This deficient practice pertains to intake MI#00130116: Based on observation, interview, and record review, the facility failed to provide fluids in the prescribed texture/consistency for one Resident (#9) of two residents reviewed for food/beverages served in proper form. This deficient practice resulted in the delivery of fluid of inappropriate consistency which resulted in episodes of choking and aspiration (accidental breathing of food/fluid into the lungs, which can cause pneumonia), and the likelihood of aspiration pneumonia and potential for death. Findings include: Review of Resident #9's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnoses including Huntington's Disease, aphasia, dysphagia, abnormal weight loss, and esophageal obstruction. …
F805 citations in Michigan
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
Michigan cites F805 less often than its own record predicts
0.09 times the national share — cited less often here than elsewhere.
Of every deficiency written in Michigan 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 Michigan surveyors wrote
F805 findings written in Michigan, 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.
This citation pertains to Incident 3044880Based on interview and record review, the facility failed to ensure a snack was given in a form consistent with physician diet orders for one (R302) of four residents reviewed for therapeutic diets resulting in R302 choking on a peanut butter sandwich requiring emergency intubation and was hospitalized with extensive hypoxic ischemic brain injury [brain damage due to loss of oxygen]. Findings include:A Facility Reported Incident [FRI] was received by the State Agency [SA] on 6/9/26 that reported in part R302 ate a peanut butter and jelly sandwich, staff performed the Heimlich Maneuver and R302 was transported to the hospital.Review of the closed record revealed R302 was admitted into the facility on 2/2/23 with diagnoses that included: acute… …
Based on observation, interview, and record review, the facility failed to prepare vegetables to the proper food consistency for four residents receiving pureed textured meals in the facility. Findings include: On 3/3/26 at 11:04 AM, during observations of the kitchen lunch service with Head [NAME] S and Dietary Manager (DM) Q, the steam table was set with pans of food ready to be served to facility residents. Due to a lack of space on the steam table, the pan of prepared pureed green beans, also ready to be served to the residents, was sitting in a pan of water on the hot stove. While taking food temperatures, the pureed green beans appeared lumpy. DM Q and the two State Surveyors present obtained and tasted a sample of the green beans. …
The short window
Recent years
| Year | Share of Michigan citations | vs expected |
|---|---|---|
| 2023 | 0.21% | 0.59× |
| 2024 | 0.11% | 0.30× |
| 2025 | 0.03% | 0.09× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Michigan surveyors cite →
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