Failure to Prevent Shellfish Allergen Exposure in Resident Meal Service
Summary
Facility staff failed to prevent an allergic reaction for a resident with a documented severe shellfish allergy when the resident was served and consumed lobster ravioli provided by the facility. The resident’s electronic health record listed a shellfish allergy categorized as a food allergy with a severe reaction manifestation and severity, and this allergy was also reflected in the resident’s care profile. The resident had a cognitive communication deficit and was assessed as moderately impaired in cognition for making daily decisions, scoring 12 out of 15 on the BIMS. Despite these documented conditions and allergy information, the facility’s dinner menu for the skilled nursing floor included lobster ravioli, and the resident received and ate 100% of this meal. Around the time of the evening meal, the resident activated the call bell, and an LPN responded. The resident reported difficulty breathing and stated that the dinner served was shellfish, to which he was allergic. The LPN obtained vital signs, which were documented as blood pressure 124/74, heart rate 121, temperature 97.8°F, and oxygen saturation 96% on room air. Although the vital signs were noted to be within normal limits, the resident continued to report trouble breathing. The LPN attempted to contact the on-call physician service but was unable to reach a provider and then called 911 to have the resident transferred to the emergency room for further evaluation and medical management. The LPN later confirmed that the lobster ravioli had come from the facility. At the hospital, the resident was evaluated for acute onset shortness of breath and undifferentiated shock after exposure to shellfish, briefly requiring vasopressor support. The hospital documentation noted a differential diagnosis of bronchiolitis versus allergic reaction, and the resident was treated with 25 mg of Benadryl and admitted for further evaluation. Facility interviews and documentation indicated that the dietary department had a process in which resident food allergies were to be communicated via a notify form and posted allergy lists in the pantry, and that dietary aides were expected to reference these lists when plating meals. The dietician stated that the resident knew he ordered lobster ravioli and that the dietary aide should have caught the shellfish allergy, while a dietary aide described relying on the posted allergy list when plating meals. Despite these procedures and the posted allergy information, the resident with a documented severe shellfish allergy was able to order, receive, and consume lobster ravioli, resulting in an allergic reaction that required emergency treatment and hospitalization and was cited as Immediate Jeopardy with harm.
Removal Plan
- Reinforce use of the communication log posted in the Skilled Nursing pantry.
- Dietary staff verify identified residents with food allergies at each meal service using a daily updated log and dietary notification communication of resident allergies provided to dining staff.
- Educate all Skilled Nursing Facility staff (including agency staff) on the facility process: nursing enters orders into PCC; nursing completes diet notification form including food allergies and provides it to dietary; allergy is reflected on the menu ticket following manual order transcription; kitchen staff receive and verify diet order including any food allergies; kitchen staff sign and acknowledge resident food allergy via the compliance log with every meal.
- Ensure all nursing and dietary staff are educated before start of their shift; staff on PTO are educated upon return prior to next assigned shift.
- DON (or designee) audits new admission records weekly to ensure data entry and communication form process was followed for a defined period or as determined by the QAPI committee.
- Dietary Manager (or designee) monitors meal tickets for residents with food allergies weekly to ensure food allergies are included on the meal ticket for a defined period or as determined by the QAPI committee.
- Monitor process compliance and audit results in the facility QAPI program; administrator responsible for ongoing compliance.
Penalty
Resources
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The facility failed to provide alternate meal choices of similar nutritional value and did not consistently honor resident food and beverage preferences during a period when the main kitchen was closed and meals were prepared from the dining room using limited equipment. Only a single entrée was offered at each meal, with peanut butter and jelly or deli sandwiches as the only substitutes, and several residents reported they could not order and were simply served whatever was prepared, including food they disliked or items that did not match their stated preferences. Residents also did not consistently receive requested beverages such as chocolate milk, 2% milk, cranberry juice, fruit punch, or ice with meals, and one resident reported being served burnt pizza with no alternative. The Dietary Manager confirmed there was no second meal option of similar nutritive value during the shutdown and that new dietary aides had not been fully trained on tray line duties.
A resident with Alzheimer’s disease and other comorbidities, who was cognitively impaired and dependent on staff for care, was not provided a meal consistent with documented food preferences and restrictions. During a breakfast service, the resident received pureed sausage, scrambled eggs, pureed toast, and cranberry juice, despite a meal ticket specifying yogurt, half a banana, tea, and no juice or soda. A CNA confirmed the resident did not receive the ordered items and was served juice contrary to the documented restriction, in violation of facility policy requiring that individualized food preferences and restrictions be reflected in the tray ticket system.
