Incident investigation·January 6, 2026

On January 6, 2026, Licensing Program Analyst (LPA) Murial Han conducted a Case Management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit. On December 23, 2025, the facility report an incident that happened on December 14, 2025 concerning resident #1 (R1) who appeared to be choking while eating in the dining room. Sequently, staff performed Heimlich Maneuver and called 911. When the paramedics arrived, R1 appeared to be back to baseline and R1 was not transferred to the hospital. During today's visit, the administrator stated that R1's physician and responsible party were notified of the incident. The administrator stated that the physician changed R1's diet to mechanical soft with small bites and ordered speech therapy and swallowing assessment test. The administrator stated that the facility has followed the physician's order and changed R1's diet and the responsible party will arrange for the swallowing assessment test and speech therapy. During today's LPA interviewed the kitchen staff who was able to report that they were serving R1 mechanical soft diet with small bites. LPA observed R1 eating lunch in the dining and the administrator confirmed that the consistency of the lunch was mechanical soft diet. No deficiency is cited today. This report is reviewed and discussed with the administrator. A copy is provided.