Improper Diet Texture and Lack of Meal Supervision Lead to Fatal Choking Event
Summary
The deficiency involves the facility’s failure to ensure a resident received food in the correct mechanically altered texture as ordered and to accurately assess and implement needed supervision during eating. The resident had a physician’s order for a low concentrated sweet, no added salt, mechanical soft diet with thin liquids and a divided plate. The care plan and Nutrition and Hydration Status Assessment documented that the resident had chewing problems and required supervision or assistance at mealtimes, including that the resident fed self with supervision. Speech therapy records showed a history of dysphagia, aspiration pneumonia due to food inhalation, cerebrovascular disease, hemiplegia, and muscle weakness, with recommendations for mechanical soft/chopped textures, upright positioning, alternating food and liquids, and small bites. The resident’s DOSS score indicated restricted diet consistencies and a need for distant supervision during meals. On the day of the incident, a CNA who knew the resident was on a mechanical soft diet provided a regular-texture ham sandwich as an evening snack after the resident requested a sandwich. The CNA later admitted she was aware of the altered diet order but believed the thinly sliced ham was acceptable, even though it was not chopped or otherwise modified to a mechanical soft consistency. The DON confirmed that the ham sandwich given was not of the appropriate texture for a mechanical soft diet. The resident was not being supervised while consuming this snack, despite documentation in the Nutrition and Hydration Status Assessment that the resident required supervision during meals. The DON stated she interpreted “supervision” on the assessment as only meaning set-up assistance, and the dietetic technician later stated that the documentation of supervision needs on the assessment was a human error and that the resident only required set-up assistance. Later that evening, during medication pass, an RN observed the resident in the doorway of his room in a wheelchair, clutching his throat with both hands and attempting to gag himself with his finger. The RN asked if he was choking, and the resident nodded yes but was unable to cough or speak. The RN inspected the resident’s mouth and did not see an obstruction, then called for help and initiated the Heimlich maneuver and back blows. Multiple staff, including CNAs and a respiratory therapist, responded and each attempted the Heimlich maneuver without success. The resident became unresponsive and pulseless, and staff initiated CPR with use of a backboard, crash cart, oxygen, and bag-valve-mask ventilation until EMS arrived. EMS found the resident pulseless and apneic with a reported full airway obstruction, used video laryngoscopy and forceps to remove a large piece of meat completely obstructing the trachea, and then intubated and resuscitated the resident before transferring him to the hospital. Hospital records and the death certificate documented that the resident experienced acute hypoxic respiratory failure, aspiration pneumonia, cardiac arrest, and ultimately anoxic brain death due to choking on food.
Removal Plan
- RN responded to Resident #77, EMS was called, and the resident was transferred to the hospital.
- RN notified Resident #77's physician of the incident.
- The DON reviewed Resident #77's diet order for accuracy.
- The DON initiated an investigation of events surrounding Resident #77's choking incident.
- The DON conducted a root cause analysis and determined Resident #77 choked when CNA #151 provided Resident #77 with the incorrect diet texture during the evening snack.
- The DON reviewed all facility residents' care plans to ensure they accurately reflected current diet orders.
- The DON conducted a full house audit to ensure no additional residents received incorrect diet consistency or improper feeding assistance.
- The DON educated CNA #151 on ensuring each resident received their diet as ordered.
- The DON educated all nursing staff and the Dietetic Technician on ensuring resident care plans accurately reflected current diet needs.
- The DON educated all nursing staff on the facility policy to ensure each resident received their diet as ordered and where to verify a resident's diet order.
- The Administrator, the DON, the LPN/UM, the RDO, and the RCD reviewed facility policies on assisting residents with in-room meals, snack serving, and therapeutic diets.
- An ad hoc QAPI meeting was held to review the choking incident and the facility's corrective action plan.
- The Dietary Manager posted a list of mechanical soft approved foods in the nutrition rooms on each floor of the facility.
- The Dietary Manager posted a list of residents with mechanically altered diets in the nutrition rooms on each floor of the facility.
- The Dietary Manager and/or designee will monitor and update the lists as diet orders change, with new admissions, and as needed.
- The Dietary Manager placed separate bins identifying regular snacks and mechanically altered snacks in the nutrition rooms.
- The Dietary Manager and/or designee will ensure appropriate food items are placed in each bin based on safe foods for each diet texture.
- The DON will audit nursing staff to ensure understanding of mechanically altered diets, with results reported to the QAPI committee.
- The DON will audit residents to ensure meals and snacks being served are appropriate based on the ordered diet, with results reported to the QAPI committee.
- The DON audited all Nutrition and Hydration Status Assessments to ensure accuracy regarding residents' feeding capabilities, including supervision and assistance.
- Any inaccuracies in Nutrition and Hydration Status Assessments were corrected immediately by the Dietetic Technician.
