**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, record review, document review, and review of facility policies, the facility failed to ensure that menus/food provided to residents met the individual needs for four (Resident (R) 312, R19, R104 and R15) of 28 sampled residents, and an additional five (R89, R62, R63, R91, and R6) supplemental residents. Although food allergies and textures were noted in physician orders and/or dietary records, two sampled residents (R 312 and R89) were provided foods to which they had documented allergies and/or which was in a texture could be unsafe to consume. Additional supplemental residents, (R19, R62, R63, R91, and R6) who had cognitive impairment which could affect their ability to recognize unsafe foods (either due to allergy or texture) were also placed at risk due to the facility's failure. The facility's failure to assure that residents did not receive diets to which they were allergic and/or which were in a texture other than that ordered by the physician resulted in immediate jeopardy due to the probability of serious harm or death through complications such as anaphylactic shock (severe allergic response causing the closure of mouth/lips and/or throat) or choking. Additionally, R104 and R15 received diets that did not accommodate preferences and residents stated that they were unable to access menus to assist them to make dietary selections. On 08/04/22 at 05:19 PM, the Administrator was notified of the immediate jeopardy (IJ) at F803-K (Menus and Nutritional Adequacy.) The immediate jeopardy began on 08/04/22, the day the survey team identified that R312's meal tray included strawberries, to which she had a documented food allergy. The facility provided a removal plan on 08/05/22 at 11:00 AM. The removal plan included re-education of the Dietary Manager (DM), dietary, and nursing staff about food allergies, tray accuracy, and meal pass process including the implementation of additional safety checks during meal service in the dietary department and by nursing, as well as an audit of resident food allergies and highlighting of food allergies for resident meal tickets and the implementation of a Quality Assurance and Process Improvement (QAPI) project to address meal tray accuracy and ongoing monitoring by management. Prior to verification of all steps of this plan, observation revealed Immediate Jeopardy continued to exist, as on 08/05/22 at 12:25 PM. At that time, observation revealed that a meal tray, designed to meet one resident's food needs, was incorrectly delivered to, and left unsupervised with R89, a cognitively and visually impaired resident who had food allergies to the food that was incorrectly provided. In addition, the tray incorrectly delivered to F89 contained a regular diet; however, R89 had orders for a pureed diet. Surveyor intervention prevented R89 from accessing/ingesting any of the food incorrectly provided to the resident. The Administrator was notified that immediate Jeopardy was ongoing on 08/05/22, and that additional steps to assure that each resident was correctly identified to ensure delivery of the correct diet were required. On 08/05/22 at 04:50 PM, an additional removal plan was received that included the auditing of all resident identification bands and photographic identification of residents and the implementation of a Quality Assurance (QAPI) project to monitor resident identification by nursing and facility management. After verification of each step of the plan, including observation of the evening meal of 08/05/22 at 6:00 PM, the survey team notified the Administrator that the IJ was removed. The Scope and severity of the deficiency was lowered at that time to an E (Pattern) until ongoing compliance with all requirements of the regulation could be verified. Findings include: 1. During an interview on 08/04/22 at 8:35 AM, R312 stated that she had an allergy to berries. R312 stated she received waffles with strawberries that morning for breakfast and had taken a picture of the meal tray, prior to calling staff to remove the tray which contained a food to which she was allergic. Observation of the picture, dated 08/04/22 at 7:57 AM, revealed R312's uncovered breakfast tray sitting on an overbed table with strawberries on the waffles. R312 said that prior to her admission to the facility, she had an anaphylactic reaction to berries, resulting in her lips and throat swelling. R312 stated she has been prescribed an epi pen (an emergency injection device with epinephrine for intramuscular injection for severe allergic reaction, often carried by persons with severe allergies) by her allergist for this possible reaction. R312 stated that she normally carries the epi pen in her purse but did not have the purse with her in the facility. Review of R312's Dashboard from the facility's electronic medical record (EMR) revealed that R312 was admitted to the facility on [DATE], for rehabilitation with diagnoses including; acute on chronic diastolic and systolic heart failure, diabetes mellitus types 1 and type 2, morbid obesity, asthma, hemiplegia (paralysis of one side of the body), difficulty walking, and muscle weakness. Allergies listed on the Dashboard included berries. Review of R312's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/26/22, revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident had no cognitive deficit. The MDS showed a Personal History Questionnaire (PHQ-9) score of zero (0) indicating no depression, and no behaviors. Per the MDS, the resident needed limited assistance of one-person with eating. Review of R312's Orders tab in the EMR revealed orders for a regular No Added Salt (NAS) and Carbohydrate Controlled Diet (CCD) with thin consistency. No orders regarding allergies or an epi pen were specified. Review of R312's Care Plan, initiated on 07/26/22, reflected that the resident was care planned for multiple food allergies, including an allergy to berries. The care plan did not indicate the resident had any behaviors. During an interview on 08/04/22 at 8:40 AM, interview with Certified Nursing Assistant (CNA1) revealed that if a resident has food allergies, they should not be served that food. CNA1 stated that the nurse should