**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Facility Reported Incident (FRI) #MI00144562. Based on observation, interview, and record review, the facility failed to provide adequate supervision per the plan of care for three residents (Residents #508, #509, and #510) during mealtimes. This deficient practice resulted in two choking/aspiration events for Resident #509 which resulted in hospitalization and subsequent death. Findings Include: The Immediate Jeopardy began on 5/5/24 at 2:40 PM when the facility failed to provide supervision during a mealtime for a resident (Resident #508) with a known history of choking/aspiration. This resulted in R508 experiencing a choking event in his room. R508 experienced a subsequent choking event on 5/7/24 at 6:24 PM when R508 was left unsupervised on two different occasions in the dining room during a dinner time meal and was found unresponsive. R508 required life-saving efforts and was ultimately transported to a local hospital where he later expired. The Nursing Home Administrator (NHA), Senior Regional NHA, and Director of Nursing (DON) were notified of the immediate jeopardy on 5/16/24 at 12:10 PM. At that time, a written removal plan was requested from the facility. This surveyor confirmed by interview and record review that the immediacy was removed on 5/16/24 at 3:35 PM, however, noncompliance remains at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Resident #508 (R508): Review of R508's electronic medical record (EMR) revealed admission to the facility on 5/4/24 with diagnoses including history of traumatic brain injury (TBI), dysphagia (difficulty or inability to swallow), and chronic obstructive pulmonary disease (COPD). Review of R508's Brief Interview for Mental Status (BIMS) assessment revealed a score of 00, indicative of severe cognitive impairment. Review of R508's discharge summary from the acute care hospital revealed the following: .Dysphagia: it was noted last week that he is impulsive with eating, and this may in part cause him to choke/cough when eating . Review of R508's Speech Therapy Clinical Swallowing Evaluation at the acute care hospital on 4/25/24 revealed the following recommendations: .he [R508] is noted to be an impulsive/fast eater per many recent ST [speech therapy] swallowing evaluations .if speed of intake is an ongoing issue, recommend direct supervision/assist w/ [with] pacing during meals. This has been recommended during each swallow assessment in the past . Review of R508's Nursing admission Evaluation dated 5/4/24, indicated the following: 1. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Supervision or touching assistance, was selected by the evaluator. 2. Most support needed for eating. Supervision/cueing needed, was selected by the evaluator. Review of a Nursing to Dietary diet order form dated 5/4/24 completed by Registered Nurse (RN) E revealed the following: .[R508] is a feed. On 5/16/24 at 11:25 AM, a phone interview was conducted with RN E who verified she completed R508's Nursing admission Evaluation and Nursing to Dietary diet order form on 5/4/24. RN E stated she indicated R508 required supervision and cueing with eating on the Nursing admission Evaluation because, the hospital told me that he stuffs his mouth and doesn't swallow and just keeps putting more and more in [his mouth]. RN E stated she talked with R508's sister/guardian [Guardian F] who stated R508 needed frequent cues to slow down when eating due to his impulsivity. RN E was asked for clarification behind the meaning of, [R508] is a feed on the Nursing to Dietary diet order form. RN E said, he [R508] has to have supervision to eat, he can't eat by himself . I meant that somebody has to be in his direct presence, they can't leave him alone in the room with his tray . On 5/16/24 at 8:20 AM, an interview was conducted with Occupational Therapist (OT) O who verified Guardian F was present at the time of her evaluation. OT O stated Guardian F revealed R508 needed supervision whenever he was eating. OT O recalled Guardian F was feeding R508 peanuts at the time of her evaluation and continued to repeat, chew, chew, chew! to cue R508 and reduce the risk of choking. Review of OT Evaluation and Plan of Treatment signed 5/5/24 read, in part: .Medial hx (history): .impulsive and eats to [sic] fast . Prior Level(s) of Function: .Eating = Supervision or touching assistance (Patient is impulsive and eats very fast. 