A cognitively intact resident with multiple chronic conditions, including DM2, mental health disorders, paraplegia, and breast cancer, did not consistently receive preferred food items as indicated on meal tickets and as known by staff. On multiple observed meals, items such as 2% milk, cranberry juice, and yogurt were missing or provided in lesser quantities than ordered or routinely requested, leading the resident to refuse at least one meal. A CNA and an LPN confirmed that the resident’s usual preference for two milks and two yogurts at each meal was not consistently honored, despite facility policy requiring nutrition care consistent with individual preferences.
Surveyors found that the facility failed to honor documented food preferences and allergy restrictions for two residents. One resident, with multiple behavioral and medical diagnoses, was served rice despite a recorded dislike and reported frequently receiving tomato-based items that upset her stomach. Another resident, with COPD and an allergy to raw onions, was served sautéed peppers and onions even after dietary staff verbally reminded each other to avoid onions, and the resident reported repeatedly receiving onions, mayonnaise, and sour cream despite stating he did not want them.
Two residents with intact cognition and multiple medical conditions did not receive the food items they selected on their meal tickets, such as vegetable soup and crackers. Staff interviews and Resident Council notes confirmed ongoing complaints about residents not receiving their requested menu items, despite CNAs being responsible for collecting and submitting meal selections to the kitchen.
Two residents with specific dietary preferences, including avoidance of pork and beef due to health and religious reasons, did not have their preferences consistently honored. Nutrition assessments were not completed in a timely manner, and staff failed to accurately document and follow dietary restrictions, resulting in residents receiving meals with items they wished to avoid.
Failure to Provide Alternate Meal Choices and Honor Resident Food Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide appealing meal options of similar nutritive value and to honor residents’ food preferences during a prolonged kitchen shutdown and subsequent transition period. For 19 days while major plumbing repairs were performed in the kitchen and dry storage, the facility prepared meals out of the dining room using limited equipment such as roasters, crockpots, a microwave, a griddle, and a waffle maker. During this time, only one meal choice was offered at each meal, and the only substitutes available were peanut butter and jelly sandwiches or deli sandwiches. The Dietary Manager confirmed that there was no second meal option of similar nutritional value available during the kitchen shutdown. Multiple residents reported not being able to order or receive their preferred items. One resident stated there were no second options or substitute items and that he was simply given food he did not like, including peas, carrots, and rice. Another resident’s meal ticket indicated a preference for chocolate milk, which was not provided on the tray. A different resident reported she does not order and is just served whatever is given; her stated preferences for 2% milk, cranberry juice, and fruit punch resulted in her receiving only fruit punch. Another resident reported being served burnt pizza with no other option when the kitchen was down and stated that even when she tells staff what she wants, she usually does not receive it; her ticket also indicated she should receive ice with every meal and fruit punch at lunch, neither of which were delivered. The Dietary Manager further acknowledged that new dietary aides were still in training and had not been given sufficient time to learn their tray line duties during and immediately after the kitchen relocation.
Failure to Follow Documented Food Preferences and Restrictions
Penalty
Summary
The facility failed to provide meals according to a resident’s documented food preferences and restrictions. A resident with Alzheimer’s disease, congestive heart failure, anxiety, and seizures, admitted in mid-September 2024, had a comprehensive MDS indicating a cognitive deficit and dependence on staff for all care. The resident’s care plan showed a need for supervision and occasional feeding assistance. On the observed breakfast service, the resident was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice, with appropriate adaptive equipment. However, review of the resident’s meal ticket for that breakfast showed the resident was supposed to receive yogurt, half a banana, and tea daily, with explicit instructions for no juice or soda. Despite these documented preferences and restrictions, the resident was served juice instead of tea and did not receive the ordered yogurt and banana. A CNA confirmed that the resident was not supplied the ordered food and acknowledged that residents’ preferences changed often. Facility policy on accommodation of food preferences required that resident food preferences be listed in the tray ticket system and that alternate menu items be available to meet individualized needs and requests, but this was not followed in this instance.
Failure to Consistently Honor Resident Food Preferences
Penalty
Summary
A cognitively intact resident with multiple diagnoses, including type 2 diabetes mellitus, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and breast cancer, did not consistently receive food items according to documented preferences and meal tickets. The resident’s medical record showed admission on 07/01/25, and the MDS dated 01/08/26 confirmed intact cognition. The facility’s meal ticket for breakfast on 03/09/26 indicated the resident was to receive two 2% milks, cranberry juice, and yogurt; however, observation showed the tray was missing both milk and cranberry juice, leading the resident to refuse the meal due to not having the requested items. The facility’s policy stated that the Food and Nutrition Services Department would promote optimal nutrition status consistent with each individual’s needs and personal preferences. Further review of meal tickets and observations on subsequent dates showed repeated failures to provide the resident’s preferred items. A lunch meal ticket dated 03/12/26 indicated the resident was to receive two 2% milks and yogurt, but observation revealed only one milk and one yogurt were provided. The resident reported that although the meal ticket showed one yogurt, the dietary department knew she wanted two milks and two yogurts at every meal. A CNA confirmed that the resident always wanted two milks and two yogurts at each meal and verified that the resident did not receive them per preference. On 03/16/26, the lunch meal ticket again showed two 2% milks and yogurt, but observation revealed no yogurt on the tray, which an LPN also verified. These findings demonstrated that the facility did not consistently provide food that accommodated the resident’s stated preferences as required.
