On 11/19/08, a resident died after choking on a whole meatball that was served to him at lunch in his room where he ate unsupervised. After he was discovered choking, EMS arrived and removed large amounts of food and a large meatball from his airway. He was transported to the emergency room where he was pronounced dead. The coroner reported that he died due to asphyxia from aspiration of food. The 54 year old resident had suffered from dementia and schizophrenia and his doctor had prescribed a special mechanical soft diet due to a history of dysphagia (difficulty swallowing). He required supervision while eating. The failure to follow his prescribed diet and to provide supervision while he ate led to his death.