Based on review of clinical records review, physician's orders, review of the Medical Examiner's limited autopsy dated [DATE], review of the Georgia Nutrition Consulting, Inc. Modified Textures policy dated [DATE], review of the facility Incident report findings, dated [DATE] and staff interviews, the facility failed to follow physician's orders for a therapeutic diet, thus resulting in aspiration and death for one (1) resident (R) #11 from a sample of fourteen 14 residents. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. …
F808 citations in Georgia
Nutrition and Dietary Deficiencies
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Georgia cites F808 less often than its own record predicts
0.78 times the national share — cited less often here than elsewhere.
Of every deficiency written in Georgia in 2025, this is the portion that was F808.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F808 findings written in Georgia, 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 observation, interview and record review the facility failed to assure that two residents (R) (R34 and R90) from a sample of 47 residents, received and consumed foods in the appropriate form as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with goals and preferences. The deficient practice increased the risk of adverse clinical outcomes. Findings include:Record review of the facility diet type report dated 03/05/2026, revealed R90's diet was listed as regular, mechanical soft, reduced concentrated sweets, no added salt. The report specified R34 should receive a mechanical soft, regular diet, reduced concentrator sweets, no added salt. 1.R90 was admitted [DATE]. …
The short window
Recent years
| Year | Share of Georgia citations | vs expected |
|---|---|---|
| 2024 | 0.07% | 0.40× |
| 2025 | 0.11% | 0.78× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Georgia surveyors cite →
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