Plan Of Correction
F806 Resident Allergies, Preferences, Substitutes The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. As of 3-17-2026 Resident #4 is ensured by the dietary Manager that she is now receiving requested 2 milks and 2 yogurts and cranberry juice with each tray. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Dietary manager has done a sweep of all facility residents and determined likes and ensured these likes are on their meal tickets. Completed 3-17-26 What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DM in serviced dietary staff in reading and following dietary tickets In-service completed 3-17-2026. How the corrective action will be monitored to ensure the deficient practice will not recur. DM/designee auditing all trays for compliance with meal tickets 5 x a week X4 weeks during lunch and dinner. Results submitted to QAPI committee.to ensure all residents receive the requested diet. Identified concerns by audits are immediately corrected and staff reeducated.
Failure to Honor Resident Food Preferences and Allergy Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to provide food that met documented resident preferences and allergies for two residents out of three reviewed for food preferences, in a census of 38. For one resident admitted with multiple diagnoses including post-traumatic stress disorder, alcohol use, major depressive disorder, generalized anxiety disorder, history of traumatic brain injury, convulsions, anemia, essential hypertension, vitamin D deficiency, and insomnia, the food preference and allergy sheet documented numerous dislikes, including any type of tomato products and rice. During observation of the lunch tray line, this resident was plated rice despite the tray card indicating rice as a disliked item, which was confirmed by the Dietary Manager and another staff member. In interview, the resident reported that tomatoes upset her stomach and that she often receives tomato-based soups or spaghetti sauce, which she does not eat when they are served. For a second resident admitted with diagnoses including chronic obstructive pulmonary disease, emphysema, acute chronic respiratory failure, anxiety disorder, essential hypertension, and major depressive disorder, the food preference and allergy sheet documented an allergy to raw onions and dislikes of tomatoes or tomato products and yogurt. During observation of the lunch tray line, the Dietary Manager reminded a staff member not to give this resident sautéed peppers and onions, and the resident’s tray card showed an allergy to raw onions. Despite this, the plated meal for the resident included sautéed peppers and onions, which was confirmed by the Dietary Manager and the staff member. In interview, the resident stated he keeps receiving onions despite telling staff multiple times he did not want them and also reported repeatedly receiving mayonnaise and sour cream, which he does not like. This deficiency was investigated under Complaint Number 2722647.
Failure to Provide Residents with Selected Menu Items
Penalty
Summary
The facility failed to ensure that residents received the menu items they selected at mealtime, as evidenced by observations, interviews, and review of records. Two residents with intact cognition and specific medical diagnoses, including hemiplegia, type II diabetes mellitus, hypertensive heart disease, and heart failure, did not receive the food items they had chosen on their meal tickets. One resident did not receive vegetable soup as selected, and another did not receive crackers, despite both items being available and provided only after staff intervention during the meal service. Staff interviews confirmed that residents frequently complained about not receiving their requested menu items. Further review revealed that CNAs were responsible for distributing and collecting menu tickets, but there were ongoing issues with ensuring residents' selections were honored. Resident Council Food Committee notes documented concerns about menus not being filled out and residents not getting what they requested. These findings demonstrate a pattern of the facility not providing food according to residents' documented preferences and selections.
Failure to Complete Timely Nutrition Assessments and Honor Dietary Preferences
Penalty
Summary
The facility failed to ensure that nutritional assessments were completed in a timely manner to determine dietary preferences and failed to honor food preferences for two residents. For one resident with multiple diagnoses including congestive heart failure, diabetes, and moderate cognitive impairment, the care plan and physician orders did not specify the resident's request to avoid pork and beef, despite documentation and interviews indicating these preferences. Observations confirmed that this resident received beef on his meal tray, and staff verified the presence of beef despite the resident's stated aversion. Another resident, with a history of kidney transplant, end stage renal disease, and diabetes, also reported a preference to avoid pork for religious reasons. Although the dietician was made aware of this preference, the resident continued to receive pork on meal trays and had to return them. Staff interviews revealed that dietary staff did not consistently review meal tickets thoroughly and relied on cheat sheets, which were incomplete regarding certain preferences. The facility's policy required interviews within 72 hours of admission to determine food preferences, but this was not completed for one of the residents involved.
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