- The DON reviewed all residents' care plans to ensure they accurately reflected the residents' feeding and eating capabilities, including supervision and assistance.
- The DON educated all nursing staff on following the care plan and Kardex to identify a resident's level of assistance required when eating.
- The Registered Dietitian educated the Dietetic Technician on completing Nutrition and Hydration Status Assessments to accurately reflect a resident's level of assistance required when eating.
- The DON will audit residents to ensure they are receiving feeding assistance and supervision as needed, with results reported to the QAPI committee.
- The DON will complete random audits of resident charts for the most recent admission, quarterly, and change of condition Nutrition and Hydration Status Assessments for accuracy of the resident's level of assistance required when eating, with results reported to the QAPI committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, dysphagia, and muscle weakness had a physician order for a chopped texture diet, but was served unchopped quiche and matzoh balls during a meal. The family member reported this happened often and said they had to chop the resident's food themselves, while the DON and DFD confirmed the resident should have received the correct texture and that some items were not chopped before being sent to the unit.
Failure to Follow Ordered Texture Diet: A resident with dysphagia and an ordered puree/liquified diet received sponge cake instead of the prescribed texture. The resident later developed N/V, SOB, and possible aspiration after eating non-pureed food, requiring ED evaluation via 911. The DM confirmed the wrong texture was served, and the DON/ADON acknowledged that diet orders were not followed.
A resident with a dysphagia puree diet order was served a regular consistency roll at lunch. An NA buttered the roll and gave it to the resident in the dining room until a surveyor intervened and had it removed; the NA acknowledged the resident should not have received it.
Incorrect Diet Texture Served to a Resident with Dysphagia: A resident with severe cognitive impairment, dysphagia, and malnutrition was ordered a mechanical soft diet with thin liquids, but staff served meals with incorrect textures, including whole asparagus, thick-cut bacon, and a whole hard-boiled egg. The NA said she was new and did not know the resident’s diet needs, while dietary staff said the meal tickets and food preparation were inconsistent and that some items were not prepared to the ordered texture.
A resident with severe cognitive impairment, dementia, and malnutrition did not receive diet care consistent with the ARNP’s orders. Staff failed to transcribe updated orders for honey-thick liquids and specific feeding instructions into the EMR/Kardex, the resident continued receiving a nectar-thick supplement, and staff were observed feeding and assisting the resident from the wrong side instead of the ordered right side.
Failure to Serve Ground Meatloaf for Mechanical Soft Diets: The facility did not serve ground meatloaf as listed on the menu extension sheet for residents on mechanical soft diets. During tray line service, a dietary staff member stated there was no ground meatloaf because she had been told the meatloaf was mechanical soft friendly. The DM and RD agreed with that interpretation, while the ST stated mechanical soft meats are typically ground and that the affected residents should have received ground meatloaf.
Resident on chopped diet received unchopped meal items
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered chopped texture diet received food prepared in the correct form. The resident had diagnoses including dementia, dysphagia, and muscle weakness, and care plan interventions called for diet and food consistency per physician order, along with assistance and monitoring during meals. The physician order required no concentrated sweets, chopped texture, and thin liquids, and a speech language pathologist note documented that the resident continued to tolerate a chopped diet with thin liquids. On the dinner meal in question, the resident was served a slice of quiche and matzoh balls in soup that were not chopped, despite the chopped diet order. The resident's family member stated they often had to chop the resident's food themselves and reported that the unchopped meal was shown to an LPN. The Director of Food Services confirmed the resident was on a chopped texture diet and received unchopped quiche and matzoh balls, and stated these items were not chopped before delivery to the unit because kitchen staff did not chop certain foods to preserve their structure and presentation. The DON stated nursing staff must ensure residents on mechanically altered diets received the appropriate textured food, and the LPN stated they would chop food upon request but could not recall whether they assisted with this meal.
Failure to Follow Ordered Texture Diet
Penalty
Summary
The facility failed to ensure that a resident with dysphagia received food prepared in the ordered texture. Resident 1 was admitted with multiple diagnoses, including dysphagia, and the MDS indicated difficulty swallowing and a mechanically altered diet. The resident’s OSR listed a liquified texture diet, and the care plan directed staff to follow the diet/MD order. Despite these orders, the resident received sponge cake, which was not the prescribed puree-type texture. The physician progress note documented that the resident had been sent to the ED via 911 after nausea, vomiting, and possible aspiration following ingestion of non-pureed food. The note stated the resident developed nausea/vomiting and shortness of breath after consuming pound cake with raisins despite being on a strict pureed diet due to dysphagia, and was noted to have spitting up mucus and vomiting, raising concern for aspiration. The Dietary Manager confirmed the resident received a different texture than ordered, and the ADON acknowledged that all diet orders were expected to be followed and confirmed the resident’s prescribed diet was not followed.
