Citation Number: 110005265
Citation Date: 7/29/2008
Violation Date: 10/16/2007
Class: AA
Penalty: $ 100000.0

On 10/14/07, a wheelchair-bound resident who suffered from dementia and was on a pureed diet choked to death on a cinnamon roll while in the dining room during snack time. The staff were not made aware of his presence when he was brought into the dining room and did not know how he acquired the cinnamon roll, which was sold in the facility vending machine. An autopsy report stated the cause of death as asphyxia due to aspiration of food. A staff member described the resident as the facility's "number one high risk for choking" due to a history of stuffing food in his mouth and because he had no teeth. The facility was cited for lack of supervision and for neglecting to take necessary precautions.