Based on a review of facility policies, observations, and staff and resident interviews, it was determined that the facility failed to provide meals in accordance with resident needs and preferences to ensure adequate nutrition and hydration and failed to consistently provide bedtime snacks as required for 3 of 36 residents. This deficient practice resulted in a lack of nutritionally adequate meals for 36 of 36 residents in the facility, created the potential for nutritional deficiencies, and placed all residents in Immediate Jeopardy to their health and safety. Findings include: A review of the facility's undated policy titled Frequency of Meals revealed that each resident shall receive three meals daily as well as snacks in between meals. …
F809
Nutrition and Dietary Deficiencies
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F809 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F809 finding.
The harm level
How severely F809 is cited
0.3% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L10.1% |
| Actual harm | G10.1% | H10.1% | I— |
| No harm, potential for more than minimal | D17319.8% | E49356.5% | F19121.9% |
| No harm, potential for minimal | A— | B70.8% | C60.7% |
In the surveyor’s words
What an F809 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.
Based on observation, interview, and record review the facility failed to provide a bedtime snack and breakfast for two (R1, R3) of three residents reviewed for food services on a sample list of six. Findings include:The facility's undated Passing Meal Trays policy provided by the facility documents that nursing will be responsible for delivering all trays to residents whether the resident is eating in the dining room or in the resident room. Nursing will advise Food Service of residents not eating in their usual location. The facility's Meal Schedule undated policy provided by the facility documents that three meals will be served daily at similar times as served in the community. …
Based on observation, interview, and record review, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for 3 of 3 (lunch on 09/08/2026, 09/09/2026, and 09/10/2026) meals observed for dietary services.The facility failed to serve the 09/08/2026, 09/09/2026, and 09/10/2026 lunch meals on time at the scheduled time based on the meal postings.This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life.The findings included:Observation on 09/08/2026 at 12:00 p.m. …
Based on interview, the Resident Council Meeting, the facility's MEAL SERVICE TIMES, and the facility's policy for FREQUENCY OF MEALS; the facility failed to ensure cart deliveries of meals were not scheduled to exceed 14 hours between service from Dinner to Breakfast for Rehab/West Hall, North Hall, South Hall, and Meal Assist. This had the potential to affect 84 of 84 residents receiving meals at the facility.Findings Include: The facility's policy for FREQUENCY OF MEALS, last revised 6/2017 and last reviewed 12/2023, included the following: . POLICY: . There is no more than a fourteen (14) hour span between a substantial evening meal and breakfast. …
By state — 2025
Where F809 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- Pennsylvania2.30× · 29 citations
- Illinois2.27× · 29 citations
Co-occurrence
Cited alongside F809
Of the 2025 surveys that cited F809, these tags appeared in the same inspection more often than chance would predict.
- F80323.7% of F809 surveys · 9.2× chance
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- F80427.5% of F809 surveys · 7.2× chance
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
- F72517.4% of F809 surveys · 5.4× chance
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- F55033.3% of F809 surveys · 3.8× chance
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F58432.4% of F809 surveys · 3.7× chance
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Cited in the same inspection, not caused by one another.
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