Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs (requirements for a person's well-being, such as food) for:1. Three (3) of eight (8) sampled residents (Resident 14, Resident 96, and Resident 24) on pureed diet (a texture modified diet that consist of smooth, pudding-like consistencies that are easy to swallow) by not following the recipe for puree oatmeal and in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks) when on 1/13/2026, Resident 14, Resident 96, and Resident 24 were served regular oatmeal with lumps, grains, and was not pureed.2. …
F805 citations in California
Food in a form residents can eat · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F805 more often than its own record predicts
1.39 times the share F805 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F805.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F805 findings written in California, 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, medical record review, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed as ordered by the physician for one of eight residents (Resident 16) observed during dining. * The facility failed to ensure Resident 16 received the correct therapeutic diet per the physician's order. This failure posed a risk for choking or aspiration (a condition in which the food, liquids, saliva, or vomit is breathed into the airway) episodes.Findings: Review of the facility's P&P titled Therapeutic Diet Orders dated 12/19/22, showed the facility provides all the residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the… …
Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' meal was served according to their diet order for all the residents receiving meal from the kitchen as per the facility P&P. * The facility failed to ensure prior to serving the meal trays, the licensed nurse checked the foods served to the residents were according to the physician's order. This failure posed the risk for the residents to not receive the correct diet as ordered by the residents' physicians.Findings: Review of the facility's P&P titled Dining Program revised 1/30/25, under the section for Staff Assignments - Licensed Nurses, showed to check the meals against the attending physician's order. On 8/1/25 at 1209 hours, a dining room meal observation was conducted. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.41% | 1.17× |
| 2024 | 0.35% | 0.98× |
| 2025 | 0.42% | 1.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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