**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents with allergies were provided foods that were free from allergens for 1 (Resident #89) of 13 residents sampled who had food allergies. Resident #89 had a documented severe seafood allergy. On 8/16/2024 at approximately 12:15 PM, Resident #89 was served a meal that consisted of a fish entrée by Staff O, Certified Nursing Assistant. Staff O reviewed Resident #89's meal ticket that documented seafood and shellfish allergy. At approximately 12:30 PM Resident #89 consumed a bite of the fish and began to experience shortness of breath and coughing. Resident #89 notified facility staff and was treated with medication for an allergic reaction. At approximately 1:40 PM Resident #89 experienced shortness of breath, was transferred to a local hospital and treated for an allergic reaction/anaphylaxis. Findings include: Review of Resident #89's medical record documented the resident was admitted on [DATE] with diagnosis to include paraplegia (loss of sensation and movement in the lower half of the body); anemia; major depressive disorder, recurrent, unspecified; personal history of pulmonary embolism; dizziness and giddiness; type 2 diabetes mellitus with diabetic autonomic (poly) neuropathy; ulcerative (chronic) proctitis without complications; other chronic pancreatitis; gastro-esophageal reflux disease without esophagitis; obstructive sleep apnea; anxiety disorder unspecified; heart failure unspecified; long term current use of anticoagulants; personal history of other venous thrombosis and embolism; IVC (inferior vena cave) filter. Review of Resident #89's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA [Agency for Health Care Administration] Form 5000-3008) dated 8/15/2024 revealed documentation in Section G. Patient Risk Alerts that read, Allergies - Yes, list below: Seafood, shellfish, derived [products]. Review of Resident #89's Matrix data entries for the facility for allergy report documented allergies of Anaphylaxis/Severe: Seafood, Iodine; Rash/Severe: Shellfish. Review of Resident #89's nursing progress note dated 8/16/2024 at 12:20 PM read, Patient called this nurse into room. Patient asked what kind of meat was on her tray. Meat appeared to be fish. Patient states she is allergic to fish. Patient states she did touch the fish. Meal tray was removed from patient's room and patient washed hands. No s/s [signs and symptoms] of allergic reaction at this time. Review of Resident #89's nursing progress note dated 8/16/2024 at 12:30 PM read, CNA [Certified Nursing Assistant] called nurse into room. Patient noted to be coughing and appeared short of breath. Patient alert and oriented x [times] 4. Vitals 176/84 hr [heart rate]; 109. Spo2 [peripheral oxygen saturation] 90% [percent] on room air. Patient placed on non rebreather at 15L [liters], spo2 up to 99%. [Medical Doctor #1's name] in on rounds and assessed patient, gave orders for epi. Epi [Epinephrine] noted to be effective, patient respirations even and non labored. Denies SOB [Shortness of Breath]. Vitals 127/74 hr 95 spo2 99% on room air. Patient states she feels better. Review of Resident #89's physician order dated 8/16/2024 read, Epinephrine solution;1 mg/ml [1 milligram/milliliter]; amt [amount]: 0.3 ml intramuscular special instructions: dx [diagnosis]: anaphylaxis food once-one time 12:30 PM. Review of Resident #89's physician order dated 8/16/2024 read, Epinephrine solution;1 mg/ml; amt: 0.3 mg intramuscular special instructions: dx: anaphylaxis food once-one time 12:30 PM. [NOTE: This is not a repeat, the order was written twice, once for 0.3 ml and the second for 0.3 mg]. Review of Resident #89's Medication Administration Record (MAR) documented epinephrine solution 0.3 mg was administered on 8/16/2024 at 12:30 PM. Review of Resident #89's nursing progress note dated 8/16/2024 at 12:36 PM read, Cart nurse made this nurse aware that patient touched fished on plate. Cart nurse called kitchen and made aware of fish on plate and seafood allergy. MD [Medical Doctor] on rounds and made aware of patient touching fish. MD gave orders to monitor patient. Cart nurse had patient wash her hands with soap and water. CNA made nurse aware patient eyes itching and having SOB. This nurse came down hallway to observe patient having SOB. MD made aware of situation and came to observe patient. Patients stated she ingested small amount of fish with potatoes. MD gave orders for epi pen [a hand-held, self-injectable device used to administer epinephrine in emergency situations, particularly for severe allergic reactions like anaphylaxis]. MD made aware of no epi pen in [name of the medication dispensing system] and ordered epinephrine 0.3 ml IM [Intramuscular] injection and wasted 0.7 ml. Review of Resident #89's nursing progress note dated 8/16/2024 at 1:40 PM read, CNA called patient into room [Sic.]. Patient SOB [short of breath], able to talk. Alert and oriented x 4. Pt [Patient] placed on non [re]breather [used to deliver a high concentration of oxygen to patients who are breathing on their own but need additional oxygen support]. [Medical Doctor #1's name] contacted with no answer. 