Based on record review, observations, and staff interviews, the facility failed to serve 3 of 4 meals observed (the lunch meal on 7/19/26 and the breakfast and lunch meals on 7/21/26) at scheduled mealtimes. This failure had the potential to affect all residents who received food by mouth on 2 of 2 hallways (Halls 100 and 200). The facility had a census of 115.Findings included: a. Review of the meal serving times provided by the facility for the lunch meal on 7/19/26 revealed the lunch trays were scheduled as follows:1st cart at 11:30 AM to the dining room2nd cart at 12:00 PM to the 200 hallway3rd cart at 12:15 PM to the 200 hallway4th cart at 12:30 PM to the 100 hallway5th cart at 12:45 PM to the 100 hallwayDuring an observation on 7/19/26 at 11:30 AM, no resident was eating lunch in the… …
F809 citations in North Carolina
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
North Carolina cites F809 more often than its own record predicts
2.77 times the share F809 takes of citations nationally.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F809 findings written in North Carolina, 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, record reviews, and resident and staff interviews, the facility failed to provide the residents with meals served at regularly scheduled times for 2 of 16 sampled residents reviewed for dining observations. (Resident #161 and Resident #313). Findings included: 1.The admission Minimum Data Set (MDS) dated [DATE] had Resident #161 coded as cognitively intact and was independent with eating. The meal tray times read: 400 hall at 12:45 PM. The form which documents when meal carts come to the hall dated 06/06/2021 read in part: 400 Hall -----. During the 400-hall lunch observation on 06/06/2021 at 12:30 PM, staff were waiting for the lunch trays to come out. …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 0.53% | 2.40× |
| 2024 | 0.44% | 2.06× |
| 2025 | 0.53% | 2.77× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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