Failure to Provide Gluten-Free Meal to Resident With Documented Allergy
Summary
The facility failed to ensure a resident with a documented gluten allergy received a breakfast tray free of gluten-containing food. The resident’s admission record, admission assessment, diet order and communication, and care plan all identified gluten as a food allergy. The care plan also included interventions to honor the resident’s reasonable food preferences and to offer substitutes for meals as needed. The resident’s MDS indicated the resident was cognitively intact and required only supervision, setup, or clean-up assistance for mobility, dressing, personal hygiene, and eating. Despite these documented allergies and care plan interventions, on 12/22/2025 the resident was served a breakfast tray that included sourdough toast, which contains gluten, along with eggs. A CNA reported that the resident informed him at that time that they were allergic to gluten and could not eat the sourdough toast on the tray. The facility’s failure to prevent the inclusion of gluten-containing food on the resident’s tray had the potential to result in an allergic reaction such as anaphylaxis, as noted in the report.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide resident-selected menu items: Two residents did not receive the food items listed on their meal tickets during lunch observations. One resident ordered 4 oz of tomato juice but did not receive it, and another resident’s tray did not match the requested items listed, despite the facility policy requiring resident food and beverage preferences to be identified on tray tickets.
A facility failed to consistently serve meals according to resident meal tickets, dislikes, and preferences. One resident received the wrong breakfast and a lunch tray without a meal ticket, while other residents were served eggs, chicken, bacon, or missing fruit despite those items being crossed out or listed as dislikes. Dietary staff and CNAs reported that meal tickets were not always followed on the tray line, and the DNM acknowledged that some staff needed additional training.
A resident with documented food allergies was served a tray containing carrots despite physician orders, the care plan, and the diet ticket all noting a carrot allergy. The resident reported repeated issues receiving foods he was allergic to, and a DA verified the carrots were on the plate when the tray was observed.
A resident with a documented severe melon allergy was served watermelon during lunch even though the EMR and diet card listed melon as an allergy. Staff interviews showed the dietary aide forgot the allergy and gave the resident the food while the tray verification process was not followed correctly. The resident had vascular dementia and a BIMS score of 8, and the daughter reported prior melon reactions including facial and throat swelling.
Failure to honor and communicate resident food preferences: residents reported receiving meals that did not match the menu, including sugary cereal for a diabetic resident and pork served to residents who did not eat it for personal or religious reasons. The DON said the menu was rarely followed and pork was served twice in one day without an alternative, while the dietician kept notes on likes and dislikes but did not share them with the IDT or collaborate with nursing, leaving cooks unaware of resident preferences.
A resident with a documented severe peanut allergy was served peanut butter on a dinner tray and fed the item by a CNA. After eating it, the resident developed coughing and shortness of breath, received epinephrine and Benadryl, and was sent to the ED. Interviews and record review showed the tray service process was supposed to match items to the dietary ticket, but the resident’s care plan did not reflect the severe peanut allergy.
Failure to Provide Resident-Selected Menu Items
Penalty
Summary
The facility failed to provide resident selected menu items for two residents during lunch observations. The facility policy stated that individual dining, food, and beverage preferences are to be identified for all residents and that tray assembly tickets should identify allergies, food and beverage preferences, special requests, and adaptive equipment as appropriate. During a lunch observation, Resident R90, who had diagnoses of CAD, HTN, and diabetes and was ordered a regular CCHO diet with regular texture and consistency, was listed on the meal ticket to receive 4 ounces of tomato juice but did not receive it. A nurse aide confirmed that the tomato juice was not provided as indicated on the meal ticket. During another lunch observation, Resident R203, who had diagnoses of CAD, HTN, and hyperlipidemia and was ordered a no added salt diet with regular texture and regular consistency, had a meal ticket listing savory chicken noodle soup, barbecued beef, white bread, deli ham and cheese on white, potato chips, saltine crackers, hot chocolate, pear crisp, chocolate milk, and whole milk. The tray received instead included deli ham and cheese sandwich on white, peanut butter and jelly sandwich on white, hot chocolate, pear crisp, chocolate milk, and whole milk. An RN confirmed the tray did not match the resident's requested items, and the DON and Nursing Home Administrator later confirmed the facility failed to provide resident selected menu items for two of five residents.
Meals Not Consistently Matched to Resident Preferences
Penalty
Summary
The facility failed to ensure that residents received meals that matched their documented dietary preferences and dislikes. The facility policy stated that each resident should be provided a nourishing, palatable diet that considers resident preferences, and that food service staff should inspect trays to ensure the correct meal is provided. During observation, interview, and record review, surveyors found that dietary staff did not consistently follow meal tickets or resident preferences for several residents. Resident 3 reported that a breakfast ticket listed scrambled eggs, bacon, a cinnamon roll, and fruit, but the resident was served pancakes and sausages instead. Later, when lunch trays were delivered, Resident 3 had not yet received lunch, and when a tray was finally brought to the room, it contained grilled cheese sandwiches and zucchini with no meal ticket attached. Staff G stated the lunch had not been sent from the kitchen and that they did not know how to verify it was the correct meal. Resident 3 stated they had not requested the meal that was served. Resident 4's meal tickets showed items crossed out and listed eggs and chicken under dislikes, yet a breakfast tray with scrambled eggs was placed on the tray line and a lunch tray with orange glazed chicken breast was also served, despite the ticket indicating chicken was a dislike. Resident 5's breakfast ticket listed fruit, but the tray was sent without fruit, and Staff K stated, 'I do not have fruit for everybody.' Resident 6's breakfast ticket showed scrambled eggs and bacon crossed out and listed as dislikes, yet a tray with scrambled eggs and bacon was placed on the tray line. Resident 6 stated the facility continued to serve those items despite the resident's medical condition and that this had happened several times. Staff interviews confirmed that dietary staff were not consistently following meal tickets and resident preferences.
