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F0804
E

Failure to Provide Palatable and Properly Prepared Meals

Carbondale, Illinois Survey Completed on 08-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide hot, palatable, and properly prepared food to several residents, as evidenced by multiple complaints and direct observations. Four residents, all cognitively intact and with various medical diagnoses including diabetes, chronic pain, and chronic obstructive pulmonary disease, reported receiving meals that were cold, unappetizing, or improperly cooked. One resident received a cold piece of cheese pizza and had previously received burned hamburgers, providing photographic evidence of the poor food quality. Another resident refused to eat a cold meal with a breadstick that was too hard, and no substitution was offered. Test trays taken directly from the steam table confirmed that the pizza was served at 116.2°F, which was too cool, and the breadstick was hard and crunchy. Additional residents reported that scalloped potatoes served at lunch were undercooked, raw, and unpalatable. One resident, who consistently ate in her room, stated that her meal trays were always cold and that the food quality was consistently poor. Direct sampling of the scalloped potatoes from the steam table confirmed they were undercooked and crunchy. These findings were based on resident interviews, direct observation, and food temperature measurements, demonstrating a pattern of failure to ensure that food and drink were served at safe, appetizing temperatures and in a palatable condition.

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