911 activated. Patient observed until EMS [Emergency Medical Services] arrived. Pt transported to [Name of local hospital] for evaluation. [Resident #89's family member's name] made aware. Review of Resident #89's Nursing Home Progress Note from Medical Doctor #1 dated 8/16/2024 read, HPI [History of Present Illness]: recent admit sec [secondary] to GIB [gastrointestinal bleed]; incidentally was having lunch and took a bite of fish which she is allergic to; had SOB/dysphagia [difficulty or discomfort swallowing]; epi 0.3 mg given . Assessment/Plan: 1. GIB-Prothrombin Time [a blood test that measures how long it takes for blood to clot], CBC [complete blood count]. 2. DM [Diabetes Mellites] - HgbA1C [glycated hemoglobin test measures the average blood sugar level], lipids 3. PE [Pulmonary Embolism]-stable. 4. Anaphylaxis - await response from epi Review of Resident #89's nursing progress note dated 8/16/2024 at 11:30 PM read, Patient (PT) returned from [name of local hospital] at this time. New orders for Benadryl 25 mg tid PRN [three times a day as needed] for allergic reaction and famotidine 20 mg BID [twice a day]. Review of Resident #89's Emergency Department note dated 8/16/2024 at 2:21 PM read, 8/16/24 - 14:21 [2:21 PM] diphenhydramine (Benadryl) 25 milligrams (mg) IV [intravenous] x1; famotidine (Pepcid) 20 mg; sodium chloride 0.9% (Normal Saline 10 ml) 3 ml IV x 1. Indication: Anaphylaxis/Allergy - methylprednisolone sod succ [sodium succinate] SOLU-Medrol [used for severe allergic reactions] 60 mg water for injection, sterile (Sterile water for injection 10 ml) 1 ml IV x1. Review of Resident #89's Emergency Department Note dated 8/16/2024 at 2:45 PM read, HPI notes - past medical history hypertension, brought by EMS from assisted living facility after patient developed an allergic reaction patient allergic to fish and accidently fish went into her food since then experience mild shortness of breath nurse personal [Sic.] prior to arrival administer atropine, vital signs remained stable brought here for further evaluation at this time patient denies fever, chills, chest pain, palpitations, GI [gastrointestinal] symptoms. Review of Systems - Respiratory: Reports shortness of breath; Psychiatric: Denies agitation, anxiety or homicidal ideation . Re-Evaluation/Progress: Time of re-evaluation: 15:46 [3:46 PM]: well appearing, no distress patient received IV methylprednisolone, IV Pepcid, IV Benadryl symptoms improved. Need close PCP [primary care physician] follow-up, warning signs and ED [emergency department] recommendations given. Review of the Risk Management Witness Statement - SF [Statement Form] read, I [Staff L, Cook's name] was serving the lunch tray line on 8/16/2024. In the process of making lunch plates, I did over look one allergy diet to fish. However, I did notice the other fish allergies and those meal tickets were given hamburgers instead of fish. The statement was signed by Staff L, Cook, and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, I CNA [Staff O, CNA's name] brought patient [Resident #89's name] her meal tray to her room about 12:15 PM. [Resident #89's name] asked me to place tray on the table, and that she would eat when she is ready. The patient meal slip did not say anything about allergies to fish. The statement was signed by Staff O, CNA, and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, I was informed that [Resident #89's name] received a tray with seafood and she is allergic to it and I was told by her nurse to make sure she washes her hand with soap and water. I put soap and water in a rag and let her wash her hands off. I came back and told the nurse she was rubbing her eyes and I was told to go back in and let her rinse her eyes. When I was wetting the rag in the bathroom I asked [Resident #89's name] was she itching and she told me yes, her eyes hands and throat were itching and right after that she started to breathe hard and lean over while grabbing her chest and I ran to the hallway to call for a nurse. The statement was signed by Staff N, CNA and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, When the ticket came to me I did not notice the allergy listed I will do better with reading the tray card completely. The form was signed by Staff M, Dietary Partner and dated 8/16/2024. Review of the Risk Management Witness Statement - SF read, This nurse was made aware by cart nurse that patient touched fish on plate. Medical Doctor (MD) on rounds and made aware of patient touching fish. Orders given by MD to observe patient. Cart nurse told patient to wash hands. Patient eyes began to itch and SOB. CNA made cart nurse aware. This nurse made MD aware and MD observed patient. Patient stated she ingested some fish with potato and states it happened before at other facility. The other facility gave her fish and was out to get her. MD gave orders for epi pen. MD was made aware that there was no epi pen in [name