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 citations in Pennsylvania
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
Pennsylvania cites F809 more often than its own record predicts
2.30 times the share F809 takes of citations nationally.
Of every deficiency written in Pennsylvania 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 Pennsylvania surveyors wrote
F809 findings written in Pennsylvania, 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 review of facility policy, resident and staff interviews, and a review of facility documentation it was determined that the facility has failed to provide meals at a regular time each day and a nutritious snack at bedtime for two out of ten resident council members (Resident R80 and R187).Findings Include: Review of the facility policy titled, HS Snack last reviewed August 2026 states, Policy-All residents (unless NPO) will be offered a bedtime/HS snack based which will meet their dietary restrictions and needs. During the confidential resident group meeting held on August 6, 2026, at 11:00 a.m. there were concerns expressed by several residents about not receiving an evening snack. Resident R80 stated they have not received any snacks since being in the facility. …
Based on review of facility documentation, the facility's meal schedule, resident and staff interview, and observation, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs for one of five meal carts. (Doc's dining room) Findings include: Review of the Food Committee Minutes from March 26, 2025, and April 30, 2025, revealed that residents had stated that their meal trays were often served late. In a group interview on May 28, 2025, at 10:30 a.m., Residents 3, 9, 24, 34, 58, and 60, stated that the meals were frequently delivered late to the main dining room and it was an on-going problem. In an interview on May 28, 2025 at 12:15 p.m., Resident 35 stated that meal trays can often be served late. …
The short window
Recent years
| Year | Share of Pennsylvania citations | vs expected |
|---|---|---|
| 2023 | 0.57% | 2.59× |
| 2024 | 0.56% | 2.63× |
| 2025 | 0.44% | 2.30× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Pennsylvania surveyors cite →
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