A 70 year old male resident was admitted to Anberry Nursing and Rehabilitation Center in April 2017 with diagnoses that included dysphagia (trouble swallowing). During the resident’s stay, he had multiple teeth extractions, exacerbating his risk of choking, but no changes were made to his care plan. On 4/18/18, the resident was diagnosed with Progressive Supranuclear Palsy by a neurologist but the new diagnosis was not communicated to the resident’s primary care physician and no changes were made to the resident’s care plan. On 11/29/19, the resident was given breakfast, left alone, and choked to death on an uncut tortilla. Abdominal thrusts proved ineffective. Rather than call 911 for emergency assistance, a nurse called a local ambulance company which did not show up until 33 minutes later, possibly because the company believed the call was for a non-emergency transport. The facility was cited for failing to make a speech therapy referral, failing to update the resident’s care plan to reflect his additional risk of choking, and delaying emergency services. As a result of these failures, the resident died.