Based on observation, interview, and record review the facility failed to ensure 1 of 6 residents (CR#1) reviewed for puree diets received the diet ordered per physician order. The facility failed ensure and provide CR #1 had puree diet for his HS snack. CR #1 was given a peanut butter and jelly sandwich to eat in his room. CR#1 choked and died from asphyxiation. This failure affected 1 expired resident. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility had implemented effective interventions and monitoring in place. …
F808 citations in Texas
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
Texas 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 Texas 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 Texas surveyors wrote
F808 findings written in Texas, 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 ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for one (Resident #1) of 6 residents reviewed for therapeutic diets. - LVN A did not follow Resident #1's physician ordered for a pureed diet and gave the resident cookies. Resident #1 started chocking and was transferred to the hospital where she was diagnosed with [REDACTED]. This failure affected 1 resident placing her at risk of choking and aspiration pneumonia. Findings include: Resident #1 Record review of Resident #1's face sheet revealed that the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility 04/18/2019. …
Based on observation, interview and record review the facility failed to ensure the therapeutic diet prescribed by the physician or his delegate were adhered to by the kitchen staff for 19 of 19 residents (Resident #13, #14, #23, #29, #30, #34, #37, #57, #62, #64, #72, #75, #78, #79, #83, #85, and #86) prescribed a mechanical soft and mechanical soft with ground meat diet. -The facility failed to serve food in the appropriate form on 08/11/2026 at 11:38 a.m. when [NAME] L blind poured milk into the food processor for the puree diets of Salisbury steak, rice, okra, and bread.-The facility failed to serve food in the appropriate form on 08/11/2026 at 12:00 p.m. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.18% | 0.92× |
| 2024 | 0.18% | 1.05× |
| 2025 | 0.11% | 0.78× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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