Failure to Prevent Serving Allergen-Containing Food to Resident with Documented Food Allergies
Summary
A resident with documented allergies to gluten and lactose was served cream of wheat for breakfast, despite multiple records indicating these allergies. The resident's care plan, physician's orders, allergy list, dietary profile, and other medical documentation all specified the need for a gluten-free and lactose-free diet. The resident's meal ticket did indicate a gluten restriction, but the actual food provided did not comply, and the meal ticket did not specify the correct gluten-free substitute (cream of rice). The resident reported previous instances of being served foods containing gluten and stated that staff had been informed of these allergies. The dietary staff prepared only oatmeal and cream of wheat for breakfast, and cream of rice, the appropriate substitute, was not available in stock. Staff responsible for preparing and checking trays were either unaware that cream of wheat contained gluten or had been incorrectly informed that it was safe for gluten-free diets. The kitchen staff had not received training on gluten-free diets, and the facility's software failed to update the meal ticket to reflect the resident's dietary needs. The food service manager or supervisor did not check the resident's tray for the correct diet before it was delivered, as required by facility policy. Interviews with staff revealed gaps in knowledge and communication regarding food allergies and dietary restrictions. The licensed nurse who checked the tray was not able to accurately identify whether the hot cereal was gluten-free and relied on incomplete information from the meal ticket. The dietary aide responsible for tray accuracy had been told by a previous supervisor that cream of wheat was acceptable for gluten-free diets, leading to repeated errors. The facility's purchasing records showed that cream of rice had not been restocked in a timely manner, further contributing to the deficiency.
Removal Plan
- The DON immediately assessed Resident 71 for any adverse reaction and there were none noted.
- The facility notified Resident 71's attending physician and Resident 71's family of the incident of giving food containing allergies. The attending physician did not give any new orders.
- The Minimum Data Set Coordinator 1 (MDSC 1) updated Resident 71's allergy Care Plan to remove gluten allergy and Resident 71's nutrition risk Care Plan to reflect gluten intolerance prior to a diagnostic test for allergies.
- The Registered Dietitian (RD) evaluated Resident 71 and updated food preferences, reviewed allergies and food intolerances, and completed a nutritional assessment.
- The Director of Staff Development (DSD) provided one-on-one in-service training to Licensed Vocational Nurse 3 (LVN 3, who checked Resident 71's breakfast prior to serving) to ensure: a) Identification of food allergies using the daily Allergy Report provided by DON and/or designee. The daily Allergy Report can be found in a special needs binder located at each nursing station and dining room. b) Prior to tray passing to residents during mealtimes, a licensed nurse will check all trays for accuracy of meal ticket and physician diet orders against what is on the residents' meal tray using the diet report. c) Prior to passing the meal trays to the residents during mealtimes, a licensed nurse will check the diet type report and the meal ticket on each tray against the food on the resident's meal tray. d) Prior to tray passing to residents during mealtime, a licensed nurse will check all the trays to ensure any resident with a gluten allergy is not served unless food item on food tray is labeled gluten free.
- The DON, the DSD, the RD, the Dietary Supervisor (DS) initiated an in-service to staff (including RNs, LVNs, CNAs, Rehabilitation Therapists, the Dietary Manager, cooks, tray line staff, dishwashers, Dietary Preparation staff, and Department Heads) about identification of food allergies using the daily Allergy Report, 2 licensed nurse will check all the trays to ensure meal ticket, physicians orders and Diet Type Report are accurate against resident's food trays. The in-service also included checking all the trays to ensure all trays are checked for gluten allergies and not served foods containing gluten. Snacks for residents on gluten free diet will be labeled gluten free. A licensed nurse will check the diet type report, snacks label and food to ensure accuracy before serving it to the residents.
- The DS completed an in-service to the dietary staff (Dietary Manager, cooks, tray line staff, dishwashers, and dietary preparation staff) related to food allergy, labeling of gluten-free food items, and ensuring all trays are checked accurately to ensure residents are not served a food item they are allergic prior to trays being sent out of the kitchen. Tray line staff will refer to Diet Manual for Guidance on alternatives for residents on gluten restricted diet/gluten allergy/intolerance. Staff that have not yet been in-serviced (those on vacation and per diem employees) will be in-serviced on their first reported day back to work.