of the medication dispensing system]. MD gave order for epinephrine 0.3 ml and wasted 0.7 ml in the [name of the medication dispensing system]. MD verified 0.3 ml epinephrine. The form was signed by Staff P, Registered Nurse (RN). Review of the Notice of Disciplinary Action read, Employee Name: [Staff O, CNA's name]; Department: NSG [nursing]; Position: CNA; Supervisor: [Staff T, Risk Manager's name]; Position: Risk Manager; Date 8/16/24; Written Warning Documented; Supervisors' Statement: patient [Resident #89's name] received fish on her lunch meal tray. Patient has an allergy listed to shellfish and seafood. CNA gave patient meal tray with fish on tray despite listed allergy. Employee's Plan of Correction: Please read meal tray ticket prior to giving patient's meal tray. If patients have a food allergy listed on meal tray, ensure food is not on meal tray being delivered for patient. If food allergy is on meal tray, do not give patient meal tray. Supervisor's Response: CNA stated he placed tray in front of resident and resident stated to 'leave it.' CNA did not lift lid on plate to see fish that had been delivered. Reiterated to CNA to check meal tray before delivering tray to residents. The notice was signed by Staff O, CNA, and Staff T, Risk Manager, and dated 8/16/2024. Review of the Notice of Disciplinary Action read, Employe Name: [Staff L, Cook's name]; Department: Dietary; Position: Cook; Supervisor: [the Food Service Director's name]; Position: Food Service Director; Date: 8/16/24; Supervisor's Statement: On 8/16/24 Patient received fish on her meal tray. Pt tray card has allergy to shellfish, seafood, in bold print on tray card, item baked fish was not listed on tray card. Employee was person that plated food on patient's meal tray. Employee's Plan of Correction: Employee will slow down and read tray ticket thoroughly before plating food. Employee will also read list of patients with specific food allergies. Employee will complete educational Inservice on food allergies. Supervisor's Response: Employee will read tray card and plate food as directed insuring that any patient with food allergies do not receive any foods that may cause them to have a reaction. Any further disregard for listed allergies will result in termination. 8/16/2024 Employee suspended x 3 days. The notice was signed by Staff L, Cook, and the Food Service Director, and dated 8/16/2024. Review of the Notice of Disciplinary Action read, Employe Name: [Staff M, Dietary Partner's name]; Department: Dietary; Position: Diet Aide; Supervisor: [the Food Service Director's name]; Position: Food Service Director; Date: 8/16/24; Supervisor's Statement: On 8-16-24 - Patient received fish on her meal tray. Patient tray card has allergy to shellfish, seafood in bold print on tray card, item Baked Fish was not listed on tray card. Employee was the person that is to check all trays for accuracy before being sent. Employee's Plan of Correction: Employee will slow down and read tray ticket thoroughly and check for accuracy before placing tray on tray cart. Employee will complete Educational Inservice on Food Allergies. Supervisor's Response: Employee will read tray card and check tray for accuracy as directed insuring {sic} that any patient with food allergies do not receive any foods that may cause them to have a reaction. Any further disregard for listed allergies will result in termination. 8-16-24 - Employee suspended x 3 days. The notice was signed by Staff M, Dietary Partner, and the Food Service Director, and dated 8/16/2024. During an interview on 6/4/2025 at 2:48 PM, the Administrator stated, The CNA came into the room and the resident stated to please leave the tray, so he did not get to check the tray. The kitchen staff missed it [the allergy] and the staff did not get an opportunity to check the meal since the resident said to leave it there. The staff should have been checking, whoever lays hands on the tray needs to check. It can be done before or after entering the resident room as long as they are checking and laying eyes on the meal. During an interview on 6/4/2025 at approximately 4:30 PM, Resident #89 stated, The first day after I was admitted , I was eating lunch, and I thought the meat was chicken, but it was fish. I took one bite and within a few minutes I swelled up, my lips got swollen, and my throat started to close. I broke out in hives. I got the nurse who then called the doctor, and they gave me a shot of Epi. They did not have an Epi pen in the facility. They had to call the ambulance and when they got there, they had to give me another Epi shot. They then took me to the hospital, and I got another shot of Epi in the ER [Emergency Room]. During an interview on 6/5/2025 at approximately 10:00 AM, Staff L, Cook, stated, I recall the incident with [Resident #89's name] receiving fish, but I can't recall all of the details. I was working on the tray line for lunch on 8/16/24 as the server, putting the hot food on each plate. The server is the second person on the line, putting the hot foods