Based on observation, interview, and document review the facility failed to ensure mechanically altered diets were served as prescribed for 6 of 6 residents (R1, R2, R3, R4, R5, R7) with a physician ordered modified texture diet. This resulted in R1 receiving the incorrect diet, an unaltered piece of pizza, on 6/10/26. R1 required the Heimlich maneuver to dislodge the pizza from her throat. The immediate jeopardy (IJ) began on 6/10/26, at approximately 5:30 p.m., when facility staff served R1 the incorrect diet resulting in R1 needing the Heimlich maneuver performed to dislodge a piece of pizza from her throat. The IJ was identified on 7/1/26, the administrator was notified of the IJ on 7/1/26, at 3:15 p.m. …
F803 citations in Minnesota
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
Minnesota cites F803 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F803 findings written in Minnesota, 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 document review, the facility failed to serve menu items as listed and planned for 1 of 3 residents (R37) reviewed for nutrition services.Findings include:R37's facesheet printed 9/10/25, indicated diagnoses of chronic pain syndrome, edema, liver transplant, and pain.R37's care plan dated 8/1/25, indicated potential for alteration in nutrition with interventions of low sodium diet, soft and bite sized textures, take orders at meals and offer alternatives.R37's physician's order dated 1/6/25, indicated low sodium diet, thin liquids, sit upright for all meals.R37's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, no rejection of care, independent with eating after setup assistance, and no weight loss.During observation… …
Based on observation, interview and document review the facility failed to follow the established menus. This had the potential to affect all 13 residents currently residing at the facility.Findings include:R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4's diagnoses included depression, anxiety, post-traumatic stress disorder (PTSD), and diabetes. R4's cognition was intact.R4's care plan dated 5/4/26, directed staff to provide and serve diet as ordered. Registered dietician (RD) to evaluate and make diet change recommendations as needed and to provide and serve diet as ordered (regular diet). R4's care plan lacked information regarding R4's food preferences.During an interview on 7/15/26 at 11:25 a.m., R4 stated cereal with water was served for breakfast this morning. …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 0.35× |
| 2024 | 0.35% | 0.49× |
| 2025 | 0.35% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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