The man, identified as R7 in the August inspection report, had ordered the hamburgers for his noon meal at Integrity HC of Carbondale. Instead of eating them, he photographed the evidence of what he called the kitchen's latest failure.
"I was angry because for the noontime meal I had ordered 2 hamburgers, and the cook had burned them," R7 told inspectors during their August 16 visit. The diabetic resident said he now keeps frozen hamburgers in case he doesn't like what the kitchen serves.
That evening, R7's dinner tray arrived with a piece of cheese pizza he described as "cold and unappetizing." When inspectors tested pizza taken directly from the steam table with a calibrated thermometer, it measured just 116.2 degrees Fahrenheit.
The pizza "felt too cool, and when tasted the pizza lacked flavor," inspectors wrote.
Federal inspectors found that four residents out of 12 reviewed received food that was either cold, undercooked, or both during their complaint investigation at the 120-bed facility.
R3, who has chronic obstructive pulmonary disease and diabetes, received the same cold pizza dinner on August 16. The breadstick on his tray was "too hard to eat," he told staff. "Take that back! I'm not eating that," R3 said, according to the inspection report.
Staff removed his meal tray. No substitution was offered.
Five days later, the kitchen's problems continued with lunch. Multiple residents complained about scalloped potatoes that were undercooked and crunchy.
R2, who has diabetes and chronic venous hypertension with leg ulcers, told inspectors at 12:38 PM that "the scalloped potatoes weren't cooked and were not good."
R9, another diabetic resident with chronic obstructive pulmonary disease, said her noon meal tray was cold when it arrived. She always ate in her room, she explained, "and her meal trays were always cold."
"The food is so bad here," R9 told inspectors. Her lunch tray sat mostly untouched on her overbed table, with only a few bites taken.
R7 described the same scalloped potatoes as "raw, crunchy, and gross."
When inspectors sampled the scalloped potatoes directly from the steam table at 12:23 PM, they confirmed the residents' complaints. The potatoes were "undercooked and crunchy."
All four residents who complained were cognitively intact, with Brief Interview for Mental Status scores of 15 indicating they could accurately assess their food quality. R7 had been at the facility since June 2021, R9 since June 2021, R2 since October 2023, and R3 since December 2024.
The facility's dietary orders showed R7 was supposed to receive low concentrated sweets with regular texture and double protein portions with all meals due to his diabetes. Instead, he was getting cold pizza and burned hamburgers.
R3's meal removal without a substitute violated basic dietary standards for residents who refuse food due to quality issues.
The inspection found the facility failed to ensure food was served at safe and appetizing temperatures, a fundamental requirement for resident nutrition and satisfaction. Cold food delivery appeared to be an ongoing problem, particularly for residents who ate in their rooms rather than the dining room.
The temperature violations extended beyond individual complaints. The systematic issues with the steam table suggested problems with food holding and delivery processes throughout the facility.
R9's statement that her meal trays were "always cold" indicated the problem was not isolated to the inspection days but represented an ongoing failure to maintain proper food temperatures during transport and service.
The burned hamburgers R7 photographed demonstrated additional kitchen management failures beyond temperature control, suggesting inadequate cooking supervision and quality control procedures.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm to residents, but the widespread nature of the complaints across multiple meal services and several days suggested systemic dietary department failures.
The facility serves residents with serious medical conditions including diabetes, chronic obstructive pulmonary disease, and kidney disease, conditions that require proper nutrition and appetizing meals to maintain health and encourage adequate food intake.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Integrity Hc of Carbondale from 2025-08-27 including all violations, facility responses, and corrective action plans.