Resident 35 was supposed to receive only pureed food after the May 13 choking episode. Their care plan specifically directed staff to provide small bites, check for pocketed food after meals, and keep their head elevated during eating. The resident had severe cognitive impairment and required substantial help with meals.
But on June 14, Staff V delivered a breakfast tray with regular-texture scrambled eggs and chopped sausage alongside pureed pancakes. The tray card clearly marked the resident's diet as "dysphagia pureed" — food blended into a smooth, uniform texture for people with swallowing difficulties.
Staff V sat down and began feeding the resident the wrong food.
The same morning, Staff W fed identical regular-texture eggs and chopped sausage to Resident 125, another resident on a pureed diet. When asked what diet the tray card specified, Staff W correctly answered "pureed" — while feeding the resident food that could cause choking.
Resident 125 had severe cognitive impairment and was receiving hospice care.
The facility's dietary manager had implemented what she called a "triple check" system to prevent exactly this type of error. The cook was supposed to read the tray card and plate the correct food texture. A dietary aide would then verify the tray contents matched the card. Finally, nursing staff would check the tray against the diet order before delivering it to residents.
All three checks failed.
Staff D, the head cook and dietary manager in training, explained that the regular cook had called in sick that morning. A new, untrained cook prepared the meals without supervision because Staff D had to cover the dietary aide position, preparing cold dishes and beverages. The certified dietary manager from another facility who was training Staff D hadn't arrived yet.
"Staffing and their inability to provide oversight of the new cook contributed to the diet texture errors," Staff D told inspectors.
When asked if kitchen staff used recipes to prepare pureed diets, Staff D said no.
The facility had removed residents' breakfast trays by the time inspectors could fully document both incidents. Staff Z, a regional nurse consultant, confirmed that chopped sausage remained on Resident 35's tray at 8:50 AM — food that could have lodged in the throat of someone who had choked three weeks earlier.
Resident 35's medical history showed a pattern of swallowing problems. A May 21 progress note documented another episode where the resident coughed and had difficulty swallowing during lunch. A nurse alternated small bites of food with small sips of fluid, but the resident's coughing persisted.
The facility's failures extended beyond immediate choking risks. Resident 61, who had experienced significant weight loss after a stroke, told staff repeatedly that he wouldn't eat the facility's frequent servings of pasta and vegetables. The cognitively intact resident had completed food preference forms and spoken to multiple staff members about his dietary needs.
Progress notes documented the resident's refusal to eat due to food dislikes on January 29, February 5, February 19, February 26, March 28, and April 14. A February 12 entry noted that a dietary referral was required for food preferences.
"Resident not eating due to food dislikes," staff wrote again and again.
Staff H, the social services director, completed a food preference record in late May 2024, specifically noting that Resident 61 didn't want pasta for lunch or dinner, didn't want applesauce or broccoli, and wanted little rice. Staff H delivered the form directly to Staff Y, the former dietary service manager, who was supposed to input the preferences into the computer system.
When Staff H followed up two weeks later, nothing had been entered.
Staff H completed a second food preference record on June 7, again delivering it directly to Staff Y. A nursing assistant had also informed the dietary manager about the resident's preferences.
The preferences were never entered into the computer.
On June 14 and June 17 — the day inspectors arrived — Resident 61's tray card still showed no dietary preferences. The facility continued serving the foods he had refused to eat for months while documenting his weight loss and malnutrition.
Staff N, a regional registered dietitian, confirmed that kitchen staff were supposed to follow recipes when preparing pureed food. She said recipes had been reviewed and updated, and staff had been educated on their use — but only after inspectors discovered the violations.
The facility lifted the immediate jeopardy designation on June 17 after implementing corrective measures. But for Resident 35, who had already choked twice on food, and Resident 61, whose weight loss continued as staff ignored his documented food preferences, the damage was done.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Port Washington Post Acute from 2024-06-18 including all violations, facility responses, and corrective action plans.