Avalon Care Center - Sonora
19929 Greenley Road Sonora, CA 95370
Citation Number: 030012183
Citation Date: 04/20/2016
Violation Date: 8/23/2014
Class: AA
Penalty: $80,000

On 8/23/14, a 90 year old resident was hospitalized and died after choking on a large piece of chicken served to him at lunch. The resident had a history of dysphagia (difficulty swallowing) and had experienced previous choking incidents at the nursing home that caused him to become cyanotic. He was on a mechanically soft diet that called for all meat to be ground or chopped and he was supposed to receive assistance with eating during meals to protect him from choking. On the date of his death, there was a single CNA passing trays and no one directly assisting the resident with his meal. When he started choking, 911 was called, paramedics responded and removed a large piece of chicken that was completely blocking his airway. He was pronounced dead at the Emergency Room shortly afterward. The coroner confirmed that choking on the large piece of chicken (not chopped or ground) was the cause of death. The facility was cited because its failure to ensure adequate supervision and direct assistance with his meal and failure to ensure the meal was provided in a texture the resident could safely swallow led to his death.