Based on clinical record review, interviews, observation, and review of facility policy, the facility failed to ensure that the resident's environment was free of accident/ hazards relating to a food allergy. As a result of this failure, a resident experienced an anaphylactic reaction, requiring administration of epinephrine and emergency transport to an acute care hospital for 1 of 2 residents reviewed for hospitalization (Resident #32). Findings: A review of Resident #32's clinical record was conducted. Resident #32 was originally admitted to the facility in early June of 2022, with a documented allergy to onions. A dietary order dated 6/8/22 states Food Allergy(s): onions and a care plan initiated on 6/8/22 which states Goal: [Resident #32] will tolerate prescribed food/liquid texture diet, Interventions: Dislikes (list): Allergy to onions. Review of a clinical note, dated 11/11/22, states .1745-Dietary informed this staff member that resident has soup with onions in it. (pearl) Resident is allergic. Met resident in the hall who states [he/she] feels bad but is vague and unable to explain. Resp uneven and unlabored. Resident was assisted back to [his/her] room and placed in bed .provider agreed not to administer epi pen at this time, okay to give Benadryl 23 mg x1 . Review of a clinical note, dated 11/20/22, states Dietary down to unit with [CNA] and stated that resident had onions in [his/her] beef tips. Resident ate approx. 25% of the meal. Resident states [he/she's] fine, originally refused to have vitals taken. No Resp distress noted, no need for EPI pen. Call placed with [Provider] who okayed a 25 mg Benadryl XL. Review of a clinical note, dated 1/18/23, states at 12:20 p.m., this RN notified that resident consumed at lunch -onions in the meat sauce .resident by nurse's station, speech started to become more garbled and redness to face, sweating, lungs diminished, poor airway exchange, 911 called, given PRN epi pen at 12:28 . Review of the acute care hospital Emergency Report, dated 1/18/23 states .reported history of allergy to onions .after receiving IV diphenhydramine and IM epi-pen for developing symptoms suspicious for allergy. [He/She] reportedly had some tomato sauce that contained onions unknowingly and afterward developed erthroderma [red skin], diaphoresis, dyspnea all improved after IM epi . Diagnosis: anaphylaxis. During an interview on 5/23/23 at 12:01 p.m., Director of Support Services (DSS) indicated that the facility Cooks were the primary focus for the education provided on 2/14/23 because they are the ones that prepare all the food for service. DSS further indicated that kitchen staff don't always have time outs [dietary staff huddle prior to delivering meals to floor to discuss what is being served, what is in the food, who has allergies and what alternatives they are getting] as they should prior to serving. DSS further indicated that the dietary staff that received the food shipments is responsible to label any food items that contained onions with a green sticker and that all foods containing onions have a green sticker. DDS indicated that he was not aware of the incidents on 11/11/22 or 11/21/22, so there were no measures put into place as far as he knows. At this time DSS confirmed above findings. During an interview on 5/23/23 at 12:32 p.m., [NAME] #1 indicated that she was aware that Resident #32 had an onion allergy, and she did not take the time to look at the tomato/meat sauce label as she normally would. [NAME] #1 further indicated that after she served the meal, she observed Resident #32 eating the tomato/meat sauce and she immediately went to the nurse and informed them of what had happened. During an interview on 5/24/23 at 7:00 a.m. Resident #32 confirmed that [he/she] has had an allergy to onions since the age of 3. [He/she] further indicates inability to have raw or cooked onions, and [he/she] can't touch or eat them. On 2/12/23 the facility completed a Root Cause Analysis related to the 1/18/23 event a review of that analysis states Date of Event: 1/18/23; Root Cause Analysis Event: Received onions with known allergy .Further review revealed 11/11/22: Received onions in soup, 11/21/22: Received onions on [his/her] beef tips [he/she] had 25% of meal when CNA [certified nursing assistant] caught it. Benadryl given. 1/18/23 received onions in spaghetti sauce: canned sauce. Had resp distress, redness, sweating. [He/she] received Epi pen and went to [acute care hospital]. Below are some of the changes that we have made since this occurred: -Menu slips have been colored coded to help flag allergens, diets, and constancy's -Green labels have been added to all canned items that contain onions .At the beginning of each meal service, cooks and aids need to do a time out. Review the allergies and what the resident with these allergies can or cannot have .review allergies at the daily huddle . Review of Onion Allergy Event Inservice dated 2/14/23 states .All long-term care staff have to take these allergies very seriously. We have seen an increase in allergies over the years and I need each kitchen staff member to do the following: -Read all labels, with the particular resident any items that contains onions including onion powder cannot be served to [him/her]. During an observation of the dry storage room on 5/23/23 at approximately 12:32 p.m. two surveyors, Director of Support Services (DSS), and cook observed multiple soup cans and approximately 4 bags of stuffing that also contained onions that were not labeled with a green sticker. At this time SSD indicated that at the time he was so concerned with the initial cause of Resident #32's reaction [tomato sauce] he did not think to check all the other food items in the storage room. Review of facility policy Food Allergies undated states Individuals with food allergies will be provided with safe foods and fluids, and appropriate substitutions to maintain health. On 5/23/23 at 4:04 p.m., the surveyor confirmed in an interview with the Administrator and the Director of Nursing, Resident #32 was served meals containing onions, and the dry storage room contained food items which did not identify (with the green label) that the items contained onions.