Integrity HC of Carbondale: Wrong Diet Served to TBI Patient - IL
The resident, identified in inspection records as R4, had a diet order on file since July 22, 2024, requiring mechanical soft texture food and thin liquid consistency. The order also called for pudding at supper, along with extra butter, margarine, and sauces or gravies with every meal. None of those items appeared on her tray that evening.
What did appear: pizza pieces that dietary staff had torn apart by hand, some larger than one inch by one inch, some containing the hard outer crust. And a whole, unmodified breadstick.
Inspectors recorded that R4 was unable to bite through the hard outer pizza crust or the breadstick.
R4's cognitive status made her unable to advocate for herself. A May 30, 2025 assessment documented a BIMS score of 4, placing her in the range of severe cognitive impairment. Her care plan, last revised in March 2025, flagged her as at risk for nutritional deficit because of her diagnoses. The plan named her traumatic brain injury, her dementia, and her rectal cancer as the reasons she needed close monitoring and intervention.
The facility's own weight assessment and intervention policy, written in 2024, laid out the framework the staff was supposed to follow. The policy identified chewing and swallowing abnormalities as a factor requiring diet modifications. It committed the multidisciplinary team to preventing and monitoring undesirable weight loss. It required the dietitian to review weight records monthly to track trends over time.
None of that framework was visible on R4's tray on June 18 at 5:57 in the evening.
The inspection, conducted August 27, 2025 and based on a complaint, resulted in a citation under F0692, covering the requirement that residents receive food that matches their assessed needs and physician orders. CMS rated the level of harm as minimal harm or potential for actual harm, with few residents affected.
That classification captures the regulatory category. It does not capture what it looked like: a woman with a brain injury, dementia, and cancer sitting in front of food she could not bite through, with no pudding, no butter, no sauce, no accommodation for the swallowing and chewing difficulties her own care plan had documented.
The torn pizza pieces were not cut by a kitchen tool. Dietary staff tore them by hand. The sizes varied. Some still had the hard crust attached. The breadstick was whole.
R4's order had been in place for more than eleven months by the time inspectors documented this meal. Whether June 18 was an isolated lapse or part of a longer pattern, the inspection report does not say. What it says is that on that evening, the standing order was not followed, the prescribed supplements were not provided, and the resident could not eat what she was given.
She went without her pudding. She went without the extra butter and sauces meant to add calories to her meal. She sat with food in front of her that her own care team had determined, nearly a year earlier, she should not be served.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 1, 2026 · Our methodology
INTEGRITY HC OF CARBONDALE in CARBONDALE, IL was cited for violations during a health inspection on August 27, 2025.
The order also called for pudding at supper, along with extra butter, margarine, and sauces or gravies with every meal.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.