(ABC 6 News) – A dementia patient died because a Rochester facility failed to address their increased choking risk, according to the Minnesota Department of Health.

The MDH investigated Cascade Creek, an assisted living facility with dementia care, in July of this year, according to a report released Aug. 6.

According to the MDH report embedded in full below, after a choking incident, Cascade Creek neglected the client by failing to communicate a medical directive to cut their food into small pieces — leading to two more choking incidents, the second of which killed them.

According to the report, the first time the resident choked, a doctor ordered the facility to cut meals into pieces “smaller than a quarter.”

There was no evidence the facility passed that information to dietary staff or unlicensed caregivers, according to the MDH, and the resident choked again 10 days later, after being given a cookie as an evening snack.

Again, the MDH found no instructions to cut the resident’s food into small pieces in the dietary plan, although staff was ordered to “(encourage) the resident to take small bites and to prompt resident during meals.”

Six days later, the resident was given corn chips and dip at an event and choked again, according to the report.

Staff attempted the Heimlich Maneuver and CPR, and the resident died two days later “due to complications of CPR following choking on food.”

ABC 6 News reached out to Cascade Creek Memory Care for comment Wednesday and received the following statement:

“We take the care, safety, and health of our residents very seriously, and this incident has deeply affected us. Our goal has always been to provide the highest quality of care. In light of this event, we conducted a thorough investigation and are reviewing processes continually. We remain committed to ensuring the safety and well-being of all our residents.”