**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure dietary allergies and dietary preferences were honored for four residents (#146, #37, #101, #11) out of five residents reviewed for nutritional services. These failures resulted in emotional harm to one resident (#146) resulting in a discharge against medical advice (AMA), and potential harm due to food allergies to two residents (#37, #11) when the wrong dietary trays were served on multiple occasions. Finding included: 1) During an interview on 07/21/2025 at 10:00 a.m., Resident #146 stated, “I am leaving today, I cannot do this anymore. They always bring me food that I don't eat. Saturday, I went hungry because when they brought my tray it had bacon on it. I have talked to them; my family even came down from Canada to talk to them. I am a vegetarian and don’t eat any kind of meat. I asked them to get beans, and they cannot do that. I filed a grievance, but the Unit Manager wrote it, and it was not in my own words. They make me seem more senile than I am. I would rather go home and live by myself and risk my friends and family finding me before I stay in this place any longer. Someone will find me before I start to stink.” During the interview, Resident #146’s eyes were observed to be red, swollen and watering. Resident #146 had tears streaming down her face and was using a tissue to wipe her eyes and nose. Review of Resident #146's admission record revealed an admission date of 06/19/2025 and a discharge date of 07/21/2025. Resident #146 was admitted to the facility with diagnoses to include: Syncope and Collapse, Heart Failure, unspecified, Ischemic Cardiomyopathy, Other Seizures, Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus, Personal History of Transient Ischemic Attack (Tia), And Cerebral Infarction Without Residual Deficits. Review of Resident #146's Medicare 5 Day Minimum Data Set (MDS), dated [DATE], revealed Section C. Cognitive Patterns, Brief Interview Mental Status (BIMS) of 11 out of 15 showing moderate cognitive impairment. Review of Resident #146 Orders revealed: 06/29/2025- Consistent Carbohydrate Diet (CCHO) No Added Salt (NAS) diet Regular texture, thin consistency, for Diet change VEGETARIAN ! Please send broccoli, green beans, corn and beans (pinto, black, or kidney beans) for lunch and dinner. Review of Resident #146’s Care Plan dated 06/20/2025 revealed: Focus: Resident #146 is at risk for altered nutrition r/t chronic disease, advanced age, variable by mouth (PO) intake, therapeutic diet. Resident #146 is vegetarian. Goal: Resident #146 will maintain weight without significant fluctuations through next review date; Resident #146 will maintain adequate nutrition by consuming at least 75% of most meals by next review date; Resident 146 will tolerate diet as prescribed through next review date. Interventions: Honor food preferences within meal plan; Dietitian consult as needed; Nutrition evaluation as indicated; Observe and report to the physician: Any new indications of significant weight loss, chewing/swallowing difficulties; Observe for signs and symptoms of aspiration such as coughing, choking, pocketing, runny nose, watery eyes spitting food out, wet vocal quality, wet lungs; Notify nurse/ Speech Language Pathologist (SLP) if any symptoms are present; Observe intake of meals/ fluids; Obtain weight as indicated; Provide diet as ordered; Provide supplements as ordered. Review of Resident #146’s Nutrition Risk Screen, dated 06/25/2025, revealed CCHO NAS diet, Regular texture, thin consistency. Comment: Resident shows variable intake at meals. Tolerates current therapeutic diet for DX: Diabetes Mellitus (DM), Heart Failure (HF) Stable weight recommended. On diuretics for HF [heart failure] which may cause fluid weight fluctuations. Will continue to monitor and provide care as needed. RD [Registered Dietician] Recommendations: Continue Plan of Care (POC). Review of Resident #146’s Discharge Against Medical Advice Assessment, dated 07/21/2025, revealed a handwritten note at the bottom of the page stating, “I leave this facility because of the conditions and treatment of the facility. I am just learning of the rules, but I continue to leave because I am afraid that someone will kill me. Most days I can’t eat; the food is not fit for human consumption no matter how I complain there is no change. I do everything for myself with no help. So that’s why I decided to go home. I feed