The resident was found unresponsive on August 16, 2025, during the night shift. When emergency responders arrived, they discovered food lodged in the person's mouth and airway. The resident died despite resuscitation attempts.
Federal inspectors found the facility failed to properly investigate the circumstances surrounding the death, missing critical evidence that could have revealed whether the resident choked on food they weren't supposed to have.
The resident had a documented history of wandering into other residents' rooms and taking their food. Staff knew about this behavior and were supposed to redirect the person when they saw them with unauthorized food items.
Physician #1, who signed the death certificate, listed cardiac arrest due to hyperlipidemia as the cause of death. The doctor told inspectors they received a call informing them the resident had died, but were not notified of the resident's condition prior to death because another physician was on call during the night.
The physician confirmed the resident was at high risk for aspiration and required a specialized diet of pureed textures, nectar-thickened liquids, and soft sandwiches. Most importantly, the resident needed monitoring and assistance during meals to ensure they followed their prescribed diet restrictions.
Nobody monitored the resident that night.
Certified Nursing Assistant #2 told inspectors they found the resident unresponsive around 4:30 AM while making rounds. The assistant said they immediately called for help and began transferring the resident to their bed.
The nursing assistant claimed they didn't see any food on the resident and hadn't served them any food. But the assistant acknowledged the resident "had behavior of always moving around, wandering into other resident's rooms and taking their food."
The assistant said if they observed the resident with food, they would take it away. But that protocol failed on the night the resident died.
Emergency responders found the resident with food in their mouth and airway when they arrived. This evidence suggested the resident may have obtained food they weren't supposed to have and choked on it.
The Director of Nursing told inspectors they were informed by Registered Nurse Supervisor #1 sometime during the night of August 16 that the resident was found unresponsive. The director collected statements from night shift staff but made a critical decision that would compromise any investigation.
"The Director of Nursing stated they did not investigate because the staff responded immediately and appropriately," inspectors wrote.
This decision meant nobody examined whether the resident's known wandering behavior and food-seeking had contributed to their death. The director acknowledged that when a resident is found unresponsive, staff typically call a Code Blue, contact 911, begin cardiopulmonary resuscitation, and apply an automated external defibrillator.
All of those emergency protocols were followed. What wasn't followed was any attempt to understand why a resident with aspiration risk died with food in their mouth.
The Director of Nursing told inspectors they weren't aware the resident was found with food in their mouth. This admission revealed a breakdown in communication between emergency responders and nursing leadership about crucial evidence at the scene.
The director made another telling statement to inspectors: "If Resident #1 was found unresponsive during mealtime, staff would have been more likely to check their mouth."
But the resident wasn't found during an official mealtime. They were found during night rounds, when they should have been sleeping, not eating. The presence of food in their mouth during non-meal hours should have triggered immediate questions about how they obtained it.
The director confirmed they knew about the resident's pattern of taking other residents' food and that staff were supposed to redirect this behavior. But no investigation examined whether this known risk factor played a role in the death.
Federal inspectors cited the facility for failing to ensure residents receive proper treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The violation resulted in actual harm to the resident.
The inspection revealed a facility that understood the risks facing this vulnerable resident but failed to connect those risks to the circumstances of their death. Staff knew the resident wandered and took food. They knew the resident had aspiration risk and required dietary restrictions and meal supervision.
When the resident died with food in their mouth and airway, these known risk factors should have prompted immediate investigation. Instead, administrators collected statements and closed the matter without examining whether their safety protocols had failed.
The resident's physician wasn't even informed of the circumstances surrounding the death. The doctor who signed the death certificate had no knowledge that the person they were certifying had been found with food blocking their airway.
This case illustrates how nursing home deaths can be misclassified when facilities fail to investigate suspicious circumstances. A resident with documented aspiration risk and food-seeking behavior died with food in their mouth, but nobody examined whether inadequate supervision contributed to the death.
The facility's decision not to investigate meant that critical questions went unanswered. How did the resident obtain food during night hours? Was the food consistent with their prescribed diet restrictions? Had staff failed to monitor the resident's wandering behavior? Did choking contribute to the cardiac arrest?
Those questions remain unanswered because Peninsula Nursing and Rehabilitation Center chose not to ask them. The resident died on August 16. Federal inspectors didn't arrive until October 31, more than two months later, when memories had faded and evidence was long gone.
The resident's death certificate lists cardiac arrest due to hyperlipidemia. It makes no mention of the food found in their mouth and airway, or their known aspiration risk, or their pattern of taking unauthorized food from other residents' rooms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Peninsula Nursing and Rehabilitation Center from 2025-10-31 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Peninsula Nursing and Rehabilitation Center
- Browse all NY nursing home inspections