'Tries to shove whole piece of toast in his mouth' per sister [Guardian F]) . Review of R508's progress notes revealed the following entry on 5/5/24 at 2:40 PM, written by Licensed Practical Nurse (LPN) D: Resident left unsupervised for meal. Resident observed coughing up hot dog during lunch. Checked O2 [oxygen saturation] mid 80s [percent saturation] and pulse [heart rate] in 120s .nurse called on-call provider and got [an] order for 2 liters O2 to maintain O2 sat [saturation] 92% and above . On 5/15/24 at 12:36 PM, a phone interview was conducted with Certified Nursing Assistant (CNA) C who verified she passed lunch trays on R508's hallway on 5/5/24. CNA C stated she attempted to locate R508's diet order and level of supervision in the EMR system but was unable to find the orders. CNA C indicated she asked the floor nurse, LPN D, of R508's diet orders and eating assistance requirements. CNA C indicated LPN D stated R508 was on a regular diet, therefore she subsequently placed the meal tray, which consisted of a hot dog, in front R508 and left him unattended in his private room. CNA C stated she went on a break soon after delivering R508's lunch tray, and it wasn't until after she returned from break that she learned R508 experienced a choking event. Upon return CNA C stated CNA B informed her R508 required supervision when eating. CNA C stated, I felt like an idiot, because I didn't know that [R508 required supervision during meals]. It wasn't in his chart or in the computer . You feel dumb and helpless when things like this happen. There's a lack of communication in the facility, especially regarding newly admitted patients and their diet orders. A lot of times we're [nursing assistants] scrambling around trying to figure out what they [residents] can eat or how they transfer . On 5/15/24 at 10:00 AM, an interview was conducted with CNA B who verified she worked with CNA C on 5/5/24. CNA B stated she passed R508's room and noticed [R508] was rigid in his chair and his whole body was shaking like he was having a seizure. CNA B stated R508 was positioned in his wheelchair with his tray table in front of him, his chin was down toward his chest, his feet were sticking straight out, and his arms were out to his sides. CNA B indicated, his jaw was open a little bit and the hot dog was partially chewed and falling out of his mouth. CNA B stated she immediately grabbed a napkin off the lunch tray and began removing partially masticated hot dog from R508's mouth. CNA B stated, I held him so he wouldn't fall out of his chair because he was rigid .I called his name, and he didn't respond. I kept trying to get food to come out of his mouth . CNA B indicated R508 snapped out of it after approximately 20-30 seconds and she then yelled for LPN D for assistance. CNA B recalled, When I first went in the room, I noticed his lips were a blue or purplish color. CNA B stated she was unsure why R508 did not receive supervision during the lunch time meal. On 5/15/24 at 10:20 AM, an interview was conducted with LPN D who verified he responded to R508's choking incident on 5/5/24 after CNA B reported R508 had food coming out of his mouth, was shaking, and his lips were turning blue. LPN D stated he entered R508's room and noticed he was shaking a bit because, he had a lot of coughs backed up and was trying to breathe. LPN D stated R508's oxygen saturation would not exceed 85% following the choking event, when previously they had been around 95% on room air. LPN D indicated he called the on-call provider for an order of supplemental oxygen and chest x-rays but did not report the seizure-like activity, the discoloration of R508's lips, nor did he request a diet texture downgrade. When LPN D was asked why the change in R508's condition was not disclosed to the on-call provider, he stated R508 did not have a history of seizures and LPN D was most concerned about his low oxygen saturation. LPN D stated no changes to R508's diet order were made following the choking incident on 5/5/24 and admitted , I didn't let [the DON] know [about the choking incident] which was my bad .she probably would have told me to downgrade the diet but I didn't know I could do that as a nurse . LPN D verified R508 was supposed to be supervised during meal times, but CNA C had not heard him report it. LPN D stated after he notified Guardian F of the choking event she disclosed R508 was so impulsive that he attempted to consume the plastic cracker sleeve when eating a snack on the day of his admission. On 5/15/24 at 12:53 PM, a telephone interview was conducted with Nurse Practitioner (NP) P who verified she was on-call on 5/5/24. NP P stated she was not notified R508 experienced seizure-activity during the choking incident on 5/5/24. NP P indicated based on standards of practice she would have likely sent R508 to the hospital for further evaluation if he did not have a history of seizures. Review of R508's medical history did not reveal a history of seizures. Review of the Nursing to Physician communication binder located at the nursing station revealed the following entry on 5/5/24: .