William E Christoffersen Salt Lake Veterans Home.

“The provider was out of compliance with this rule by not providing each resident with a safe diet that met the special dietary needs of each resident. Specifically, a resident had a diet order for soft and bite-sized texture and was served a sandwich for a snack which resulted in the resident choking and passing away.<br/><br/>It was determined the provider's non-compliance with this rule had caused harm. However, based on the facility's corrective actions and a review of its current compliance, the deficiency was determined to be past noncompliance.<br/><br/>The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by 10/16/25 included the following measures: The facility implemented staff education, limited access to sandwiches in the memory care unit, and increased locations to access resident diet orders and education for staff. The survey team verified that all these interventions were completed before the survey start date.”

“Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.”

“Dietary requirements”

“Reasonably accommodate the needs and preferences of each resident.”

“Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.”

“Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.”

“Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.”

“Provide and implement an infection prevention and control program.”