on and then the tray goes to the bottom of the line, where the third person puts on desserts and drinks. The process had been that the first or top person on the tray line would set-up the tray, putting on the utensils, condiments, and the meal tickets, and then calling out all the important things [diet, allergies]. The third person on the line is supposed to check to make sure everything is on the tray that is supposed to be there as well as serving as the last check to make sure there is nothing on the tray that should not be there. [Resident #89's name] allergies may have been on the meal ticket, but I do not recall. During an interview on 6/5/2025 at approximately 10:40 AM, Staff M, Dietary Partner, stated, I was working on the tray line during the lunch shift on 8/16/24, as an EA2, which is the third position on the line. The normal process was for the bottom or third position on the tray line included reading the meal ticket to make sure it is right, make sure everything is complete, which included looking at the type of diet and if there were allergies; to make sure they don't get it [an allergic food item]. During an interview on 6/5/2025 at 11:03 AM, the Medical Doctor #1 stated, I do not recall the specific details regarding the incident on 8/16/24 with [Resident #89's name] other than she had a reaction. [Resident #89's name] was given epinephrine, but I do not know if it was one dose or two. [Resident #89's name] came into the facility with the allergy to fish and seafood. I do not know if [Resident #89's name] allergies were life threatening, and I have never seen a life-threatening food allergy. [Resident #89's name] did believe that her food allergies were life threatening. During an interview on 6/5/2025 at 11:33 AM, Staff N, CNA, stated, I remember the incident with [Resident #89's name] on August 16, 2024, having an allergic reaction. The resident was passed a tray that had a food on it that she was allergic to. The nurse instructed me to assist the resident to wash her hands because she had touched the fish, and when I went into [Resident #89's name] room the resident was rubbing her eyes, but she said she was fine. [Resident #89's name] appeared to not be able to breathe well and that she was choking, and I went to get the nurse. The process was for the CNAs to double-check the ticket and the meal, to make sure none of the allergens were on the tray. During an interview on 6/5/2025 at 12:50 PM, Staff D, Licensed Practical Nurse (LPN), stated, A CNA alerted me that there was an issue with Resident #89. She discovered that the resident had fish on the tray and she [Resident #89] was allergic. The resident told her that she had touched the fish, so she had her wash her hands and they washed the surface, and removed the tray. I alerted [Staff P, RN's name] who then contacted the doctor. When I entered the room the second time I was alerted by the CNA, that the resident appeared to be short of breath, but I do not recall the resident having any swelling or discoloration. During an interview on 6/5/2025 at 12:53 PM, Staff P, RN, stated, I was notified of the situation with [Resident #89's name] and I got the doctor, as he was in the building. The doctor assessed the resident and stayed in the room until the resident was breathing normal and was stable. He gave an order to administer an epi pen, but there was not an epi pen in the [name of the medication dispensing system], so I got the order to give the epinephrine and once I had a filtered needle I administered the medication. The resident had a second incident [signs and symptoms after the epinephrine administration] and I attempted to contact the doctor. He returned my call and gave an order for a second dose of epinephrine, which I administered. The doctor also gave an order to call 911, which I did. During an interview on 6/5/2025 at 2:10 PM, the Corporate Risk Manager stated, I was notified immediately of [Resident #89's name] incident on 8/16/24, and I came to the facility on 8/19/24 to do a follow-up Ad Hoc [means for this: created or done for a particular purpose] QAPI [Quality Assurance Performance Improvement] and follow-up education with the staff. As I understood it, the Resident had a BIMS [Brief Interview for Mental Status] score of 14 [cognitive function is largely intact] and had instructed the CNA when he delivered her lunch tray not to remove the lid, just to leave it until she was ready to eat. The resident had requested to have the lunch tray left with her for her to be able to eat other food items, the potatoes, off of the plate, because she knew she was allergic to the fish and would not eat it. During an interview on 6/5/2025 at 5:32 PM, the Medical Director stated, I remember the case with [Resident #89's name] being served a meal where she ate something off of the plate and had an allergic reaction, due to human error. [Medical Doctor #1's name] was on site, and the resident was treated for the allergic reaction. I believe that the allergic reaction was a rash and that it was classified