Based on observation, interview, and record review, the facility failed to follow diet orders for residents who receive mechanical soft diets, failed to document residents' noncompliance with mechanically altered diets, and failed to educate facility staff on residents who are on mechanically altered diets. These failures resulted in R1, who has a history of choking and requiring the Heimlich Maneuver, being able to purchase snacks from V5 (Medical Records) that were not part of R1's physician ordered diet texture. These failures have the potential to affect all 20 residents (R1, R4 through R22) who reside in the facility that receive a mechanically altered diet.These failures resulted in an Immediate Jeopardy that began on 7/12/25. …
F803 citations in Illinois
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.
Against expectation — 2025
Illinois cites F803 more often than its own record predicts
1.64 times the share F803 takes of citations nationally.
Of every deficiency written in Illinois in 2025, this is the portion that was F803.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F803 findings written in Illinois, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview, and record review, the facility failed to provide the correct textured diet for 1 of 19 (R2) residents reviewed for diet in a sample of 19. This failure resulted in R2 choking and being sent to the hospital. Findings include: R2's admission Record documents an admission date of 10/28/2024 with diagnoses including in part dementia and dysphagia oropharyngeal phase. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. …
Based on observation, interview and record review, the facility failed to ensure residents receive nutritionally adequate meals and follow recipes. These failures have the potential to affect all 172 residents receiving food prepared in the facility's kitchen. Findings include:On 07/28/26 at 3:23 PM, R1 stated orange juice is not served every day, so the residents are not getting their Vitamin C. R1 said, Isn't that a rule or something? Don't we need a certain amount of Vit C in the day? R1 stated on the menus it is only listed as beverage so, the kitchen gives them apple juice or cranberry juice or lemonade or fruit punch. R1 asked, but that is not real juice, right? Plus, when they give us any kind of juice it is watered down with ice. R1 said, Don't get me started on the milk. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 1.27% | 1.71× |
| 2024 | 1.00% | 1.38× |
| 2025 | 1.02% | 1.64× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction