Carbondale, IL

Manor Court Of Carbondale

3-star overall rating with 4-star inspections with $73,161 in total fines with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

2940 W Westridge Place, Carbondale, IL

(618) 457-1010

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

102

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Unlimited Development, Inc.

Operator or chain grouping

Approved since

2014-09-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.52

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.81

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

2.95

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

4.28

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.33

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.49

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.47

CMS adjusted RN staffing hours

Adjusted total hours

3.86

CMS adjusted total nurse staffing hours

Case-mix index

1.52

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

55%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,843

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

10.10

Composite VBP score used to determine payment impact.

Payment multiplier

0.9809

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 23.95% · Performance 24.00% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 9.82% · Performance 10.50% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

1.52

Baseline 63.20% · Performance 57.45% · Measure score 1.52 · Achievement 1.52 · Improvement 1

Adjusted total nurse staffing

2.52

Baseline 4 hours · Performance 3.79 hours · Measure score 2.52 · Achievement 2.52 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.14%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 218 · Observed rate 11.93% · Lower 95% interval 8.35%
Discharge to community	49.76%	50.57% 0.8 pts worse	No Different than the National Rate · Eligible stays 243 · Observed rate 43.62% · Lower 95% interval 43.41%
Medicare spending per beneficiary	1.32	1.02 0.3 pts worse
Drug regimen review with follow-up	99.29%	95.27% 4 pts better	Numerator 140 · Denominator 141
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 141
Discharge self-care score	36.36%	53.69% 17.3 pts worse	Numerator 32 · Denominator 88
Discharge mobility score	28.41%	50.94% 22.5 pts worse	Numerator 25 · Denominator 88
Pressure ulcers or injuries, new or worsened	4.26%	2.29% 2 pts worse	Numerator 6 · Denominator 141 · Adjusted rate 3.72%
Healthcare-associated infections requiring hospitalization	10.5%	7.12% 3.4 pts worse	Worse than the National Rate · Eligible stays 159 · Observed rate 13.21% · Lower 95% interval 7.44%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 161
Staff flu vaccination coverage	46.34%	42% 4.3 pts better	Numerator 76 · Denominator 164
Discharge function score	39.77%	56.45% 16.7 pts worse	Numerator 35 · Denominator 88
Transfer of health information to provider	93.62%	95.95% 2.3 pts worse	Numerator 44 · Denominator 47
Transfer of health information to patient	92.96%	96.28% 3.3 pts worse	Numerator 66 · Denominator 71
Resident COVID-19 vaccinations up to date	40.48%	25.2% 15.3 pts better	Numerator 34 · Denominator 84

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.3	2.0 0.3 pts worse	1.9 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.4 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	2.3 0.5 pts better	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.4%	89.6% 9.8 pts better	93.4% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 98.6% · Q4 100.0% · 4Q avg 99.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	91.6% 8.4 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.8%	3.3% 1.5 pts worse	3.3% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 5.3% · Q3 2.8% · Q4 7.8% · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.2%	50.3% 48.1 pts better	11.4% 9.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 1.6% · Q4 1.5% · 4Q avg 2.2%
Percentage of long-stay residents who lose too much weight	1.5%	6.5% 5 pts better	5.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 2.9% · 4Q avg 1.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	6.4%	18.5% 12.1 pts better	19.6% 13.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 6.2% · Q3 4.5% · Q4 5.7% · 4Q avg 6.4%
Percentage of long-stay residents who received an antipsychotic medication	12.4%	22.8% 10.4 pts better	16.7% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.2% · Q3 15.4% · Q4 10.2% · 4Q avg 12.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	38.1%	17.2% 20.9 pts worse	16.3% 21.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 49.0% · Q2 59.4% · Q3 23.9% · Q4 15.9% · 4Q avg 38.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	35.1%	15.0% 20.1 pts worse	14.9% 20.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 43.2% · Q2 45.2% · Q3 30.4% · Q4 20.9% · 4Q avg 35.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	1.1% 0.9 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.0%	1.7% 0.7 pts better	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.9%	21.3% 3.6 pts worse	19.8% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.2% · Q2 17.6% · Q3 27.9% · Q4 20.6% · 4Q avg 24.9%
Percentage of long-stay residents with pressure ulcers	4.7%	5.2% 0.5 pts better	5.1% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 4.7% · Q3 3.3% · Q4 3.3% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	92.9%	68.8% 24.1 pts better	81.7% 11.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 93.3% · Q3 88.3% · Q4 94.7% · 4Q avg 92.9%
Percentage of short-stay residents who had an outpatient emergency department visit	24.2%	14.0% 10.2 pts worse	12.0% 12.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 21.6% · Expected 10.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.7%	2.3% 0.6 pts better	1.6% 0.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.1% · Q4 3.2% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	95.8%	63.0% 32.8 pts better	79.7% 16.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.7%	26.2% 3.5 pts worse	23.9% 5.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 30.2% · Expected 24.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-27 · Fire 2025-06-27

2 health deficiencies

Top issue: Infection Control (1 deficiency)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-06-14 · Fire 2024-06-14

22 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2023-04-13 · Fire 2023-04-13

10 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-27

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-09-29

F · Potential for more than minimal harm 2025-06-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-09-29

F · Potential for more than minimal harm 2025-06-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-29

E · Potential for more than minimal harm 2025-06-27

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2025-09-29

E · Potential for more than minimal harm 2025-06-27

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-09-29

E · Potential for more than minimal harm 2025-06-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-09-29

E · Potential for more than minimal harm 2025-06-27

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-09-29

E · Potential for more than minimal harm 2025-06-27

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2025-09-29

F · Potential for more than minimal harm 2024-06-14

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-05-31

F · Potential for more than minimal harm 2024-06-14

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2024-05-31

F · Potential for more than minimal harm 2024-06-14

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-05-31

F · Potential for more than minimal harm 2024-06-14

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-31

E · Potential for more than minimal harm 2024-06-14

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-05-31

F · Potential for more than minimal harm 2023-04-13

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-05-01

F · Potential for more than minimal harm 2023-04-13

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2023-04-20

F · Potential for more than minimal harm 2023-04-13

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2023-04-20

F · Potential for more than minimal harm 2023-04-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-20

F · Potential for more than minimal harm 2023-04-13

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-04-13

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2023-04-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-27

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2025-07-01

D · Potential for more than minimal harm 2025-06-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-01

G · Actual harm 2025-02-19

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-01-28

F · Potential for more than minimal harm 2024-09-24

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-09-30

E · Potential for more than minimal harm 2024-09-24

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-09-30

E · Potential for more than minimal harm 2024-09-24

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-09-12

F622 · Resident Rights Deficiencies

Health

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 2024-09-25

D · Potential for more than minimal harm 2024-09-12

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-09-12

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2024-09-18

G · Actual harm 2024-08-22

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-09-30

G · Actual harm 2024-08-22

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-09-11

F · Potential for more than minimal harm 2024-08-22

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-09-30

D · Potential for more than minimal harm 2024-08-22

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-09-27

D · Potential for more than minimal harm 2024-08-22

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-09-11

G · Actual harm 2024-06-14

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-07-02

F · Potential for more than minimal harm 2024-06-14

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-07-01

E · Potential for more than minimal harm 2024-06-14

F808 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-07-02