as severe. I am not at my computer and am not able to refer to the documentation from the emergency room regarding whether the reaction was anaphylaxis. Anaphylactic reactions could be fatal. We discussed the situation in QAPI right after it happened and addressed what could be done to avoid it [residents receiving food items to which they were allergic]. Food allergies could cause a fatal reaction, but I believe that the resident did not present as such. Review of the Allergy & Asthma Network at https://allergyasthmanetwork.org read, Epinephrine will treat a life-threatening allergic reaction immediately. Review of the Mayo Clinic webpage at https://www.mayoclinic.org/drugs-supplements/epinephrine-injection-route/description/drg-20072429, on 6/15/2025 read, Epinephrine (injection route) Epinephrine injection is used for emergency treatment of severe allergic reactions (including anaphylaxis) to insect bites or stings, medicines, foods, or other substances. Review of the Mayo Clinic webpage at https://www.mayoclinic.org/diseases-conditions/food-allergy/symptoms-causes/syc-20355095, on 6/15/2025 read, Food allergy - Symptoms and causes - Anaphylaxis: Constriction and tightening of the airways. A swollen throat or the sensation of a lump in your throat that makes it hard to breathe, shock with a severe drop in blood pressure, rapid pulse, and dizziness, lightheadedness or loss of consciousness. Review of the facility policy and procedure titled Food Allergies and Intolerances with the last review date of 1/28/2025 read, Policy Statement. Resident with food allergies and /or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergen(s). Policy Interpretation and Implementation: 4. Meals will be prepared for resident with food allergies to prevent cross-contamination as needed. 5. Resident with food intolerances and allergies will be offered appropriate substitutions of equal nutritive value for foods they cannot eat. 6. Nursing staff and food service employees shall be trained in the signs and symptoms of allergic reaction to foods and basic first aid measures in the event of a food allergy reaction. Review of the facility policy and procedure titled Resident Nutrition Services with the last review date of 1/28/2025, read, Policy Statement - Each resident shall receive meals, with preferences accommodated, prompt meal service and appropriate feeding assistance. Policy Interpretation and Implementation - 1. The Food Service Director, Dietitian, Dietetic Technician and the interdisciplinary team will collaborate to obtain resident food likes, dislikes and eating habits and develop a resident care plan based on this information as needed. 2. Nursing personnel will ensure that residents are served the correct food tray. The Immediate Jeopardy (IJ) was removed on 8/20/2024. On 8/16/2024 through 8/20/2024, the facility conducted an investigation into the incident. The RCA/PIP [Root Cause Analysis/Performance Improvement Plan] resulting in the findings of Resident #89 was served fish on the lunch tray and has an allergy to seafood. Dietary department put fish on the lunch tray and did not identify the allergy listed on the ticket, the CNA did not check the lunch tray, and the tray was served to Resident #89. The facility implemented and completed the following steps. On 8/16/2024, full house audits for all residents were conducted for accuracy of food allergies. A second check was added to the tray line for the verification of all meal tickets. Training/education was mandatory for all clinical and dietary staff in food safety, resident food allergies, meal tickets, and checking trays for allergens to include alert and oriented residents, prior to leaving the meal tray with the resident. Audits for accuracy with meal trays. Physician orders for residents who may ingest or come in contact with a food allergen for emergent use are in the unit medication room. QAPI meeting was held on 8/29/2024 to verify effectiveness and efficiency of the corrective action plan. Review of the QAPI agenda verified meetings were held on 8/16/2024 and 8/29/2024 and the corrective actions related to the allergic incident were reviewed. Review of the in-service sign in sheets dated 8/16/2024 documented 123 of 124 LPNs, RNs, and CNAs signed as having attended the training. Education for dietary staff was conducted 8/16/2024 through 8/20/2024 to include education packets of handouts, food allergens, allergic reactions signs and symptoms, and a quiz were completed by 17 of 17 dietary staff. Observations were conducted of the kitchen and dining room during lunch and dinner meal service on 6/4/2025 and 6/5/2025 of double checks of the meal tray tickets, the meal tickets were verified and documented food allergies in large, bold print. Dietary Tray Audits and Food Allergy Audits were conducted for the period of 8/16/2024 through 10/22/2024. Interviews were conducted with three LPNs, three RNs, eight CNAs, and five Dietary staff to verify education and training. The facility corrected the noncompliance on 8/29/2024.