Manor Court of Carbondale

In the surveyor’s words

From the most serious findings on record at Manor Court of Carbondale, in the surveyor’s own words.

• Actual harm, isolatedF689May 19, 2026

  Based on interview and record review the facility failed to provide safe transfers using a transfer belt and implement appropriate interventions for injury for 2 of 6 (R7, R8) residents reviewed for accidents in a sample of 49. This failure resulted in R7 receiving multiple skin tears to his leg and pain in his shoulder. Findings include:1. R7's Face Sheet documents and admission date of 2/24/26 with included diagnoses of encephalopathy, unsteadiness on feet, cognitive communication deficit, fatigue, disorientation, pain in right knee, abnormalities of gait and mobility, pain, osteoporosis, osteoarthritis, spinal stenosis lumbar region, and weakness. R7's MDS (Minimum Date Set) dated 4/28/26 documents a BIMS (Brief Interview of Mental Status) of 5, indicating severe cognitive impairment. […]

• Actual harm, isolatedF600Mar 6, 2026

  Based 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. […]

• Actual harm, isolatedF686Feb 10, 2026

  Based 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. The findings include:1.R1's Face Sheet documents an admission date of 6/23/2022 and includes diagnoses of Chronic Pulmonary Edema, Type 2 Diabetes Mellitus, Local Infection of the skin and Subcutaneous Tissue, Thyroiditis, Hyperlipidemia, Hypertension, Insomnia, and Chronic Atrial Fibrillation. R1's Minimum Data Set (MDS) dated [DATE] includes a Brief Interview for Mental Status (BIMS) score of 15 suggesting R1's cognition is intact. […]

• Actual harm, isolatedF689Feb 19, 2025

  Based 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. […]

• Actual harm, isolatedF550Aug 22, 2024

  Based 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. Findings include: 1. R1's face sheet documents an admitted [DATE]. Diagnoses upon admission included Multiple Sclerosis, cellulites of left lower limb, edema, weakness, difficulty walking, foot drop of right foot, pain, depression, anxiety disorder. R1's MDS (Minimum Data Set) dated 6/14/2024 includes a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. […]