[R508] had aspiration on food. Diet may need to be downgraded . Review of R508's EMR revealed a diet order change on 5/6/24 at 9:42 AM that read, Level 3 texture, regular fluid, thin consistency. Review of R508's Plan of Care revealed a revised intervention on 5/6/24 that read, EATING: Supervision - offer assistance with meal setup as needed. To eat in the dining room, with staff supervision. Review of a Diet Order/Change Form signed by Unit Manager/RN H on 5/6/24 revealed a checked box that read Feeding Assistance needed for R508. On 5/16/24 at 11:02 AM, an interview was conducted with Unit Manager/RN H who stated she downgraded R508's diet due to the report of the choking incident that occurred over the weekend. RN H stated, [LPN D] is a new employee and did not know how to put a diet change order in or notify the physician of a diet change which was why the change was delayed. On 5/15/24 at 11:45 PM, an interview was conducted with Speech Language Pathologist (SLP), G who stated he was made aware of R508's choking incident on the morning of 5/6/24 during a managerial meeting. SLP G evaluated R508 after the breakfast meal on 5/6/24. SLP G stated he evaluated R508 eating a cakey textured food which he was able to physically chew but, .he wanted to eat the whole thing. He had poor safety awareness. SLP G stated he then had a discussion with Unit Manager/RN H about the diet downgrade. SLP G said, I told the nurse [Unit Manager/RN H] that [R508] needed supervision . the diet downgrade was safe, but it wasn't necessarily the intervention I would have placed. [R508]'s risk of choking wasn't due to his inability to chew a regular diet; it was his impulsivity. SLP G was asked his expectation for the meaning of supervision who stated, Eyes-on the resident and being able to provide cues or assistance. SLP G was asked if R508 could safely be left alone while consuming a meal to which he replied, No. During a follow up interview on 5/16/24 at 2:49 PM, SLP G reiterated, Downgrading his diet was a safe option, it did not harm him in anyway. But it's the impulsivity that's the root cause [of R508's choking risk]. Review of SLP Evaluation and Plan of Treatment for R508, signed 5/6/24 read, in part: 1.poor carryover with swallow precautions. Benefits from close supervision with all PO [by mouth] intake to promote safety and overall tolerance . 2.Reported tolerance with Reg [regular] texture solids during hospitalization though noted to have significant impulsive behaviors and recommend supervision/assistance with meals. Patient noted to have overt difficulty with intake of hot dog over weekend and nursing staff subsequently downgrading diet to L3 [Level 3] texture solids. Continues to benefit from supervision/feeding assistance to promote swallow safety . 3.Diet downgraded to L3 following overt difficultly with reg texture hot dog. Continues to benefit from closer supervision and/or feeding asisstance [sic] given poor carryvoer [sic] with swallow safety precautions . 4.Supervision: How often does patient require supervision/assistance at mealtime d/t [due to] swallow safety = 91-100% of the time. Review of a Therapy to Nursing Communication, dated 5/6/24 at 3:11 PM read: SLP notified of overt difficulty observed with intake of reg texture solids over the weekend. RN initiated diet downgrade to L3 texture solids. Patient will benefit from 1:1 or close supervision during meals to promote swallow safety and improve carryover with recommended compensatory swallow strategies. On 5/15/24 at 2:49 PM, a follow-up interview was conducted with SLP G who reported compensatory swallow strategies include alternating solids and liquids, taking small bites, pacing, and monitoring for choking or swallowing during meals. SLP G was asked if he provides education to direct-care staff on supervision expectations during mealtimes. SLP G stated, If there is an emergent need, I'm going to the CNA and floor nurse. On the back end, I write a communication [in the EMR system] and it goes to the nursing staff. I'm generally not providing hands-on, one-to-one education. On 5/15/24 at 9:02AM, a phone interview was conducted with Guardian F who stated she discussed R508's prior level of function, medical history, and rehab goals with the Interdisciplinary Team (IDT) on 5/7/24 around 10:30 AM for a discharge planning meeting/evaluation. Guardian F stated the team discussed the hot dog choking incident at length, and the facility reassured her they were able to provide R508 with the supervision he required to mitigate the risk of choking. Guardian F stated, .I asked if the facility was capable of handling [R508] and his diagnoses, especially the TBI which causes him to be impulsive . I asked three different nurses, I was worried about him and his well-being . they said, 'yes, yes, absolutely.' Review of the Discharge Planning Evaluation signed 5/7/24, did not indicate R508's history of choking secondary to his impulsivity, the choking event that occurred at the facility on 5/5/24, or implementation of interventions to prevent future instances of choking. Review of R508's EMR revealed the following progress notes: 1. 