complaint·November 7, 2025

(Continued from LIC9099) Page 2 of 3 R1 was admitted to the facility on 12/10/2023. Upon admission, R1’s care plan included a physician’s order for a pureed diet with nectar-thick liquids. R1 had multiple medical diagnoses including aspiration risk, cognitive impairment, and visual limitations. A swallow evaluation dated 01/23/2024 recommended a mechanical soft diet with mildly thick liquids and supervised trials of thin liquids. R1 was hospitalized on 06/18/2024 for pneumonia and returned on 06/24/2024. On 07/01/2024, R1 experienced a choking incident during lunch and was transported to the hospital. Staff interviews revealed that ED Jones was present during the incident. ED Jones confirmed that 911 was called and CPR was performed. ED Jones stated that a physician’s order is required to change diets. A caregiver (Staff #2) reported placing R1 at the dining table and stepping away. Upon returning, she found R1 slumped over and called for help. Another caregiver (Staff #3) did not witness the incident but confirmed CPR was performed. A kitchen staff member (Staff #4) described dietary procedures and stated staff are expected to check the dietary list daily. Resident interviews revealed that R1 stated they could feed themselves but did not recall the choking incident or dietary details. Other residents interviewed either did not witness the incident or could not recall it. Additional residents were interviewed but did not provide relevant information. RP stated R1 had a mechanical soft diet and was not supervised while eating. RP reported that R1 had previously aspirated on different occasions and was served inappropriate foods at the facility. RP stated R1 was hospitalized with broken ribs and now resides in a skilled nursing facility. Records review revealed that a physician’s order dated 01/23/2024 prescribed a mechanical soft diet with mildly thick liquids. A speech therapist recommended supervised trials of thin liquids only as well as a mechanical soft diet. Emergency response documentation confirmed CPR was preformed and food was removed from the airway. No documentation was found requiring one-on-one supervision during meals.LPA observations revealed that residents were receiving appropriate diets. Dietary lists were posted and accessible to staff. No immediate hazards or concerns were observed during meal service. (Continued on LIC9099-C) (Continued form LIC9099C) page 3 of 3 No documentation was found requiring one-on-one supervision during meals. The department observations revealed that residents were receiving appropriate diets. Dietary lists were posted and accessible to staff. No immediate hazards or concerns were observed during meal service. (Continued on LIC9099-C) Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred. Resident #1 was receiving the prescribed diet, staff responded to the choking incident by performing the Heimlich maneuver and contacting emergency services, and there is no documentation requiring enhanced supervision during meals. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Reginald Jones, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.