Based on observations, interviews and policy review the facility failed to follow the correct therapeutic menu (mechanical soft) for four Residents (#62, #53, #50 and #4) out of a total sample of 34 residents. Specifically, 1. Resident #62, who has a known history of choking twice at the facility, requiring the Heimlich maneuver and emergent transfer to the hosital, was observed to be served the incorrect diet, placing the Resident at serious risk of a repeated choking incident and/or death, 2. Resident #53 who has a long-standing history of dysphagia (difficulty chewing and swallowing), was served food not on his/her recommended diet, and 3. two Residents (#50 and #4) were provided a meal not in accordance with the physician's order. Findings include: 1. …
F803 citations in Massachusetts
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
Massachusetts cites F803 less often than its own record predicts
0.50 times the national share — cited less often here than elsewhere.
Of every deficiency written in Massachusetts 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 Massachusetts surveyors wrote
F803 findings written in Massachusetts, 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 observation, record review, and interviews, the facility failed to follow the planned menu for one Resident (#8), out of a total sample of 24 residents. Specifically, the facility failed to ensure staff followed the Resident's diet slips, resulting in food items not being provided to Resident #8 for three of three observed meals. Findings include:Resident #8 was admitted to the facility in July 2025 with diagnoses including type two diabetes mellitus, dementia, anxiety disorder, dysphagia, adjustment disorder with depressed mood, chronic kidney disease, and gastro-esophageal reflux disease. …
Based on interviews, the facility failed to follow their scheduled menu and failed to notify residents of the changes or updates to the menu. Findings include: During an interview on 10/05/21 at 11:48 A.M., Resident #43 said, The food is okay, but they don't have what is on the menu. Last week we were supposed to have pizza and didn't have it so they gave us a [MEDICATION(S)] fish sandwich instead. Then recently we were supposed to get lasagna and they didn't have it either. During an interview on 10/6/21 at 1:53 P.M., the Dietitian said that the facility was having trouble getting food from their food vendor and she did not know if the residents were made aware. …
The short window
Recent years
| Year | Share of Massachusetts citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 0.10× |
| 2024 | 0.18% | 0.25× |
| 2025 | 0.31% | 0.50× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Massachusetts surveyors cite →
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