Integrity HC of Carbondale: Cold Food Violations - IL
Federal inspectors visited Integrity HC of Carbondale on August 27, 2025, following a complaint, and documented what they found across multiple mealtimes: food that arrived cold, undercooked, or burned, served to residents who had nowhere else to turn.
The clearest evidence came from a resident identified in the inspection report as R7, a man who has lived at the facility since June 2021 and manages type 2 diabetes, among other conditions. On the evening of August 16, staff delivered his dinner tray at 5:55 PM, containing cheese pizza, salad, a breadstick, and ambrosia. He said the pizza was cold and unappetizing. That same day at noon, he had ordered two hamburgers. The cook burned them. He pulled out his phone and showed inspectors the photograph he had taken: two hamburgers with black charred spots across the cheese.
He told inspectors he was angry. He also told them he had started buying his own frozen hamburgers, kept in his room, for nights when he didn't like what was being served.
Fourteen minutes after R7's tray arrived that evening, inspectors watched staff deliver dinner to another resident, R3, who has chronic kidney disease and COPD in addition to diabetes. His tray held the same cheese pizza, a salad, and a breadstick. He told inspectors the pizza was cold and the breadstick was too hard to eat. "Take that back," he told staff. "I'm not eating that."
Staff took the tray. No substitution was offered.
At 7:15 that evening, inspectors pulled a test tray directly from the steam table and measured the pizza's temperature with a calibrated thermometer: 116.2 degrees Fahrenheit. They tasted it. It lacked flavor. They sampled the breadstick. It was hard and crunchy.
Five days later, on August 21, inspectors returned and found the same problems at lunch. R2, a resident managing diabetes, hypertension, and venous ulcers on both legs, was eating when inspectors arrived at 12:38 PM. She told them the scalloped potatoes weren't cooked and weren't good. At 12:40 PM, R7 said the same thing, describing the potatoes as raw, crunchy, and gross. Inspectors sampled the scalloped potatoes from the steam table at 12:23 PM. They were undercooked and crunchy.
R9 had been at the facility since June 2021. She has type 2 diabetes, COPD, and hypertension, and she always eats in her room. When inspectors reached her at 1:32 PM, her tray had been sitting on her overbed table long enough that it was cold. A few bites had been taken. Most of the food remained.
She told inspectors the scalloped potatoes weren't completely cooked. She told them her meal trays were always cold when they arrived. Then she said something inspectors included verbatim in their report: "The food is so bad here."
Inspectors cited the facility for failing to provide hot, palatable food to four of the twelve residents they reviewed for dietary services. The violation was cited at the level of minimal harm or potential for actual harm.
For residents managing diabetes, consistent and adequate nutrition is not a comfort issue. Meals that go uneaten, substitutions that are never offered, and food that sits cold in a room at the end of a hallway are the practical result of what inspectors documented here.
R9's tray was still on her table when inspectors left. Most of it untouched.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
INTEGRITY HC OF CARBONDALE in CARBONDALE, IL was cited for violations during a health inspection on August 27, 2025.
On the evening of August 16, staff delivered his dinner tray at 5:55 PM, containing cheese pizza, salad, a breadstick, and ambrosia.
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.