5/7/24 at 6:45 PM: Responded to code blue with crash cart and set up suction, other nurses entered to attend as well and began performing Heimlich maneuver. Left room and contacted 911 . 2. 5/7/24 at 7:00 PM: Notified [Guardian F] per phone that [R508] left the building per EMS [Emergency Medical Services] for [local hospital] . 3. 5/7/24 at 11:32 PM: .1824 [6:24 PM] CNA came out of dining room yelling code blue . I immediately ran into the dining room to assess the patient. He was unresponsive and not breathing. Heimlich attempted without success. Another nurse tried 5 Heimlich maneuvers without success. 1826 [6:26 PM] patient lowered to the ground. Patient airway suctioned. Negative pulse check, called for AED [automated external defibrillator] .CPR [cardiopulmonary resuscitation] initiated .patient mouth suctioned CPR continued . Police arrived on scene .1833 [6:33 PM] EMS arrived . Review of a Witness Statement written by RN E read, in part: .I heard her [CNA I] come out and say 'we have a code blue!' from the dining room . I went straight into assess the patient .once I got there, he was slumped over, non-responsive, not breathing . [RN J] did a sternal rub, there was no response, he was ashen, grey at that point. Still not breathing . [RN K] did suction him .she had one hand on the mask and one hand on the bag, it was a mix of spit and some tuna that was coming out of the suction . Review of a Witness Statement written by RN K read, in part: .I heard the code paged, I entered the dining room .I pulled a glob of tuna out of his mouth and suctioned some [tuna] out of his mouth . Review of a Witness Statement written by RN J read, in part: .we laid him down to attempt suction, food was noted in his mouth, resting on his tongue . On 5/14/24 at 3:15 PM, an interview was conducted with CNA I who stated she was present in the dining room on 5/7/24 and called the code blue for R508. CNA I stated R508 was seated in a high back wheelchair at a dining room table with his back facing the dining room entrance. CNA I stated, He was getting done with his tuna fish sandwich, he ran out of his drink, so I asked him if he wanted more juice. He said he did, so I stepped out of the dining room door and asked for more juice .when I came back, his head was slumped in his chair, and he did not respond to my voice or touch to the shoulder . I ran to the door and shouted, 'code blue!' . Review of a Witness Statement written by CNA I read, in part: .he ate about half if [sic] the sandwich and half his drink. [CNA L] and I went to look at the binder, he had half his sandwich left .he fed the last half sandwich to himself .not even a minute was I looking at the book with [CNA L], she showed me the bread was fine and then I returned to him . I was aware he needed supervision, the day prior when I came to work, [RN M] told me he had problems choking and needs to be watched . On 5/15/24 at 9:11 AM, a follow-up interview was conducted with CNA I for clarification of the events leading up to the code blue for R508. CNA I revealed she had left R508 unattended earlier during the meal to check the binder on the counter which references residents' level of required assistance and lists acceptable food options according to prescribed diet texture. CNA I stated R508's meal ticket indicated he was on a level 3 diet, and she wanted to confirm that a tuna fish sandwich was an acceptable option. CNA I stated, [R508] had his tray in front of him. He already had started eating at that point, about half his sandwich was gone. I wanted to verify it was the correct food, so I walked to the counter with [CNA L] and looked in the binder. CNA I was asked how long R508 was left attended to which she replied, Just a few minutes .I just looked and came back. CNA I was unable to recall the amount of tuna fish sandwich that remained by the time she returned to the table. Review of a Witness Statement written by CNA L read, in part: [CNA I] and I were passing trays in the dining room together, we got all the trays out . [CNA I] asked me a question about level 3 diets, she asked if they were a level 3 diet what does it consist of, I said they are allowed to have bread, we went over to the book to look at [it] . On 5/15/24 at 12:26 PM, an interview was conducted with CNA L who verified she helped with the dinner-time meal on 5/7/24. CNA L stated CNA I asked her what a level 3 diet consisted of. CNA L stated both she and CNA I walked to the dining room counter and referenced the book together. CNA I was asked