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.
F808 in Illinois. Pick another state for the same tag.
Against expectation — 2025
Illinois cites F808 more often than its own record predicts
Versus expected share2.26×
2.26 times the share F808 takes of citations nationally.
Share of Illinois citations0.33%
Of every deficiency written in Illinois in 2025, this is the portion that was F808.
Illinois0.33%
National0.15%
Share of all citations that were F808.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Illinois surveyors wrote
F808 findings written in Illinois, 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.
J · Immediate jeopardy, isolatedOctober 17, 2024
Based on interview and record review, facility staff failed to implement physician's orders for a resident's (R2's) downgraded diet to mechanical soft, resulting in R2 experiencing a second choking episode. R2 expired in the local hospital on [DATE] from complications of aspiration pneumonia and choking on food. This applies to 1 of 3 residents reviewed for specialized diets in the sample of 8.
This failure resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on [DATE] when R2 experienced a choking episode and R2's nurse practitioner ordered for R2 to receive a mechanical soft diet until he was evaluated by speech therapy. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 1:30PM. …
D · No harm, potential for more than minimal, isolatedJuly 29, 2026
Based upon observation, interview, and record review the facility failed to serve diet as ordered, failed to follow physician orders, and failed to ensure that dietary cards are congruent with physician orders. This failure applies to 1 resident (R31) reviewed for therapeutic diet in the sample of 19.Findings include:R31's (4/3/23) POS (Physician Order Sheets) include Diet: General, Regular double protein at all meals. R31's (6/24/26) BIMS (Brief Interview Mental Status) determined a score of 15 (cognition intact). On 7/27/26, the facility lunch was served late due to tornado warning. On 7/27/26 at 1:41pm, the dietary card on R31's tray stated, regular diet/double portion at all meals (R31's orders state double protein NOT portions therefore the dietary card was incorrect). …
C · No harm, potential for minimal, widespreadFebruary 7, 2020
Based on observation, interview, and record review, the facility failed to follow the pureed diet menu by not serving pureed bread. This failure affected 17 residents (R6, R8, R15, R13, R30, R31, R32, R62, R63, R81, R110, R129, R163, R174, R207, R467, R468) of 17 residents reviewed for special diets.
Findings include:
On 02/05/20 at 10:42 AM, surveyor observed V10 (Cook) prepare lunch meal and special diets. Surveyor did not observe prepare any pureed bread during food preparation.
On 02/05/20 at 11:41 AM surveyor observed lunch tray line and did not see staff plate pureed bread on pureed meal trays.
On 02/05/20 at 11:42 AM surveyor asked V9 (dietary manager) to verify menu and verify if pureed bread was being served. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction