Based on record reviews, resident and staff interviews, the facility failed to provide pureed foods as ordered by the physician for 9 of 9 residents. (Resident #1, Resident #22, Resident #53, Resident #69, Resident #31, Resident #57, Resident #8, Resident #17, and Resident #26). On 01/22/23 dietary staff did not arrive for work. A central supply clerk and three nurse aides (NAs) prepared and served breakfast, lunch, and dinner to residents on pureed diets by chopping food into small pieces and not smooth consistencies. The staff had not been trained on food production and did not have skills to operate the food processor. This resulted in the high likelihood for residents to choke or aspirate. …
F805 citations in North Carolina
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
North Carolina cites F805 less often than its own record predicts
0.63 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F805 findings written in North Carolina, 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 observations, record review, Nurse Practitioner (NP), Speech Language Pathologist (SLP) and staff interviews, the facility failed to implement an effective system to ensure that a severely cognitively impaired resident with a diagnosis of dysphagia received the correct food texture (mechanical soft) as ordered by the physician (Resident #32). On 7/6/26, Resident #32 was observed in her bed sitting upright with her lunch tray in front of her on her overbed table. The lunch plate revealed a whole, soft dinner roll, ground turkey chili with beans over cream of rice, and whole asparagus spears. Resident #32 was observed trying to pick up the asparagus spears with her right hand and attempted to chew one spear but was unsuccessful in eating any of the asparagus. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.24% | 0.68× |
| 2024 | 0.32% | 0.88× |
| 2025 | 0.19% | 0.63× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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