Manor Court of Carbondale
2940 W Westridge Place · Carbondale, IL · 62901 · 6184571010
120 certified beds Non profit - Corporation Chain: Unlimited Development, Inc.
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $73,419 in fines in the last 24 months.
- 6 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$73,419 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 4.35 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.47 | 0.55–0.75 |
| Weekend hours / resident-day | 3.58 | ≈ weekday level |
| Nursing turnover / year | 52% | median 45% |
| Fines (3-yr window) | 2 · $73,419 |
Inspection citations (38 in the current record)
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Actual harm · G March 6, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 7, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G February 10, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected February 25, 2026 · Quality of Life and Care
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Potential for harm · D February 10, 2026 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected February 25, 2026 · Resident Rights
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Potential for harm · D February 10, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected February 25, 2026 · Infection Control
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Potential for harm · D June 27, 2025
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected July 1, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 27, 2025
Provide and implement an infection prevention and control program.
Corrected July 1, 2025 · Infection Control
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Actual harm · G February 19, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 28, 2025 · Quality of Life and Care
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Potential for harm · E September 24, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 30, 2024 · Resident Rights
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Potential for harm · E September 24, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 27, 2024 · Quality of Life and Care
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Potential for harm · F September 24, 2024 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected September 30, 2024 · Nursing and Physician Services
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Potential for harm · D September 12, 2024 · found via complaint
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.
Corrected September 25, 2024 · Resident Rights
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Potential for harm · D September 12, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 27, 2024 · Quality of Life and Care
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Potential for harm · D September 12, 2024 · found via complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected September 18, 2024 · Quality of Life and Care
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Actual harm · G August 22, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 30, 2024 · Resident Rights
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Actual harm · G August 22, 2024 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected September 11, 2024 · Quality of Life and Care
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Potential for harm · D August 22, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 27, 2024 · Quality of Life and Care
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Potential for harm · F August 22, 2024 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected September 30, 2024 · Nursing and Physician Services
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Potential for harm · D August 22, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected September 11, 2024 · Pharmacy Service
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Actual harm · G June 14, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected July 2, 2024 · Quality of Life and Care
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Potential for harm · D June 14, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 28, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 14, 2024
Respond appropriately to all alleged violations.
Corrected June 28, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 14, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected July 1, 2024 · Resident Rights
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Potential for harm · D June 14, 2024
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.
Corrected July 1, 2024 · Resident Rights
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Potential for harm · D June 14, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected July 1, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 14, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected July 1, 2024 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 19, 2025 | Fine | $14,763 |
| August 22, 2024 | Fine | $58,656 |
| August 22, 2024 | Payment Denial | 10 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 146171 · certified since September 29, 2014. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.