Based on facility policy review, medical literature review, clinical record reviews, review of facility documents, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for one of 40 residents (Resident R1). This failure resulted in Resident R1 choking on food that he was not ordered which caused him to cease to breathe. This failure placed an additional 40 residents that had similar diet needs at risk which resulted in an Immediate Jeopardy situation for 40 of 107 residents.Findings include: Review of facility policy Dysphagia (difficulty swallowing) Diets dated 2/16/26, indicated the following: Individuals with observed indicators of dysphagia (coughing, choking, delayed swallow, pocketing of food [storing… …
F805 citations in Pennsylvania
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
Pennsylvania cites F805 less often than its own record predicts
0.69 times the national share — cited less often here than elsewhere.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F805 findings written in Pennsylvania, 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 review of facility policy, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with the proper food consistency as ordered by the physician for one of five residents reviewed (Resident 1), who choked, requiring a hospital admission for hypoxia and aspiration. Findings include: A facility policy for therapeutic diet orders dated January 13, 2025, indicated that dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. …
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to prepare food in a form to meet physician ordered diets for one of six residents (Resident R153).Findings include: Review of the facility policy Dining and Meal Service - CU2.2 last reviewed 4/16/26, indicated food will be at the proper texture/consistency to meet each individual's needs and desires. Mechanically altered diets, such as pureed diets (food has been ground, pressed, blended or sieved into a smooth creamy and uniform paste or liquid), are prepared and served as separate entree items. Review of the clinical record indicated Resident R153 admitted to the facility on [DATE]. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.16% | 0.45× |
| 2024 | 0.20% | 0.54× |
| 2025 | 0.21% | 0.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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