myself enough and had no choice but to leave by my own choice, but last-minute information and advice. Signed Resident #146 The facility was asked on 07/22/2025 and 07/24/2025 to provide a vegetarian menu and one was not provided to the survey team. Review of Resident #146’s Tray Meal Tickets revealed: Sunday 06/26/2025- Lunch: Diced Carrots, Parslied Buttered Egg Noodles, Dinner Roll, Margarine, Fruit Monday 06/27/2025 Lunch: Broccoli Cuts, Whipped Sweet Potato, fruit Dinner: Bacon & Cheese Egg Bake, Buttered [NAME] beans, parslied buttered egg noodles, dinner roll, fruit Tuesday 06/28/2025 Lunch: [NAME] beans, [NAME] Rice, Dinner roll, fruit Dinner: Tossed Salad, Dressing, Creamy Mashed Potatoes, Garlic Bread, fruit Wednesday 06/29/2025 Lunch: California Blend Veg, fruit Dinner: Cottage Cheese & Fruit Plate, fruit Thursday 06/30/2025 Lunch: Vegetables Cheese Bake, Mixed Vegetables Capri, Mashed Potatoes, Dinner Roll, Fruit Dinner: Marinated Cucumber Salad, Fruit Friday 07/01/2025 Lunch: Creamy Coleslaw, Orzo, Dinner Roll, Fruit Dinner: 3 Bean Salad, Garlic Bread Stick, Fruit Saturday 07/02/2025 Lunch: Diced Carrots, Pasta Salad, Dinner Roll, Fruit Sunday: 07/03/2025 Lunch: Seasoned Collard Greens, Mashed Potatoes, Fruit Monday 07/04/2025 Lunch: Calico Coleslaw, Baked Beans, Fruit Tuesday 07/05/2025 Lunch: California Blend Veg, Mashed Potatoes, Dinner Roll, Fruit Dinner: Pimento Cheese Sandwich, Marinated [NAME] Beans, Potato Chips, Fruit Wednesday 07/06/2025: Lunch: Mixed [NAME] Salad, Onion Rings, BBQ Sauce, Garlic Bread Stick, Fruit Dinner: Wax Beans, Fruit Thursday 07/07/2025 Lunch: Oriental Mixed Vegetables, [NAME] Buttered Dinner: [NAME] Peas, Macaroni Salad, Country Vegetable Soup Friday 07/08/2025 Lunch: Creamy Coleslaw, Buttered Spiral Tricolor Pasta, Fruit Saturday 07/09/2025 Lunch: Diced Carrots, Mashed Potatoes, Dinner Roll, Fruit, Marinara Sauce Dinner: Buttered Kernel Corn, Fruit Sunday 07/10/2025 Lunch: Broccoli Cuts, Fruit Dinner: Tangy Coleslaw, Scalloped Potatoes, Fruit Monday 07/11/2025 Lunch: Cheddar and Broccoli Strata, House Salad, Garlic Bread, Fruit Dinner: Tossed Salad, Potato Wedges, Fruit Tuesday 07/12/2025 Lunch: Fried Okra, Parmesan Noodles, Fruit Wednesday 07/13/2025 Lunch: [NAME] Peas, [NAME] Pilaf, Dinner Roll, Fruit Dinner: House Salad, Cornbread, Fruit Thursday 07/14/2025 Lunch: Corn Casserole, Garlic Mashed Potatoes, Garlic Bread, Fruit Dinner: Cottage Cheese and Fruit Plate, Fruit Friday 07/15/2025: Lunch: Cheese Baked Ziti, Grated Parmesan Cheese, House Salad, Dinner roll, fruit Dinner: Buttered Zucchini, French Fries, Fruit Saturday 07/16/2025 Lunch: Buttered [NAME] Beans, Cornbread, Fruit Dinner: Creamy Coleslaw, Sweet Potato Fries, Fruit Sunday 07/17/2025 Lunch: California Blend Veg, [NAME] Rice, Fruit Dinner: Buttered Kernel Corn, [NAME] Buttered, Cornbread Monday 07/18/2025 Lunch: Calico Coleslaw, French Fries, Biscuit Dinner: Creamy Cucumber Salad, Country Vegetable Soup Tuesday 07/19/2025 Lunch: [NAME] Beans, Baked Potato, Fruit Wednesday 07/20/2025 Lunch: Broccoli Cuts, Scalloped Potatoes, Dinner Roll, Fruit Dinner: Marinated Broccoli Salad, French Fries, Garlic Bread, Fruit Thursday 07/21/2025 Dinner: Mixed Vegetables Capri, [NAME] Spanish Rice, Fruit Friday 07/22/2025 Lunch: Creamy Coleslaw, French Fries, Dinner Roll, fruit Dinner: Buttered [NAME] Beans, Parslied Buttered Egg Noodles, Dinner Roll, Fruit Saturday 07/23/2025 Lunch: Tossed Salad, [NAME] Buttered, Fruit Dinner: Country Tomato Salad, Potato Salad, Dinner Roll, Fruit Review of Resident #146’s Progress Notes revealed the following: 07/04/2025 Social Service Note This writer spoke with Resident #146 regarding her request to be discharged . The attending physician was notified, and the nurse practitioner (NP) was consulted. The NP stated that if the resident insisted on discharge, it would have to be against medical advice (AMA). This writer discussed the implications of an AMA discharge with Resident #146, outlining both the risks and benefits. Resident #146 was encouraged to express her concerns, which she did in detail. She stated that if her concerns were addressed, she would be willing to remain in the facility until a safe and appropriate discharge could be arranged. Resident #146’s was documented submitted as a grievance, and they been communicated to the relevant department heads for follow-up. This writer will monitor and follow up on the resolution of these concerns. Resident #146 has agreed to stay at this time, pending resolution of her concerns. 