- The DON and or designee will update the Allergy report daily at the clinical meeting (Monday to Friday), and ensure it is available at each nursing station and dining room and a copy will be provided to the kitchen.
- The DON, the Assistant DON (ADON), the MDS Nurse and the DSD observed the licensed nurses checking for tray accuracy prior to trays being served to residents. No issues were identified and the 10 residents who had food allergies and or food intolerances had accurate trays. The DON and ADON assessed the 10 residents for any signs and symptoms of allergic reaction, and none noted.
- The RD provided in-service to final tray line staff who checked Resident 71's breakfast tray.
- The DON reviewed all residents and identified 10 residents with food allergies. Resident 71 the only resident identified to be on a gluten restricted diet. One resident identified having gluten allergy had been hospitalized for unrelated medical condition. Upon this resident readmitted to the facility, the nurse will obtain an order from the MD for allergy test.
- The Regional RD observed breakfast tray line to ensure accuracy of the meal tickets to what was being placed on resident's meal trays. There were no issues identified and the 10 residents who had food allergies and or intolerances had accurate trays.
- The DON completed competency for the licensed nurse who checked Resident 71's tray and met expectations as evidenced by the licensed nurse being able to correctly check the diet orders, resident allergies against the food tray.
- The DON and or designee will complete a random daily visual check of meal trays for residents with identified food allergies using the Daily Food Allergy Audit Form. This audit will remain on-going until the goal is achieved.
- The DON and or designee will review the change in conditions daily related to food allergies.
- The DON and or designee will complete a Monthly Food Allergy Interview Audit Tool to ensure that each residents allergies are current, and up to date. This audit will remain ongoing until the goal is achieved.
- The DON obtained an order from Medical Doctor (MD) for Tissue Transglutaminase ([tTG-igA], blood test to diagnose celiac disease, a disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food) to be drawn.
- The DON discussed with MD to update Resident 71's gluten intolerance to gluten allergy. The DON updated allergy profile and care plan to reflect resident's gluten allergy. The DON provided dietary communication form to dietary staff for gluten allergy update.
- Registered Nurse Supervisor obtained order from MD for Resident 71 for psychology consult for psychosocial support.
- The RN Supervisor and or designee will update the Allergy report and special needs binder on the weekends (Saturday and Sunday) at each nursing station, and dining room.
- The RD will check food inventory weekly based on the upcoming week's menu using the Inventory form. If any items are missing, the RD will notify the Dietary Manager/designee, and the RD will approve appropriate alternative with same nutritional value if necessary.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to honor a resident’s requested diet texture. A resident with intact cognition and diagnoses including RA, PTSD, and recurrent MDD repeatedly asked for a regular diet, but staff continued serving a mechanically altered/blended diet. She reported that staff ignored her requests, while CNA and nursing interviews confirmed she was not eating the facility trays and was instead getting other foods. The DON and DOR acknowledged concern about possible choking, but also stated the resident had the right to choose her diet plan and that her request for a diet upgrade was denied without further discussion.
Failure to provide resident-selected menu items: Residents reported that meals were not being served as shown on the menu, including a missed special holiday meal and menu days that were not identified. The menu included Resident's Choice and regional breakfast selections, but the CDM stated the planned Port of Call meal could not be obtained from the distributor, and the Corporate Dietician confirmed the facility did not provide residents with their selected menu items and preferences.
Meal tray tickets did not consistently match resident preferences or allergy information. One resident with dementia was served apple juice instead of the orange juice listed on the tray ticket, and staff said tray tickets should be followed to meet resident needs. Another resident with a documented lactose allergy had a tray ticket that did not reflect the allergy, and staff interviews showed the allergy was not consistently communicated to dietary even though the resident reported still receiving milk on meal trays.
Failure to honor documented food preferences: A resident with type 2 DM and moderate cognitive impairment received a lunch tray with ham despite a tray ticket listing pork as a dislike. The resident stated dietary staff had not been following the tray ticket and confirmed the pork preference had been discussed more than once.
