Health inspection·July 1, 2025

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide the correct textured diet for 1 of 19 (R2) residents reviewed for diet in a sample of 19. This failure resulted in R2 choking and being sent to the hospital. Findings include: R2's admission Record documents an admission date of 10/28/2024 with diagnoses including in part dementia and dysphagia oropharyngeal phase. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R2's most recent Care Plan documents a focus area of R2 has nutritional problem or potential nutritional problem and interventions include in part provide and serve diet as ordered, dated 6/9/23. R2's Diet order dated 3/12/25 11:48 PM through 6/14/25 3:16 PM documents regular diet, mechanical soft texture, nectar/mildly thick consistency. R2's diet order dated 6/14/25 3:16 PM through 6/18/25 2:02 PM documents regular diet, pureed texture, nectar/mildly thick consistency. R2's current diet order started 6/18/25 2:03 PM documents regular diet, pureed texture, honey/moderately thick consistency. R2's progress note titled Health Status Note dated 6/13/25 at 12:43 PM documents Resident (R2) was sitting in the dining room eating his lunch and he ended up getting choked on a piece of sausage and went unresponsive. He was still breathing. Staff was able to remove the piece of sausage, and he is now alert and sitting up. Notified (Nurse Practitioner) who was in the dining room at the time of the event who gave orders to send to (local hospital) ER (Emergency Room). Called EMS (Emergency Medical Services) at 1235 (12:35 PM) for transport. Called to (Local Hospital) ER and gave report to RN (Registered Nurse) at 1238 (12:38 PM). Called POA (Power of Attorney) and updated her on resident (R2) being transferred to hospital. She said she would call back later to check on him if she hasn't heard anything. Transfer record, POLST (Physician Orders for Life-Sustaining Treatment), order summary, and bed hold policy sent with EMS. R2's progress note titled Health Status Note dated 6/13/25 at 12:43 PM documents EMS arrived and resident (R2) is leaving on stretcher at this time to (local hospital). Page 1 of 3 145624 145624 07/01/2025 Axiom Gardens of Flora 701 Shadwell Avenue Flora, IL 62839

F 0803 Level of Harm - Actual harm Residents Affected - Few R2's progress note titled Health Status Note dated 6/14/25 at 3:17 PM documents Resident (R2) noted to be having difficulty chewing and swallowing during lunch. Nursing intervention in place to downgrade diet to pureed and have ST (Speech Therapy) to eval (evaluate) and treat. Wife notified. R2's incident report titled Choking dated 6/13/25 at 12:43 PM documents under Incident Description; Nursing Description: It was brought to my attention that (R2) was down in the dining room choking on lunch. Upon entering the dining room, I observed (R2) laying on the ground with multiple staff members and NP (Nurse Practitioner) in the dining room. (R2) was purple in color but he was still breathing at the time. Resident Description: (R2) states that he got choked on the bread and sausage. Description: Staff performed Heimlich/abdominal thrusts which was successful. On 6/25/25 at 1:53 PM, V3 (Certified Nursing Assistant/CNA) stated R2 was served a whole bratwurst but can't remember if it was on a bun. V3 stated while she was passing trays someone yelled out that R2 was choking. V3 stated R2 was blue/purple in the face and was staring off so she yelled for help. V3 stated the nurse came and started the Heimlich maneuver. V3 stated the nurse did the Heimlich maneuver until she got tired then she took over. V3 stated the Heimlich maneuver was not working so they laid R2 on the floor on his side and started back thrusts then V2 (Director of Nursing) came in and did a finger sweep and pulled out a piece of the bratwurst and there was still a piece in his mouth that he started chewing. V3 stated his color returned to normal and he started breathing again. V3 stated she does not know what diet R2 had ordered at the time. On 6/26/25 at 12:37 PM, V4 (Speech Therapist) stated she saw R2 prior to the choking incident and he was ordered to be on a mechanical soft diet and thickened liquids. V4 stated she was not at the facility the day of R2's choking incident but she was told he received a whole bratwurst on a bun. V4 stated a whole bratwurst is not considered a mechanical soft texture diet. V4 stated she was in the facility the next day and saw R2 and that time nursing had downgraded R2 to a pureed diet when he came back from the hospital. V4 stated the goal for R2 is to get him back to a mechanical soft diet and she will be trying that diet with R2 today. On 6/26/25 at 1:17 PM, V9 (Dietary Aide) stated she was working the day R2 choked, and she served R2 a whole brat on a bun. V9 stated R2 was ordered mechanical soft textured diet. V9 stated R2 should have received the bratwurst and bun mechanical soft texture and not whole on a bun. On 6/26/25 at 1:42 PM, V2 (Director of Nursing) stated she was notified that there was an emergency in the dining room and when she arrived in the dining room and saw R2 laying in the floor and R2 was choking. V2 stated staff were doing abdominal and back thrust and it was not working so she did a finger sweep in R2's mouth and pulled out a piece of bratwurst and some gummed up bread. V2 stated the staff sat R2 up then they performed another back thrust and R2 then started coughing. V2 stated EMS arrived shortly after that and took R2 to the local emergency room. On 6/26/25 at 2:11 PM, V12 (Cook) stated she was working the day R2 choked. V12 stated she served R2 a whole bratwurst on a bun that day. V12 stated R2 was ordered for a mechanical soft diet and received the incorrect diet texture. V12 stated R2 was supposed to get his bratwurst and bun with mechanical soft texture. On 6/26/25 at 2:44 PM, V1 (Administrator) stated she was not working the day R2 choked. V1 stated she was informed R2 was served a regular texture diet, bratwurst on a bun. V1 stated R2 should have been served mechanical soft texture diet. 145624 Page 2 of 3 145624 07/01/2025 Axiom Gardens of Flora 701 Shadwell Avenue Flora, IL 62839

F 0803 Level of Harm - Actual harm R2's emergency department notes from local hospital dated 6/13/25 documents R2 presented from a local nursing home after a choking episode. The nursing home did the Heimlich maneuver, and they were able to expel the sausage the patient choked on. Patient did have an episode of non-responsiveness at the facility, but he was more alert once EMS arrived. Residents Affected - Few The facility Diet Spreadsheet for Day 20 documents the mechanical soft diet served for 6/13/25 was ground bratwurst on bun with gravy (no raw vegetables), potato salad, baked beans, and soft chopped watermelon (no seeds). The facilities recipe for mechanical soft texture diet for 6/13/25 titled Ground Bratwurst on Bun with Gravy documents under 3. Place prepared bratwurst in a washed and sanitized food processor. Pulse/grind to the size and texture of finely ground beef. 4. Place in steam table pan and add a small amount of prepared broth or gravy to keep moist. The facility policy titled Diet Summary dated 2022 documents under Dental Soft (Mechanical Soft) Diet: Foods should be moist and fork tender. Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) and should be mixed or served with gravy, broth, or another type of moistening agent. 145624 Page 3 of 3