07/21/2025 Narrative Note Resident states she wants to leave, expressed to resident it would be against medical advice. Educated residents on risks of leaving AMA. The residents stated an understanding. Notified PCP. During an interview on 7/22/2025 at 3:11 p.m., Staff V, Social Services Assistant stated they had multiple conversations in regard to Resident #146 wanting to leave and it not being safe for her to go home because she had confusion and lived alone. She is not sure if she filed any grievances for Resident #146 related to her diet. Resident #146 did voice to her that she was a vegetarian. Resident #146 told her about the food she received the night she got admitted to the facility she could not eat because she was a vegetarian. “I reached out to the dietician go get her dislikes, to do a nutritional eval for Resident #146. After this conversation I was not aware of any other concerns about her diet. I was not here when Resident #146 decided to leave. During an interview on 7/22/2025 at 3:44 p.m. Staff Y, Licensed Practical Nurse (LPN), Unit Manager, stated Resident #146 had a lot of preferences on her diet and was a vegetarian. There was one dinner where she got a plate of lettuce, “It was just lettuce, the meal ticket said salad, but it was just lettuce. I filled out a grievance on her behalf related to her food a few times. She originally said she did not want a grievance to be filled out but I told her that was the best way to get a change made. On 07/21/2025 I went to speak with her and she was already packing her clothes and said she was leaving because of the issues she had with her diet she told me over the weekend she had issues with her food and was served pork which she does not eat for religious reasons. She also believed she got her tray after everyone else had gotten theirs because she had asked for grilled cheese. I offered to fill out a grievance related to this, but she declined. I gave her the ombudsman information. I called the provider to get a discharge. Resident #146 told him that she was not waiting for the order. I told her she would sign out AMA and she said she did not care she had a home to go to.” During an interview on 7/22/2025 at 4:50 p.m., the Certified Dietary Manager, (CDM), stated when residents are admitted she speaks with them within 24-48 get their likes dislikes. If there is a concern or complaint like cold food, or food they didn't want she is the one who follows up with the resident. When she gets a grievance, she will go and speak with the resident, then she will follow up with the kitchen staff and do education. The resident’s meal ticket should list their food preferences or allergies. Vegetarian residents are offered grilled cheese and offer different types of protein like beans. They have Kidney beans, baked beans, and pinto beans. A vegetarian breakfast would consist of scrambled eggs and toast, scrambled eggs and French toast. “Resident #146 was very hard to please. We tried to make beans for her. She wanted specific items, like broccoli and beans.” Resident #146’s meal tickets said send “beans and vegetables”. “Resident #146 was not happy, and we did what we could. I spoke with her about 2-3 times, when I first spoke with her she wanted boiled eggs, and our boiled eggs are pre boiled so she did not like them so she then asked for no boiled eggs. I would change her preferences each time, she said she didn’t like something. When she first came in, she was receiving meat, and to fix it I started highlighting her ticket to make it more known to staff that she was a vegetarian and should not receive meat. There were about 5-7 times I had complaints about Resident #146 receiving meat with her meals. When this happened, I would go back and double check her ticket, make sure that it was highlighted, and speak with staff. She reviewed the meal tickets for Resident #146 and stated “these do not have my handwritten notes where I write which beans she got for that day. I know she was receiving them because I am the one who hand writes each meal ticket since I don’t have the option to add that in the computer.” She reviewed the meal ticket dated Friday 06/27/2025, Dinner, Bacon and Cheese Egg Bake, and stated I know she did not get this because my cook told me he made just a cheese and egg bake as well.” During an interview on 07/23/2025 at 5:27 p.m., the Nursing Home Administrator (NHA) stated when a resident is voicing any concerns that is their form of having their voices heard. They review it at stand up and give out the grievance to department heads to resolve. Part of the resolution is to do education with staff. “We try to close the grievance with in 72 hours.” There have been a few concerns with diets not being correct. They have done education with the dietary department. They implemented meal trays being checked multiple times, even before it goes to the residents room to ensure the correct meal is going out. “I was aware of a few grievances filed for Resident #146 related to her meals while she was here. She was not getting the correct diet. We had multiple meetings with her nephew who was visiting and went over her diet. After these conversations, “I was under the assumption that her diet was going okay. She was not aware of the conversation the Social Services Assistant had with Resident #146 7/04/2025 and Resident #146 wanting to discharge this day. “It was not safe for her to discharge, that is why they had the care plan meetings. She left on Monday because of her concerns with her food, she was served the incorrect diet over the weekend. Resident #146 was upset when she left.” During an interview on 07/23/2025 at 4:31 p.m., Staff Z, Certified Nursing Assistant (CNA) stated she first had Resident #146 when she first arrived to the facility. Resident #146 let her know about her food preferences and complained about it being cold. Resident #146's meal ticket on the tray said “vegetarian” and when Resident #146 removed the covering there was meat on her plate. Staff Z said, “Resident #146 told me that she can't eat that meat, I immediately took the food tray away and went down to dietary and told them she needed a grilled cheese and that this resident was vegetarian and had received meat. The dietary staff told me it would take 45 minutes to get grilled cheese, and I didn’t think that was quick enough, so I got her 2 Peanut Butter and Jelly sandwiches. Resident #146 was happy with the switch, and I then went and told the unit manager.” During an interview on 07/23/2025 at 4:36 p.m., Staff U, Licensed Practical Nurse (LPN), Unit Manager remembered Resident #146. She said, “Resident #146 was vocal about her food preferences. There was one meal where the CNA came and told her that Resident #146 had been served meat with her meal. She could not remember the date. When she was told about the wrong diet being provided for Resident #146, she reported it to dietary by sending an “email about her food preferences. She didn't get a response. Resident #146 mentioned being a vegetarian during her care plan meeting as well. After this she made sure to check her food trays. 2) On 7/21/25 at 12:35 p.m. Resident #37 was observed sitting in the hallway of the secured unit. A meal tray was observed on the over-bed table in front of the resident. The plate contained one breaded shrimp and French fries. Staff O, Certified Nursing Assistant (CNA) reported the resident had received shrimp (type of shellfish) for lunch. The staff member removed a portion of the breading and confirmed the item was shrimp. Staff M, CNA, (who was assisting another resident in a room across from the resident) stated, “No, (Resident #37) is allergic to it, (pronoun) will swell up.” Staff N, CNA spoke in the resident’s preferred language and stated the resident was okay with it. An observation of Resident #37's meal ticket revealed the resident was to receive “No Shellfish”, allergies: “Shellfish”. The ticket showed the resident was to receive a French Dip Sandwich for lunch. Staff O and N confirmed Resident #37 did not receive a French Dip sandwich for lunch. An interview was conducted on 7/21/25 at 12:55 p.m. with Staff Q, Registered Nurse (RN), as the staff member was returning to the unit. The staff member reported thinking Resident #37 had an allergy to shellfish. Staff Q reviewed the electronic record and confirmed the resident had an allergy to shrimp. Staff Q was informed the resident received shrimp for lunch, reviewed the meal ticket and the staff member confirmed the resident should have received a French dip sandwich. Staff Q stated she would assess the resident and notify the Unit Manager. The staff member reviewed the medical record revealing the resident had a moderate reaction of face and body rash to