of F800 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025105
Every F800 citation surveyors wrote nationally that year.
Facilities cited105
Distinct nursing homes with at least one F800 finding.
The harm level
How severely F800 is cited
0.5% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J10.2%
K—
L10.2%
Actual harm
G10.2%
H—
I—
No harm, potential for more than minimal
D29351.5%
E19634.4%
F7513.2%
No harm, potential for minimal
A—
B20.4%
C—
Every recorded F800 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F800 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
L · Immediate jeopardy, widespreadJune 1, 2026
Based on observation, interview, and record review, the facility failed to have a system in place to provide sufficient food to meet the daily nutritional requirements of residents and serve the facility planned/approved menu.This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 5/18/26 at 11:58 AM when the facility failed to maintain two days' worth of food supplies on hand, failed to purchase food in quantities/quality to be able to serve all residents the planned, palatable menu, and failed to have sufficient food to serve double portions and dietary supplements to residents with recent significant weight loss.This applies to 14 of 14 residents (R11, R15, R16, R21, R22, R23, R24, R25, R27, R28, R30, R31, R32, and R33) reviewed for residents with significant weight… …
Based on interview and record review, the facility failed to provide dietary services that met individualized dietary needs for 1 of 1 resident (Resident 64), reviewed for specialized diets. Resident 64 was on a physician ordered, gluten-free diet (no wheat, barley, or rye) related to a diagnosis of celiac disease (a disease that causes inflammation of the intestines if gluten is ingested). Resident 64 was served gluten in the form of a Salisbury steak on 12/24/2023. This failure caused harm to Resident 64 who experienced dizziness, nausea, and shortness of breath after consuming the gluten. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based upon clinical record review and staff interview, it was determined that the facility failed to ensure that a resident with a food allergy received the appropriate and dietary equivalent for one of 12 residents reviewed (Resident 34).Findings include:Review of Resident 34's clinical record revealed dietary allergies including gluten allergy, wheat bran allergy, lactose allergy, beef derived product and beef allergy.Review of dietary menus and dietary menu extensions failed to reveal evidence of a gluten free/gluten restricted dietary menu extension.Interview with Employee E4 on August 28, 2026, at 12:45 p.m. revealed that the facility had a gluten free menu extension, but it was in a drawer in the kitchen and that the menu extension wasn't usually utilized. …
B · No harm, potential for minimal, patternJuly 17, 2024
Based on observation, record review, and interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, for two Residents (#7 and #49), the facility failed to ensure the Residents' food preferences were met.
Findings include:
Review of the facility's policy titled Food Preferences, dated 2020, indicated but was not limited to the following:
-Resident food preferences are kept on file in the Dining Services Department as a part of the meal card system and used to ensure each resident's needs and desires are met. …
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide and implement an infection prevention and control program.
Cited in the same inspection, not caused by one another.
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