Failure to Honor Food Preferences and Offer Meal Alternatives: A resident with intact cognition, DM, and mild protein-calorie malnutrition reported skipping breakfast because she disliked the meals being served and said staff did not ask about her food preferences or offer substitutes with adequate nutritive value. A CNA observed an untouched breakfast tray at the bedside, took it back to the kitchen after the resident declined it, and did not offer an alternative; the RDM and RD stated meal alternatives are important to meet nutrition needs and food preferences.
A resident did not receive a fresh fruit cup that was listed in the Notes section of the lunch meal ticket as a food preference. During the meal observation, the tray did not include the fruit cup, and the resident stated she wanted it. An LVN verified the meal ticket, and the DSS stated items in the Notes section were resident preferences that should be included with the meal.
Failure to Honor Resident’s Requested Diet Texture
Penalty
Summary
The facility failed to provide food that accommodated a resident’s preference for a regular diet, despite the resident’s repeated requests for non-mechanically altered food. Resident #53 was admitted with diagnoses including rheumatoid arthritis, PTSD, and recurrent major depressive disorder. Her quarterly MDS showed a BIMS score of 15 out of 15, indicating no cognitive impairment, and her care plan reflected that she was on a regular diet/mechanical soft with thin liquids and that staff were to honor her meal choices. The care conference record also noted that she complained of diet texture and that follow-up was planned. During observation and interview, Resident #53 stated she had lived at the facility for years, had no teeth, and could not stand the food because staff insisted on serving her a mechanical blended diet. She said she ordered her own food and had CNAs prepare instant oatmeal, pasta, and other items for her, and that she had asked repeatedly for regular food but staff ignored her. She stated she had been eating a regular diet for years without problems. Observation later showed a CNA delivering a lunch tray that included a blended beef tator tot casserole, mixed vegetables, and a smoothie; the resident accepted only the smoothie and returned the rest of the tray untouched. Staff interviews confirmed that Resident #53 was not eating the facility-provided meals and was instead obtaining other foods. A CNA stated the resident never accepted her meal trays and sometimes accepted drinks, while an LVN said the resident had always bought her own food and did not eat the facility food. The ADON and DOR stated the resident had previously worked with ST because she would eat while lying down and scooping food from the plate, and they expressed concern about possible choking, though they were not aware of any choking incidents. The MDS Coordinator stated the resident requested a diet upgrade to regular food at the care conference, reported having had a swallow study and being able to eat regular food, and that the request was denied without further discussion; she also stated the resident was not informed of the outcome.
Failure to Provide Resident-Selected Menu Items
Penalty
Summary
The facility failed to provide resident-selected menu items for 5 of 12 residents identified in the report: R707, R708, R709, R710, and R711. Review of facility policy showed that meal identification and food preference cards were to be used to properly identify each individual's food and beverage needs, and the Resident Rights and Facility Responsibilities policy stated the facility would comply with resident rights. During the Resident Group Meeting, residents stated that meals were not being provided as shown on the menu, that some menu days were not identified, and that a special meal for Memorial Day was not provided. Review of the Spring Summer Menus showed a four-week rotation cycle with two Thursday lunch meals listed as Resident's Choice and two Thursday breakfast meals listed as Regional breakfast favorite. The Regional Dietician stated that certain menu choices were determined at the corporate level for Port of Call days and sent to each facility by email with the selected meal, ingredients, portion sizes, and consistency instructions, and that lunch resident choices were supposedly decided during resident council meetings. The Certified Dietary Manager stated he could not obtain the food from the distributor for the Hawaii Port of Call and therefore could not provide the planned Thursday meal. The Corporate Dietician later confirmed that the facility failed to provide residents with their selected menu items and preferences as indicated on the menus.