shellfish. Staff Q reported being unaware of the situation. Review of the facility Spring/Summer (SS) week 4 menu revealed the primary item for the second day of the week was 3 ounces of Breaded Shrimp with an alternative French dip sandwich. Review of Resident #37s electronic profile, on 7/21/25 at 1:33 p.m. revealed the resident had a dietary allergy to Shellfish. Review of Resident #37s electronic care coordination document, on 7/21/25 at 1:45 p.m. revealed the resident had a dietary allergy to Shellfish. Review of the progress note, dated 7/21/25 at 2:01 p.m., revealed the Nurse Practitioner (NP) had been notified Resident #37 had an allergy to shellfish and had consumed shellfish. New orders had been obtained to monitor for allergic reactions throughout the next 48 hours. The note did not reveal if the resident representative had been informed the facility had provided the resident with shellfish. An interview was conducted with Staff N, CNA on 7/21/25 at 2:58 p.m. The staff member stated the aides check (meal) tickets and meals. The kitchen was supposed to read the ticket. Staff N stated Resident #37 has been sent shrimp before and did not, has had it since (the reaction), was not aware of any allergic reaction. The staff member revealed Resident #37 was Spanish-speaking only. An interview was conducted with Staff M, CNA on 7/21/25 at 3:03 p.m. The staff member reported Resident #37 had been fed shrimp and there was no reaction. The resident had swelled up and (the facility) thought it was due to shrimp, has had it since and did not have a reaction. Staff M reported she “usually” looks at the meal ticket to determine the correct diet. Staff M stated she did not serve Resident #37 the meal and if she had, she would have taken it back (to kitchen) and gotten the alternate. An interview was conducted with Staff Q, Registered Nurse (RN) on 7/21/25 at 3:12 p.m. The staff member reported the ARNP saw Resident #37, ordered Benadryl which had not been given, orders to monitor for swelling, redness, hives and/or shortness of breath (SOB). Staff Q reported documenting on a safety check sheet and there would be a shift note. The staff member stated staff should have informed her so the Nurse Practitioner and Unit Manager could have been notified. Staff Q stated “normally” they look at the (meal) tickets to see if a resident is puree diet and if it (the meal) is not puree they ask so the staff member can look in the computer. The staff member stated she believed the Unit Manager was going to contact the family member. An interview was conducted on 7/21/25 at 3:17 p.m. with Staff U, Licensed Practical Nurse/Unit Manager (LPN/UM). The staff member reported being unaware of Resident #37 being fed shrimp before and said “not to my knowledge”. Staff U stated the process was a “team effort”, dietary puts the tray and meal ticket together and the aides verified the tickets and meals matched. The expectation was for staff to immediately notify the nurse who could immediately inform the doctor and monitor for a reaction such as difficulty breathing. The Unit Manager reported she would have to find out from the nurse if the resident had a guardian. The staff member reported not having contacted the representative and in this situation the facility would have the healthcare surrogate or emergency contact. Staff U stated the nurse would be asked to document the contact with family and the family should have been notified as soon as the facility verified the resident was stable and the physician was notified. The expectation was the representative should have been contacted prior this interview. Review of Resident #37's progress notes showed on 7/21/25 at 3:30 p.m. the resident’s guardian was “notified of situation with shellfish allergy. No concerns or questions at this time.” Review of Resident #37s Nutrition Risk Screen dated 7/10/25 revealed a food allergy/intolerance to “shellfish”. Review of Resident #37s care plan, accessed on 7/24/25, showed the resident was at increased nutritional risk related to chronic medical condition, psychotropic medications that can affect weight, abnormal labs, food allergy (shellfish). Body Mass Index (BMI) is elevated. Diagnosis (Dx) dementia, mood disorder can affect appetite, oral (PO) intake, initiated 8/7/22 and revised on 1/14/25. The goals include “avoid exposure to food allergen”, initiated on 1/14/25, revised on 6/24/25, and a target date of 