Based on review of facility policy, record review, and interview, the facility failed to follow Resident (R)138's diet order which resulted in R138 choking and dying. This failure had the possibility to negatively impact the 34 residents on a mechanical soft diet residing in the facility. On 07/30/26 at 4:46 PM, the Administrator and Director of Nursing were provided with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 06/26/26. The IJ was related to 483.60 - Food and Nutrition Services. On 07/30/26, the facility provided an acceptable plan for removal of the IJ. The survey team verified all elements of the facility's removal plan and determined that the facility put forth due diligence in addressing the noncompliance. …
F803 · Menus
Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F803 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F803 finding.
The harm level
How severely F803 is cited
1.3% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J290.9% | K40.1% | L— |
| Actual harm | G40.1% | H10.0% | I10.0% |
| No harm, potential for more than minimal | D96931.2% | E1,52449.0% | F52616.9% |
| No harm, potential for minimal | A— | B250.8% | C270.9% |
In the surveyor’s words
What an F803 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.
Licensure Reference Number 174 NAC 12-006.11 (A) Based on record review and interview, the facility failed to provide the correct therapeutic diet for one resident (Resident 3) of 5 sampled residents. The facility census was 142.Findings are: A record review of the admission Record with the printed date of June 25th, 2026 revealed that Resident 3 was admitted to the facility on [DATE] with the diagnosis of Pneumonitis due to inhalation of food and vomit, Dementia (a decline in mental abilities severe enough to interfere with daily life), and dysphagia (difficulty swallowing food or liquids). …
Based on observation, interview and record review the facility failed to follow the menu for 1 of 2 days (09/10/2026) reviewed for the breakfast and lunch meal service.1. Dietary staff failed to follow the breakfast menu on 09/10/2026 and served biscuits and sausage gravy, oatmeal and dry cereal and lunch menu on 09/10/2026 and served steamed red potatoes, salad with dressing mixed in, hot dog bun with steak patty and sauteed onions, sauteed bell peppers, and lemon pudding on graham cracker crumbs.2. Dietary staff failed to maintain and document menu substitutions. 3. …
Based on record review, observation and interview, the facility failed to ensure that menus were followed and that the alternatives presented were available in one of one facility kitchen. Specifically, residents and staff in the facility reported the posted menus were not followed for all residents, with alternatives being served to parts of the population due to the facility kitchen running out of the menu meal option. Alternative choices that were presented to residents were not provided due to a lack of product. The findings include: During a concurrent tour and interview of the facility kitchen on 08/17/2026 at 8:44 AM, the Dietary Manager (DM) reported the kitchen's freezers contained enough food for a minimum of three days, and a food truck was expected tomorrow morning. …
By state — 2025
Where F803 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Iowa2.65× · 39 citations
- Illinois1.64× · 68 citations
- California1.51× · 148 citations
- Ohio1.50× · 60 citations
- Pennsylvania0.76× · 31 citations
- Texas0.64× · 38 citations
Co-occurrence
Cited alongside F803
Of the 2025 surveys that cited F803, these tags appeared in the same inspection more often than chance would predict.
- F8026.9% of F803 surveys · 10.7× chance
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- F8097.3% of F803 surveys · 9.2× chance
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
- F80511.5% of F803 surveys · 9.1× chance
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- F8016.9% of F803 surveys · 6.4× chance
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
- F80610.3% of F803 surveys · 6.3× chance
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Cited in the same inspection, not caused by one another.
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