Food Allergy Not Honored on Resident Tray
Penalty
Summary
The facility failed to honor a resident’s food allergy by serving carrots on the resident’s tray even though the resident’s physician orders and diet tray ticket documented an allergy to carrots. Resident #83 was admitted with diagnoses including chronic obstructive pulmonary disease, obsessive-compulsive disorder, and anxiety disorder, and the MDS indicated intact cognition and that the resident required supervision with eating. The physician orders for July 2026 specified a regular diet with regular texture, thin liquids, and double portions, and the care plan identified multi-food allergies and intolerances, including melons and carrots. Record review and observation showed that Resident #83’s diet tray ticket listed allergies to melons and carrots, yet the resident reported having issues receiving foods he was allergic to, including carrots and melon. During observation, the resident’s tray was prepared for delivery and carrots were present on the plate. The Dietary Aide verified at the time of the observation that the tray contained carrots despite the documented carrot allergy.
Failure to Follow Food Allergy Verification Process
Penalty
Summary
The facility failed to ensure that a resident’s documented food allergies were followed when the resident was served watermelon despite an allergy list in the EMR and on the diet card identifying melon as a severe allergy with anaphylactic reaction. The resident had diagnoses including COPD, vascular dementia, chronic failure, anxiety, and depression, and the quarterly MDS showed a BIMS score of 8 out of 15, indicating moderately impaired cognitive status. The facility policy required a standardized verification process to ensure residents received the correct physician-ordered diet, texture consistency, allergy recommendations, and special instructions. The resident’s record also showed a dietary note identifying an allergy to melon and an intolerance to lactose. A progress note documented that the resident was served watermelon with lunch and that it was removed immediately after recognition; the note stated the resident had no signs or symptoms of an allergic reaction and that the POA was notified and said the resident could eat watermelon. A late entry note repeated that the resident was served watermelon, removed from the meal, and remained stable, while also stating she was allergic to cantaloupe and honeydew melon. Staff interviews showed the watermelon was served during lunch service when the resident was late to the dining room and the tray verification process was not followed correctly. The dietary aide stated she forgot and gave the resident melon, while the cook on the tray line stated she had already verified the dessert for pureed diets and had instructed the aide to pass them out. The LPN stated she was told about the incident, gave Benadryl, contacted the resident’s daughter, and monitored the resident. The daughter reported the resident had a history of reactions to melon, including facial and throat swelling with cantaloupe, and said watermelon could cause anything from a rash to a more serious reaction.
Failure to Honor and Communicate Resident Food Preferences
Penalty
Summary
The facility failed to communicate residents’ food preferences to the interdisciplinary team and failed to honor those preferences once they were known. During interviews, residents reported that the facility frequently served food that did not match the menu, including cold cereal with water for breakfast and pork being served often, even though some residents did not eat pork. One resident stated she was diabetic and did not want sugary cereal, while two residents stated they did not eat pork, including one who identified religious reasons as Buddhist and said she had told the DON, administrator, and cooks about her preference. Staff interviews showed there was no system to communicate resident likes and dislikes. The DON stated the cooks rarely followed the menu and that pork was served twice on one day without an alternative for residents who did not eat pork. The dietician stated she created the menus and interviewed residents about likes and dislikes, but did not share those notes with the IDT, did not attend care conferences, and did not collaborate with nursing or other disciplines. The administrator stated resident food preferences should be documented in each resident’s electronic health record and expected food dislikes to be listed under allergies, while cooks stated they were unaware of residents’ preferences and simply made what they were told.
Failure to Prevent Service of Peanut Butter to Resident With Severe Peanut Allergy
Penalty
Summary
The facility failed to ensure that a resident with a documented severe peanut allergy was not served food containing peanuts. The resident was admitted with cerebral palsy, had a severe peanut allergy documented in the EMR on admission, and also had a physician order noting allergies to peanuts and corn. The resident’s care plan did not include evidence of the severe peanut allergy. On the evening of the incident, the resident received peanut butter on the dinner tray and was fed the peanut butter by a CNA. After consuming it, the resident became short of breath and began coughing. Facility documentation states the resident received epinephrine and Benadryl, was monitored for respiratory changes, and later had low oxygen saturation, prompting notification of the provider and transfer to the emergency department for evaluation. Record review and staff interviews showed that the kitchen and tray service process relied on staff matching tray items to the dietary ticket, which listed allergies and accommodations. The dietary manager stated the expectation was that all food on the tray match the ticket before leaving the kitchen, and staff interviewed stated peanut butter was not supposed to be served in cups and was not known to have been placed on the tray by kitchen staff. The incident record and nursing notes documented that the resident had received peanut butter on the tray and that the CNA fed it to the resident.
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