Meal Tray Tickets Did Not Match Resident Preferences or Allergy Information
Penalty
Summary
The facility failed to ensure that residents received foods that matched their documented preferences and allergy information. One resident with dementia and severe cognitive impairment had a breakfast tray ticket that listed orange juice, but apple juice was served instead. During observation and interview, the resident stated she liked orange juice and was okay with the apple juice that day, and she also said that sometimes she did not receive everything on her tray ticket. Staff acknowledged that the tray ticket did not match the meal served and stated that tray tickets should be followed to meet resident needs and preferences. A second resident with diagnoses including burns and a documented lactose allergy had a lunch tray ticket that did not reflect the lactose allergy listed in the medical record and care plan. The resident stated he was lactose intolerant and reported that he still received milk on meal trays. He said he knew not to consume lactose products, but it would be helpful if the kitchen did not provide them. Staff interviews showed that the Dietary Manager, CNA, DON, and ADM were not consistently aware of the lactose allergy being communicated to dietary, and the DON stated the allergy should have been on the meal tray ticket. Record review showed the first resident’s care plan included providing and serving the diet as ordered, and the second resident’s care plan identified lactose allergy. The facility’s policies stated that food preferences, dislikes, and allergies should be obtained and that tray cards should be updated to reflect appropriate information. The Dietary Manager and other staff stated that meal tray tickets should be followed to ensure the right diet, texture, and resident, but the tray ticket for one resident did not match the ordered beverage and the tray ticket for the other resident did not reflect the documented lactose allergy.
Failure to Honor Documented Food Preferences
Penalty
Summary
The facility failed to honor a resident’s food preferences by serving a lunch tray that included ham despite the resident’s documented dislike of pork. Resident #12 was admitted with type 2 diabetes mellitus and had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. During observation, the resident stated that dining staff had not been following the tray ticket listing food dislikes and showed the tray ticket from breakfast, which included pork as a dislike. When the resident’s lunch tray was delivered, ham was observed on the plate, and the resident stopped the CNA delivering the tray to request an alternative main entree. The resident confirmed that pork, including the ham served, was not liked and stated this had been discussed with dietary staff on more than one occasion.
Failure to Honor Food Preferences and Offer Meal Alternatives
Penalty
Summary
The facility failed to honor food preferences and failed to offer meal substitutes of the same nutritive value for one sampled resident. Resident 122 was admitted and later readmitted to the facility and had diagnoses including osteoarthritis of the right knee, DM, and mild protein-calorie malnutrition. The MDS dated 4/2/2026 indicated the resident’s cognitive skills for daily decision making were intact, that the resident required setup and clean-up assistance with meals, and that the resident required moderate assistance with ADLs. The H&P dated 5/7/2026 indicated the resident had the capacity to understand and make decisions. During an interview on 5/18/2026, Resident 122 stated she did not like the breakfast meals being served and reported skipping breakfast because she was unhappy with the food provided. She stated that no staff asked for her food preferences and no meal substitutes with adequate nutritive value were offered. During a concurrent observation and interview on 5/20/2026, CNA 4 observed an untouched and covered breakfast tray with scrambled eggs and oatmeal at the bedside table and stated the resident declined the tray, it was taken back to the kitchen, and no meal alternative or food preference was offered. The Regional Dietary Manager stated not providing meal alternatives could lead to poor intake, and the RD stated it was important to offer other food choices when a resident refused a meal to help meet nutrition needs and food preferences. The facility’s Dignity policy stated the facility culture supports dignity and respect for residents by honoring resident food choices and preferences.
Missed Resident Food Preference on Meal Tray
Penalty
Summary
The facility failed to ensure that one of 27 sampled residents, Resident 31, received food that accommodated the resident’s preferences. During the lunch meal observation on 5/18/26, Resident 31 was observed eating in her room with a tray that included a baked hamburger with brown sauce, capri blend vegetables, fried diced potatoes, a wheat roll, and a fruit crisp dessert. Review of the resident’s lunch meal ticket showed a note to add a fresh fruit cup, but the fruit cup was not present on the tray. When asked, Resident 31 stated she would like to have her fruit cup for her lunch meal. Resident 31 had been admitted to the facility and later readmitted. During the concurrent observation and interview, LVN 7 reviewed the meal ticket and verified that the fresh fruit cup should have been included. The DSS stated that items listed in the Notes section of the meal ticket were resident preferences for the meal and that if listed, the resident should have that item in addition to the menu items. The Administrator, ADON, and DON were informed of and acknowledged the findings.
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