Based on interview and record review, the facility did not follow the menu and ensure that 13 of 13 residents who required a mechanically soft diet (R6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20) received a mechanically altered diet in accordance with established national guidelines. R6 choked on the broccoli that he received, and he later expired in the emergency room . The failure to follow the menu and ensure the resident received a mechanically altered diet, created a finding of Immediate Jeopardy that began on [DATE]. The Nursing Home Administrator (Administrator-A) and Director of Nursing (DON-B) were notified of the immediate jeopardy on [DATE] at 3:31 p.m. The immediate jeopardy was removed on [DATE]. …
F803 citations in Wisconsin
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
Wisconsin cites F803 less often than its own record predicts
0.65 times the national share — cited less often here than elsewhere.
Of every deficiency written in Wisconsin 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 Wisconsin surveyors wrote
F803 findings written in Wisconsin, 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, interview, and record review, the facility did not ensure 1 resident (R) (R20) of 2 sampled residents received portion sizes in accordance with their daily ordered diet.R20's care plan contained a goal to consume 75% of their daily ordered diet. Staff deviated from R20's diet order and served half portions without their consent.Findings include:The facility's undated Nutrition Policy indicates: Good [NAME] Nursing Home will provide residents with meals and fluids that meet their nutritional and hydration needs while taking into consideration physician/provider orders, allergies, food preferences, and individual dietary needs .2. Resident food preferences, allergies, and special dietary needs will be identified and communicated to nursing and dietary staff .4. …
The short window
Recent years
| Year | Share of Wisconsin citations | vs expected |
|---|---|---|
| 2023 | 0.44% | 0.60× |
| 2024 | 0.45% | 0.63× |
| 2025 | 0.40% | 0.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Wisconsin surveyors cite →
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