9/22/25. The interventions included instructions for dietary staff and CNAs “Provide diet as ordered. ***FOOD ALLERGY: SHELLFISH***, revised on 1/14/25. The care plan showed the resident had a communication problem due to cognitive impairment, language barrier, and aphasia. Review of an Advanced Registered Nurse Practitioner (ARNP) note, dated 3/7/24 Resident #37 was seen per staff request for “rash/facial swelling”. The facility staff had reported the resident had eaten some shrimp and face started getting red/blotchy with swelling. The staff were instructed to complete a dietary slip showing the resident was allergic to shellfish and to add shellfish to allergies. Review of Resident #37s Allergy Report revealed a dietary allergy to Shellfish with a “Propensity to adverse reactions”. The severity level was moderate and created on 3/7/24. This information was struck out by the Director of Nursing (DON) on 7/23/25, two days after the resident consumed the shellfish offered by the facility. Review of Resident #37s admission Record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to unspecified Alzheimer’s disease, cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, type 2 diabetes mellitus without complications, and aphasia. Review of Resident #37s Brief Interview of Mental Status, completed on 7/12/25 revealed a score of 00 out of 15, showing a severely impaired cognition. An interview was conducted on 7/22/25 at 1:02 p.m. with the ARNP. The ARNP reported seeing Resident #37 and did not remember exactly what happened (previously). The ARNP said the resident had swollen lips and eyes, did not have any medication changes, and one of the aides reported the resident had shrimp the previous day, and thought that was really good detective work. The ARNP state orders were given to check every 30 minutes for 4 hours and every two hours throughout the night and day, and if the resident didn’t have any reaction “we “ could discontinue the allergy. The ARNP reported seeing the resident 30 minutes to hour after the resident ate the shrimp and if the resident hadn’t had a reaction she would have had one during that time. The ARNP said nothing (allergy) was confirmed last time “we” added the allergy because it was the only thing different. The ARNP stated, It was not the best thing to happen, we were the ones who gave (the resident) the allergy. The ARNP stated they do not want to give anyone anything they have an allergy to. An interview was conducted with Staff R, Dietary Aide, on 7/22/25 at 1:50 p.m. The staff member reported not having anything to do with the lunch she does dinner service. Staff R reported the tray line began with assembling 5 trays with napkins and silverware, places meal tickets in order and check consistency of desserts. The meal tickets say the name of the resident, whether they get a mechanical or puree (consistency), if Low-Calorie Sweeteners (LCS), no-added salt (NAS) or Renal diet, allergies are listed on the meal ticket with likes and dislikes. The staff member stated if an allergy was on the tray, would hold the tray. Staff R reported the cook was on one side of the table and cannot see the meal ticket, the aides call out the type of consistency, the alternate and allergies. An interview was conducted with Staff S, Dietary Aide on 7/22/25 at 2:09 p.m. The staff member was aware of the situation (with Resident #37) yesterday, “we had a talk about it”. The staff member did not know how it happened, was not working the line. Staff S reported the first thing to do on the tray line was to set up the tray, put napkin (on tray), read the ticket, place nutrient drink , yogurt on tray and pass it down to the person on the right. The person on the right reads out the ticket to the cook, the cook plates it. The staff compare the meal ticket and the plate, has been the process for approximately a year. The aide tells the cook allergies, and if an alternate (is needed). The staff member stated if the resident was allergic to shellfish and the cook handed a plate of shrimp, the staff would not put it on the tray. An interview was conducted with Staff T, cook on 7/22/25 at 2:17 p.m. The cook reported “mostly” prepares the dinner meal, does lunch and dinner sometimes, and did the lunch yesterday (7/21/25). The aides call the ticket, they call out Renal, Mechanical, Puree, and alternate, yesterday (alternate) was French dip. The aides call out what’s on the ticket, need