how long they referenced the book together while R508 was eating unsupervised to which she replied, probably 10 minutes. Review of a Witness Statement written by the NHA read, in part: . [The DON] and I verified the tray following the event. We noted the sandwich was gone and the 4oz (ounce) beverage had been drunk . Review of R508's hospitalization records from 5/7/24 to 5/14/24 read, in part: .Pt [patient] choked on & aspirated tuna salad during dinner, becoming unresponsive . pt arrived to [local hospital] ED [emergency department] in acute hypoxic resp [respiratory] failure and was immediately intubated .that became clogged with tuna .pt noted to have significant volume of aspirated food throughout airway .he seized after arriving to the ICU [intensive care unit] likely as a result from prolonged hypoxia [low blood oxygen levels] . .Pt is known to be impulsive secondary to TBI and reportedly eats very fast w/ [with] frequent aspiration episodes .he was eating .tuna salad for dinner when he began choking, ultimately becoming unresponsive .EMS crew removed tuna salad from his mouth . Pt hypoxic .upon arrival to [local hospital] ED and was immediately intubated .with copious amounts of tuna salad noted throughout airway. Tuna removed to the best of his [ED physician's] ability, however .became clogged w/ inability to bag patient. .I [physician] was able to .intubate the patient visualizing the glottis, as well as a very large amount of what appears to be tuna salad in the posterior pharynx and the glottis and I suspect behind .patient became hard to bag and the tube was suctioned and really revealed a large amount of .tuna fish salad .saturation dropped and the tube was removed .I suspect the ET [endotracheal] tube got clogged with tuna salad . the respiratory therapist did suction numerous and multiple bits of food from the ET tube . We [physician and R508's family] reviewed that I do not feel he will return to his functional baseline and that if he were to come out of coma, an unlikely event, he would likely need 24/7 care including feeding, mobility, and toileting. We discussed how the ongoing seizure activity supports a significant degree of brain damage from the anoxia . .REASON FOR PRESENTATION: .presents to [local hospital] ED after a choking episode while at [Facility Name] for rehab. Pt choked on & aspirated tuna salad during dinner, became unresponsive . Patient was admitted to the ICU. He was maintained on mechanical ventilation .he was started on multiple antiepileptic drugs for intractable seizures. The patient failure to improve despite our best efforts. After discussion with the family the patient became comfort measures and was eligible for organ donation. The patient had a DCD [Donation After Cardiac Death] on 5/24/2024 at 1554 [3:54 PM] . .date of death : 5/14/24 CAUSE OF DEATH/DIAGNOSES AT TIME OF DEATH Acute hypoxic respiratory failure Aspiration pneumonia Cardiac arrest Anoxic brain injury with resulting seizure disorder Hyponatremia Myocardial injury . On 5/16/24 at 9:48 AM, an interview was conducted with the Senior Regional NHA, the NHA, the DON, and regional RN N. The DON verified that based on R508's medical history and acute care discharge summary, R508 required oversight, cueing, and supervision with eating due to his well-documented history of impulsivity which resulted in a choking/aspiration risk. The DON confirmed she was unaware of R508's initial choking event that occurred on 5/5/24 until she was informed during report upon arriving to work on 5/6/24. The DON confirmed LPN D was unaware of the protocol following a choking incident, including downgrading the diet and notifying the DON and/or physician. The DON stated, I would have probably downgraded the diet [on 5/5/24] if I would have known about the choking incident. The Senior Regional NHA, the NHA, and the DON all confirmed R508 should have been supervised during the lunch meal on 5/5/24. When the DON was asked if LPN D should have reported R508's seizure-like activity and discoloration of his lips to the on-call provider she stated, He [LPN D] didn't witness any seizure activity and there was nothing to alert him [of the seizure activity]. The Senior Regional NHA added, [LPN D] didn't think he [R508] had a seizure. Both LPN D and CNA B's witness statements were reviewed which stated, .food coming out of his mouth, he was shaking, and his lips were turning blue, and, he was not talking or responding ., respectively. The Senior Regional NHA stated, It's not the CNA's place to say if he had a seizure. When asked who the appropriate person would be to make that determination, the DON stated, The physician. CNA I witness statements and interviews were reviewed with the Senior Regional NHA, the NHA, the DON, and regional RN N which confirmed CNA I left