/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Integrity HC of Carbondale | 0.4 mi | Carbondale, IL | ★☆☆☆☆ | 1/5 | abuseSFF |
| Helia Healthcare of Energy | 12.9 mi | Energy, IL | ★☆☆☆☆ | 1/5 | abuse |
| Integrity HC of Herrin | 13.8 mi | Herrin, IL | ★★☆☆☆ | 3/5 | |
| Shawnee Senior Living | 13.9 mi | Herrin, IL | ★★☆☆☆ | 2/5 | |
| Integrity HC of Cobden | 14.3 mi | Cobden, IL | ★★★★★ | 5/5 | |
| Parkway Manor | 15.2 mi | Marion, IL | ★★★★☆ | 4/5 | |
| Duquoin Nursing & Rehab | 18.6 mi | Du Quoin, IL | ★★★☆☆ | 4/5 | |
| Fairview Rehab & Healthcare | 18.6 mi | Du Quoin, IL | ★★★☆☆ | 5/5 | |
| Integrity HC of Marion | 18.8 mi | Marion, IL | ★☆☆☆☆ | 1/5 | SFF |
| Integrity HC of Anna | 19.4 mi | Anna, IL | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 146171.