**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to a therapeutic diet for one resident (R) (R #11) identified at risk for aspiration.

The facility’s Administrator was informed of the Immediate Jeopardy on [DATE] at 12:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of [DATE] when R#11 was served the wrong diet tray and expired on the same day at 9:52 a.m. The Immediate Jeopardy continued through [DATE] , and was removed on [DATE].

The IJ was determined to exist as of [DATE], when R#11 became unresponsive in his room and could not be resuscitated, after being served a mechanically soft diet that included chopped eggs and chopped sausage. Review of the Medical Examiner’s (ME) report [DATE] revealed a limited autopsy was performed on R#11 on [DATE] at 1400 hours (military time). The report lists the cause of death asphyxia due to aspiration of food bolus, manner of death accident and how injury occurred; choked on food bolus. The limited autopsy report further revealed, a lump of food was found above the vocal cords, in the larynx. Residual food was found within the mouth and within the endotracheal tube, the food bolus is consistent with pieces of egg and meat product. The facility failed to ensure the care plan and therapeutic diet orders were followed to ensure the correct diet was provided to R#11 who was at risk for aspiration. This caused R#11 to aspirate on a food bolus and he expired as a result.

During an interview on Interview on [DATE] at 6:10 p.m. Assistant Director of Nursing (ADON) MM revealed, upon return to the facility, R#11’s diet order should have been verified by kitchen staff before a tray was given. R#11 was evaluated and it is not safe for him to receive a mechanical diet. ADON MM further added, it is her expectation for the nurse to know the resident’s diet and to contact the physician for clarification when needed.

Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect. You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately. We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one. Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262. You can make a difference even if your loved one has already passed away.