Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
of F807 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 202567
Every F807 citation surveyors wrote nationally that year.
Facilities cited66
Distinct nursing homes with at least one F807 finding.
The harm level
How severely F807 is cited
3.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J62.2%
K20.7%
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D16461.2%
E8029.9%
F114.1%
No harm, potential for minimal
A—
B41.5%
C10.4%
Every recorded F807 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F807 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedDecember 17, 2025
Based on record review, observation. and staff interview the facility failed to ensure Resident #8 was served liquid in a form which met his individualized needs. Resident # 8 was ordered and care planned to receive nectar thickened liquids however during the noon time meal on 12/16/25 the resident was served regular consistency milk and regular consistency coffee. The resident did drink the thin liquids and experienced coughing. This was a random opportunity for discovery and was true for Resident #8. The State Agency (SA) determined the facility's failure to serve Resident #8 with nectar thickened liquids place him at immediate risk for serious harm and/or death. …
Based on review of the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received drinks/fluids in accordance with their needs and preferences, and in sufficient amounts to maintain hydration, by failing to complete a timely evaluation of daily fluid requirements and addressing fluid preferences for one of seven residents reviewed (Resident 3), resulting in harm due to dehydration with hospitalization for Resident 3, and by failing to take follow-up actions for residents who did not consume their recommended daily fluid intake requirements for four of seven residents reviewed (Residents 2, 3, 4, 5). …
D · No harm, potential for more than minimal, isolatedAugust 20, 2026
Based on observation, interview, and record review, the facility failed to give residents drinks, including water and other liquids consistent with resident needs and preferences (Resident #1). The facility failed to ensure LVN C gave Resident #1 honey thickened liquids during med pass, as ordered, on 08/19/2026 at 1:53 PM which resulted in the resident coughing.This failure could result in residents coughing, choking, aspirating (the action of drawing fluid by suction) thin fluids into her lungs, contracting aspiration pneumonia (an infection of the lungs).Findings Included:Record review of Resident #1's admission record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Dementia (memory loss), psychotic disturbance… …
B · No harm, potential for minimal, patternJune 12, 2026
Based on interviews, observations and record review, it was determined that the facility failed to serve residents meals that matched their tickets. This was evident for seven (Resident #74, #115, #146, #171, #193, #203 & #251) out of thirty-three residents observed during dining.The findings include:
The findings include:
On 06/08/2026 at 9:20 AM, during breakfast dining observation, review of meal tickets revealed coffee was listed as part of the beverages for residents. Observation revealed coffee was not served. …
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