Based on observation, interview, and record review, the facility failed to ensure there was not more than a 14-hour gap between the evening meal (dinner) and breakfast the following day for 118 out of 158 residents (40 residents received nutrition via tube feedings). The planned meal gap between dinner and breakfast the following day was 15 hours. The resident group had not approved the 15-hour gap between dinner and breakfast. This created the potential for residents to experience hunger while waiting for breakfast. …
F809 citations in Delaware
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.
Against expectation — 2025
Delaware cites F809 more often than its own record predicts
1.11 times the share F809 takes of citations nationally.
Of every deficiency written in Delaware in 2025, this is the portion that was F809.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Delaware surveyors wrote
F809 findings written in Delaware, 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 interview and review of the facility meal times, it was determined that the facility failed to ensure that the resident group agreed on the meal span, of more than fourteen (14) hours from dinner to breakfast the following day. Findings include: Review of the meal times revealed, that dinner is served at 5:00 PM and breakfast is served beginning at 8:00 AM. There was total of 15 hours between dinner and breakfast, thus, more than 14 hours from dinner to breakfast. During an interview on 12/17/19 at 2:15 PM, E7 (NSM) revealed that meal times had last been discussed with residents three years ago. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2024 | 0.35% | 1.65× |
| 2025 | 0.21% | 1.11× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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