Failure to Provide Gluten-Free Meal to Resident With Documented Allergy
Penalty
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.
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