to have everyone be able to read, starting with the person who puts the ticket on the tray. The staff member reported putting the food item on a plate that was called out, the cook cannot see the ticket from the tray, only way it got missed. Staff T reported aide call out 3 meals in a row, makes the alternate by itself. The expectation was for the aides to double check the plate matches the ticket, would have stopped the tray (Resident #37). Staff T stated once the plate was taken off the rack it was up to the aide to make the right decision and make sure the plate had the right food items. The staff member stated “3 people responsibility”, the cook, the (dietary) aide, and the CNA who served it. The CNA should have looked at the meal to make sure it was the right meal, if not, immediately stopped and brought it back to the kitchen. An interview was conducted with the Certified Dietary Manager (CDM) on 7/22/25 at 2:32 p.m. The CDM reported the process for the tray line was the first aide was responsible for desserts, meal tickets, and any special items. The second aides responsibility was to let the cook know dislikes, allergies, anything different, and if they wanted the regular or alternate. The expectation was for the cook to make sure they were listening to the aide for the correct diet, dislikes, allergies, and any changes. The aide needed to catch the wrong food item before putting it on the tray, regarding the incident with Resident #37 was the second aide put the wrong plate on the tray and it should have been caught by the CNA. She stated she had just found out about the incident “this morning” and had not done any in-services. 3) An interview was conducted on 7/21/25 at 10:39 a.m. with Resident #101. The resident stated she is supposed to have large portions for her meals and that is never followed. Resident #101 said she had spoken to staff several times about the concern, but it was not corrected. The resident said she did not receive enough food at mealtimes and it led to her eating a lot of snacks. An observation was conducted on 7/21/25 at 1:31 p.m. of Resident #101’s lunch. The resident’s plate had approximately 10 small shrimp, 7 French fries, 1 roll, 1/2 cup of coleslaw, and 4 oz. of ice cream. The resident’s tray card indicated “Large Portions” showing she should have received 8 oz. of shrimp, 1 cup of coleslaw, 3 oz. of fries, 1 1/2 biscuits, and 6 oz. of ice cream. 4) An observation and interview was conducted on 7/22/25 at 12:41 p.m. with Resident #11. The resident stated she was lactose intolerant and could not have dairy products. She said she is served milk all the time and will give it to staff to take back. The resident said she is often served sweets even though she is diabetic also. The resident said she knows she had to be careful about eating sweets, so she only eats them sometimes and she does not eat the dairy products served to her. Resident #11’s lunch tray was observed to be served with sour cream and a cookie. Review of Resident #11’s diet order, dated 8/27/24, showed “Consistent Carbohydrate (CCHO) diet Regular texture, thin consistency, lactose allergy.” An interview was conducted on 7/22/25 at 4:32 p.m. with the CDM. The CDM reviewed the picture of Resident #101’s lunch from 7/21/25. She confirmed the meal was normal meal portions, not the large portions that was ordered. The CDM reviewed a picture of Resident #11’s lunch tray from 7/22/25. She confirmed the resident should not have been served the sour cream because it contains lactose. Review of the Consistency Census Report, which list the diet of every resident in the facility, was provided by the CDM. The report’s dietary notes showed Resident #146 as “Vegetarian NO MEAT, NO GRAVY Send Vegetables and Beans,” Resident #37 as “No Shellfish,” Resident #101 as “Large Portions,” and Resident #11 as “Lactose intolerance.” Review of the facility's undated policy titled Dining and Food Preferences, revealed the following: Policy Statement It is the center policy that individual dining, food, and beverage preferences are identified for all residents/patients. Action Steps 1. The licensed nurse will notify the dining services departments of food allergies upon admission and prior to any meals are served. 2. The Dining Services Director or designee will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, mealtimes including times outside of the routine schedule, food, and bevera