Based on observation, record review and interview, the facility failed to ensure ground meat was provided in accordance with the physician orders and failed to ensure specialized dietary instructions were provided to nursing staff for 6 of 6 residents on a memory care unit reviewed for a mechanically altered with ground meat diet. (Residents B, G, H, J, K, and L) This deficient practice resulted in a cognitively impaired resident with a history of food stuffing, ingesting the regular meat, the resident's airway becoming blocked, and the resident expired. …
F805 citations in Indiana
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
Indiana cites F805 less often than its own record predicts
0.92 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana 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 Indiana surveyors wrote
F805 findings written in Indiana, 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 record review and interview, the facility failed to provide the appropriate supervision and the appropriate textured diet for 1 of 3 residents reviewed for mechanically altered diets that resulted death. (Resident B) Finding includes: A record review was completed for Resident B on [DATE] at 4:33 P.M. Diagnoses included, but were not limited to: Parkinson's disease, hemiplegia, dementia, and atrial fibrillation. A Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], indicated Resident B had severe cognitive impairment. He was able to be understood and understand others. He required meal set-up with supervision for eating. …
Based on interview and record review, the facility failed to ensure a provided diet was comparable and compatible to the diet ordered from a rehabilitation hospital on admission for 1 of 3 residents reviewed for therapeutic diets. (Resident E)Findings include:The clinical record for Resident E was reviewed on 3/30/26 at 11:05 a.m. The diagnoses included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (inability to produce speech), and dysarthria (motor speech disorder which impairs control of the muscles used for speech).Resident E was admitted , on 1/14/26 at 11:08 a.m., from a rehabilitation (rehab) hospitalThe rehab hospital Discharge summary, dated [DATE], indicated speech-language… …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.26% | 0.74× |
| 2024 | 0.26% | 0.72× |
| 2025 | 0.28% | 0.92× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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