Based on observation, facility policy review, and staff and resident interview, it was determined that the facility failed to ensure that hot beverages were monitored and served at a safe temperature on the nursing units which placed residents at risk for burn injuries. ([NAME] Court, units 100, 200, and 300) This failure resulted in an Immediate Jeopardy situation. Findings include: Review of documentation by the American Burn Association's Burn Prevention Committee entitled, Scald Injury Prevention, revealed that a scald injury occurred when a hot liquid damaged one or more layers of skin and hot beverages were a frequent source of scald burns. Older adults were the most frequent victims of scald injuries due to thin skin, reduced mobility, and reduced ability to feel heat. …
F804 · Food palatability and temperature
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F804 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F804 finding.
The harm level
How severely F804 is cited
0.1% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G40.1% | H10.0% | I— |
| No harm, potential for more than minimal | D1,08926.0% | E2,40657.5% | F65615.7% |
| No harm, potential for minimal | A— | B250.6% | C50.1% |
In the surveyor’s words
What an F804 citation says
One finding from each severity level, 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 failed to ensure hot coffee was served at a safe temperature for 1 of 3 residents reviewed for accidents, resulting in a resident sustaining skin burns when coffee was spilled on her lap, (Resident B). This deficient practice had the potential to affect 112 of 112 residents who could choose to receive daily hot coffee from the facility kitchen.Findings include:On 4/29/26 at 9:56 A.M., Resident B's clinical record was reviewed. …
Based on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 2 of 2 meals reviewed for palatability.The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 2 of 2 meals observed on 9/15/26 for lunch and dinner.These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.The findings included:Record review of the Resident Council Minutes dated 06/15/26 revealed resident comments related to the food served in the facility. …
Based on observation, resident and staff interviews, and policy review, the facility failed to ensure food was served at safe and palatable temperatures to the residents. This had the potential to affect 66 residents who received food from the kitchen. Two residents were nothing by mouth. The facility census was 68.Findings include:Observation on 07/13/26 at 10:04 A.M. of the kitchen revealed the plates were inside of the warmer but the warmer was not plugged into the wall.Interview on 07/13/26 at 10:51 A.M. with Resident #51 revealed the food at the facility was not always served warm, and stated it depended on what staff was working and passing out the food trays. Observations on 07/13/26 from 11:45 A.M. to 12:09 P.M. …
By state — 2025
Where F804 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- West Virginia2.56× · 26 citations
- New York1.79× · 45 citations
- Iowa1.78× · 39 citations
- Massachusetts1.51× · 36 citations
- Pennsylvania1.43× · 87 citations
- Missouri1.41× · 49 citations
- Ohio1.21× · 72 citations
- Michigan1.15× · 40 citations
- Washington1.10× · 29 citations
- Wisconsin1.07× · 27 citations
- Texas1.06× · 94 citations
- Indiana0.98× · 32 citations
Co-occurrence
Cited alongside F804
Of the 2025 surveys that cited F804, these tags appeared in the same inspection more often than chance would predict.
- F8095.7% of F804 surveys · 7.2× chance
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
- F80315.9% of F804 surveys · 6.2× chance
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.
- F8023.8% of F804 surveys · 6.0× chance
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
- F8069.6% of F804 surveys · 5.9× chance
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F8057.0% of F804 surveys · 5.5× chance
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Cited in the same inspection, not caused by one another.
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