Based on interview and record review, the facility failed to ensure staff followed the physician's order for a resident on a mechanical soft diet when the wrong texture of the diet was provided and failed to provide assistance with meals which resulted in a resident choking for 1 of 4 residents reviewed for dietary requirements. (Resident B) This deficient practice resulted in Resident B's death. The Immediate Jeopardy began on [DATE], when it was identified Resident B was provided a regular diet in place of a mechanical soft diet. Resident B choked on her dinner, was provided the Heimlich Maneuver, lost consciousness, and expired in the facility. …
F803 citations in Indiana
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
Indiana cites F803 less often than its own record predicts
0.23 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana 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 Indiana surveyors wrote
F803 findings written in Indiana, 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, observation, and record review, the facility failed to ensure a resident's preference for his meals was met for 1 of 32 residents reviewed for food and food preferences (Resident J). Findings include:During the initial pool interview, on 3/2/26 at 3:30 p.m., Resident J indicated he had requested more food with his meals, but they had not been giving him bigger portions. He had requested this quite a while back, but they still just gave him the regular small amounts. He got hungry in between his meals. During the lunch meal observation, on 3/5/26 at 12:06 p.m., Resident J's lunch tray was observed. Double portions were not observed, in the resident's meal tray, when compared to a regular portion meal tray. …
Based on observation, interview, and record review, the facility failed to ensure daily menus were posted for 3 of 5 days observed during the survey dates. Finding includes: During an observation, on 5/26/26 at 10:00 a.m., the posted daily menu was dated 5/24/26.During an observation, on 5/28/26 at 4:00 p.m., the posted daily menu was dated 5/27/26.During an observation, on 5/29/26 at 9:35 a.m., the posted daily menu was dated 5/27/26.During a review of the resident council minutes and grievance logs, on 5/29/26 at 8:18 a.m., a titled facility form, I Would Like To Know, dated 2/17/26, indicated the Resident Council voiced concerns about the daily menu not yet being posted on that day. The concern was reviewed during a morning meeting on 2/18/26. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.34% | 0.45× |
| 2024 | 0.34% | 0.47× |
| 2025 | 0.14% | 0.23× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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