R508 unattended twice during the 5/7/24 dinner meal. The Senior Regional NHA stated, I don't know what to say to you, that's not what I heard . I was told he [R508] was never left unattended with his food. When CNA I's witness statement was reviewed which read, he ate about half if [sic] the sandwich and half his drink. [CNA L] and I went to look at the binder, he had half his sandwich left .he fed the last half sandwich to himself .not even a minute was I looking at the book with [CNA L] the NHA replied, She [CNA I] never told us she left [R508 unattended]. All parties confirmed R508 was care planned for direct supervision in the dining room at mealtimes at the time of the incident on 5/7/24. Resident #509 (R509): Review of R509's EMR revealed admission to the facility on 4/19/24 with diagnoses including cerebral infarction (stroke), dysarthria (difficulty speaking), and dysphagia. Review of R509's Brief Interview for Mental Status (BIMS) assessment revealed a score of 9, indicative of moderate cognitive impairment. Review of R509's Plan of Care read, in part: .EATING: 1 person assist, 1:1 supervision, initiated 5/8/24. On 5/15/24 at approximately 1:40 PM, R509 was observed eating lunch in the A-side dining room. Two facility staff members, Resident Voice/Staff Member Q and Registered Dietitian (RD) R were in the dining room. R509 was observed with a meal tray placed in front of her with no staff supervision. R509 was observed eating for the duration of her meal without receiving cueing or assistance from staff. On 5/15/24 at 1:50 PM, an interview was conducted with the DON regarding facility personnel expectations in the dining rooms during mealtimes. The DON indicated there should be two staff members in the dining room as, a rule of thumb. When asked if the staff members should be a CNA she replied, Yes. The DON was asked if a non-CNA could assist in the dining and stated, As long as they're not providing direct care or feeding. On 5/15/24 at 2:46 PM, a follow up interview was conducted with the DON and Resident Voice/Staff Member Q. The DON was asked her expectations for a resident who required 1 person assist or 1:1 supervision during mealtimes. The DON stated she considered 1:1 supervision to be, sitting next to the resident, providing cues and assistance, and being able to visualize the resident. Resident Voice/Staff Member Q was asked if she was aware of any residents in the dining room who required 1:1 supervision during mealtime to which she replied, No. Review of R509's meal tray card read, Alerts: 1:1 feeding assistance, supervision with meals. On 5/15/24 at 2:49 PM, an interview was conducted with SLP G who verified R509 required 1:1 supervision during mealtimes. When asked why R509 required 1:1 supervision, SLP G stated, Because she has zero motivation to feed herself . she's a failure to thrive. If she has one-on-one assistance, she'll accept that assistance [and eat]. When asked his definition of 1:1 assistance, SLP G replied, Eyes-on the resident, cueing, helping her feed herself. Resident #510 (R510): Review of R510's EMR revealed initial admission to the facility on [DATE] with diagnoses including dysphagia, cognitive communication deficit, and schizophrenia. Review of R510's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. Review of R510's Plan of Care read, in part: .EATING: 1 person assist, initiated on 12/9/24. On 5/16/24 at 7:35 AM, R510 was observed in the East-side dining room in a high back wheelchair in the rear left corner with his back facing the dining room entrance. At 7:39 AM, the Assistant Director of Nursing (ADON) was observed placing R510's tray in front of him then walking away and leaving him unsupervised. R510 was observed eating the entirety of his breakfast meal without assistance from staff. Review of discharge instructions from an acute care hospital, dated 12/9/23, read, in part: .Diet after discharge: dysphagia diet . Will need 1:1 assist. Hx [history] of choking on solids . Review of a Progress Note written by written by NP S on 12/11/23 read, in part: .He [R510] is on a modified diet and recommended to have one-to-one feeding assist . Dysphagia, unspecified type: history of aspiration pneumonia .recommend to have 1:1 feed assist . Review of R510's progress notes revealed the following entries: 1. 12/9/23: .requires assist and supervision with meals-recent aspiration pneumonia . 2. 12/10/23: .resident drinks very fast and requires staff to assist with eating and drinking . 3. 12/12/23: .low safety awareness, impulsive 1-1 assist/sup [supervision] for feeding . 4. 12/13/23: .recommend 1:1 feeding assistance with all intake. 5. 12/14/23: .resident drinks very fast if left unattended during meals . Review of R510's most recent SLP Evaluated, dated 2/1/24, read, in part: .P[TRUNCATED]