Inappropriate Food Texture Served to Resident on Puree Diet
Penalty
Summary
Food was not provided in a form designed to meet an individual resident’s needs when Resident #111, who had an order for a regular diet with dysphagia puree texture and thin liquids, was served a regular consistency roll at lunch. The resident’s diet order also included fortified cereal at breakfast, fortified soup at lunch and dinner, and a two-handled cup with lid for meals. During a dining room observation, Nurse Aide #64 served the resident’s lunch tray and buttered a regular roll for the resident. Before the resident ate it, the State surveyor intervened and had the nurse aide remove the roll. Nurse Aide #64 confirmed the resident was on a puree diet and should not have received a regular roll, stating, “Yeah, you’re right,” and that she did not think it looked right.
Incorrect Diet Texture Served to Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a severely cognitively impaired resident with dysphagia received the ordered mechanical soft diet texture. The resident had diagnoses including oropharyngeal phase dysphagia and moderate protein-calorie malnutrition, and the record showed she was edentulous with dentures not available during a prior hospital SLP evaluation. The SLP documented oral holding and prolonged oral transit with puree solids and thin liquids, and later recommended a mechanical soft diet with thin liquids, small bites and sips, slow rate, and supervision while eating. During observation, the resident was served meals that did not match the ordered texture. At lunch, the tray contained a whole soft dinner roll, ground turkey chili with beans over cream of rice, and whole asparagus spears; the resident attempted to eat the asparagus but was unsuccessful. At breakfast, the tray contained a large slice of thick cut bacon and a whole hard-boiled egg with only a small area of teeth indentation. The meal tickets indicated mechanical soft textures, but the foods served did not match the ordered diet texture for the resident. Interviews with nursing and dietary staff showed confusion and inconsistency in how the diet order was interpreted and prepared. The NA who delivered the trays stated she was new and did not know the resident required a mechanical soft diet or that certain foods needed to be ground or mashed. The Dietary Manager stated the facility did not offer a mechanical soft ground diet, did not know why the ticket reflected that notation, and was not aware that asparagus should have been chopped or that the hard-boiled egg needed to be mashed. The SLP, RD, DON, NP, and Administrator all stated the resident should have received the correct mechanical soft texture, and staff acknowledged that the incorrect textures were served on both observed meals.
Failure to Follow and Transcribe Ordered Therapeutic Diet
Penalty
Summary
The facility failed to serve the appropriate therapeutic diet for Resident #5 according to the resident’s diet order. Resident #5 had a BIMS score of 1, indicating severe cognitive impairment, and diagnoses including Alzheimer’s disease, non-Alzheimer’s disease, and malnutrition. The resident’s MDS documented a mechanically altered diet, and the care plan directed staff to provide the diet as ordered and monitor for signs and symptoms of aspiration or difficulty swallowing. A diet order dated 4/13/26 directed a regular diet with pureed texture and nectar-thick fluids, and a progress note dated 7/2/26 documented new physician orders and feeding instructions for honey-thick liquids, positioning on the resident’s right side, giving a drink after each bite, and continuing the pureed diet. The resident’s record was not updated to reflect the new physician orders and feeding instructions in the physician order tab or Kardex. The July 2026 MAR listed a mighty shake as nectar-thick, and the resident received the nectar-thick supplement from 7/2/26 through 7/20/26. On 7/21/26, surveyors observed thickened water with a lid and straw in the resident’s room, and the DON verified it was nectar consistency. Later that morning, Staff B provided one-on-one feeding assistance while sitting on the resident’s left side instead of the right side ordered by the ARNP, and Staff C also sat on the resident’s left side while assisting with the mighty shake. The DON acknowledged staff did not transcribe the 7/2/26 physician orders to the electronic medical record.
Failure to Serve Ground Meatloaf for Mechanical Soft Diets
Penalty
Summary
The facility failed to ensure ground meatloaf was served for residents on mechanically altered diets according to the menu extension sheet. The lunch menu for 07/22/26 listed homemade meatloaf, mashed potatoes with gravy, and California blend vegetables, and the menu extension sheet specified that the mechanical soft meatloaf should be ground using a #10 scoop with one ounce of gravy, while pureed meatloaf and vegetables had separate serving sizes. During observation of the lunch tray line, the dietary staff member plating the meals stated there was no ground meatloaf for the mechanical soft diets because she had been told the meatloaf was mechanical soft friendly. Review of the diet type report showed four residents received a mechanical soft diet and one resident received a regular diet with ground meat. The Dietary Manager and Registered Dietitian stated the meatloaf was considered mechanical soft friendly even though the menu extension indicated it should be ground for the mechanical soft diet. The Speech Therapist stated that for mechanical soft diets, meats were typically ground, that meatloaf was considered a formed food unless cut up, and that residents on a mechanical soft diet should have received ground meat. She also verified that four residents she knew needed ground meat and confirmed that the resident she did not know received a mechanical soft diet and should have received ground meatloaf per the menu extension sheet.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.