F0806

D

Failure to Honor Diet Allergies, Preferences, and Always Available Menu Items

Washington, District Of Columbia Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure that food services accommodated one resident’s documented egg allergy and preference for double portions, and another resident’s meal timing and access to items on the Always Available Menu. One resident was admitted with multiple diagnoses including spinal stenosis, type 2 diabetes with hyperglycemia, discitis, end stage renal disease, and weakness. The resident’s medical record included a physician’s order for an LCS/NAS diet with regular texture and thin liquids, and a History and Physical documenting allergies to aspirin, codeine, and eggs. A comprehensive MDS showed intact cognition and a therapeutic diet, but the comprehensive care plan, revised on a later date, did not address the resident’s egg allergy or preference for double portions.

During an interview, this resident reported that over the past weekend the facility repeatedly sent eggs on meal trays despite the documented egg allergy and did not provide the requested double portions. The resident stated they had taken pictures as evidence and had personally called the kitchen and spoken with the Director of Kitchen Services on several occasions about these issues. In a subsequent interview, the Food Services Manager described a process in which 14 staff, including a supervisor or assistant, check meal trays before they are sent to the units, and noted that more than 70 residents receive some type of double portion. After reviewing the resident’s photos, the Food Services Manager acknowledged the issue and was unable to explain how the errors occurred.

Another resident, with diagnoses including cervical spinal stenosis, quadriplegia, central cord syndrome, type 2 diabetes with peripheral angiopathy, major depressive disorder, and hypertension, was assessed as alert, oriented, able to communicate needs, and requiring assistance with ADLs. This resident had a physician’s order for a regular diet with regular texture and thin liquids and no documented food allergies, and had documented multiple food preferences and a request for access to a regular diet for greater choices. On one observation day, the resident complained in the early afternoon that lunch had not yet been received, and the tray was not delivered until approximately 1:55 PM, more than an hour after the scheduled delivery time of 12:45 PM. The resident also reported that a cheeseburger ordered from the Always Available Menu the previous day was not received. Staff interviews revealed that the cheeseburger tray was not sent with the unit’s meal trays and had to be obtained separately, and that although cheeseburgers were available in the kitchen, buns were not, leading to conflicting information given to staff that cheeseburgers and hotdogs were not available, despite the item being listed on the Always Available Menu.