check the trays and that CNAs should too. CNA1 stated she did not know which staff was responsible for passing trays to R312 that morning and was not involved in the incident described by the resident. During an interview on 08/04/22 at 8:45 AM, Registered Nurse (RN) 1 stated that on that morning, she was the nurse on the unit on which R312 resided. RN1 stated that the nurse, as well as CNAs, should check for allergies before serving a tray to a resident. RN1 confirmed she did not check R312's tray that morning and was unaware of the incident involving R312. During an interview on 08/04/22 at 9:10 AM, the Dietary Manager (DM) stated that she was working the food line and made an error, confirming that she should not have sent the strawberries to the resident. During an additional interview with the DM on 08/04/22 at 10:14 AM, the DM stated that the cook was plating the meals and that she had been checking the trays to ensure that they were correct. Review of R312's meal ticket for 08/04/22, provided by the DM on 08/04/22, clearly stated food allergies including berries. During an interview on 08/04/22 at 10:19 AM, Cook#1 stated he had plated R312's food and the DM had checked the tray. Cook#1 stated he did not know the process. He said that the kitchen was called about the meal and told that the resident was allergic to berries; the kitchen then delivered a new tray to the resident. During an interview on 08/04/22 at 10:23 AM, the Director of Nursing (DON) stated that the nursing policy indicated nurses should review trays for accuracy and CNAs should also check them. The DON stated that staff should not serve foods to residents to which they are allergic. The DON stated that she had heard of the problem that morning; however, she was told the resident did not get the food as the error was identified by the CNA before providing the meal. The DON stated that it was her expectation that nursing staff follow the facility policies. An additional interview was conducted with R312 on 08/04/22 at 10:28 AM. The resident, who had hemiplegia, was sitting in her bed, and was observed to have difficulty in moving herself while in bed. R312 reiterated that prior to her admission to the facility, she had had anaphylactic reactions to berries and bananas that were diagnosed by her allergist. R312 confirmed that she did receive the tray with the strawberries that morning, stating that the CNA left the tray in the room. R312 stated she called staff to report the problem. Since there were no other witnesses to the incident, the surveyor requested to photograph R312's phone/photograph of the delivered meal that contained a time/date stamp. The resident granted permission, and a copy of the photograph, which showed that R312 received strawberries with her breakfast meal, was obtained. Review of the photograph reflected that the breakfast meal, which contained waffles, strawberries, and bacon, was placed on a plate on a tray sitting on an overbed table. No cover for the plate was present in the picture and no staff were in the picture. Observation of the resident's room at this time revealed that the resident's overbed table appeared to be the same table as in the picture and was angled toward the window and was partially over the bed. On 08/04/22 at 10:35 AM, the Administrator came to the conference room and stated that she had spoken to CNA2, whom he identified as the staff who delivered the meal tray to R312. Per the Administrator, CNA2 never served the tray to the resident. During an interview on 08/04/22 at 10:37 AM, CNA2 denied serving the resident the food tray because it contained strawberries (an allergen). CNA2 stated that she had started to deliver R312's tray, but when she lifted the lid, she saw that it had berries and therefore, did not leave the tray with the resident. Although the photograph provided by the resident showed that the uncovered tray was served on the bedside table and no staff were present in the photograph, CNA2 reiterated that the tray was never near the resident or left in the room. CNA2, who said that she was in trouble over the incident, stated she reported the incident to the Infection Control Registered Nurse (ICRN) at the time of the delivery. The ICRN instructed her to call dietary and get a new tray which they did. CNA2 stated that she would not serve food to residents if they were allergic. During an interview on 08/04/22 at 10:41 AM, the ICRN stated that she was aware of the issue but did not know if CNA2 served the tray to the resident. ICRN stated that she had not checked the tray herself because she was on a different tray line. During an interview on 08/04/22 at 12:11 PM, the Medical Director, who was not R312's attending physician, was informed that R312 was served strawberries although she had a documented allergy to strawberries, and that R312 stated that she had an epi pen for her allergies. The Medical Director said that, in his opinion, if a resident carries an epi pen, the allergy is real. He said he would not serve strawberries to a resident with unknown reaction/food allergy, and that it was better not to serve food to residents who claim a food allergy because you do not know what reaction they would have. 2. Record review of the Dashboard in the EMR revealed that R89 was admitted on [DATE], with diagnoses including; dementia, glaucoma, and macular degeneration. Per the Dashboard, the resident had allergies including chocolate, fish, and shrimp. Review of the Orders tab for 08/2022, revealed R89 was to receive a pureed diet. Review of R89's Annual MDS, with an ARD date of 07/04/22, revealed the resident had highly impaired vision. A staff assessment was conducted and found the resident had severely impaired cognitive skills for decision making. Per this MDS, R89 required extensive assistance with one-person physical assistance with eating. During lunch observation on 08/05/22 at 12:15 PM, in the 3rd Floor Dining Room, the DON was observed checking each meal tray against the dietary card to confirm that the food on the tray was accurate. After checking each tray for accuracy, the DON would then hand the tray to a CNA or other staff in the dining room to deliver it to the resident. At 12:25 PM, observation revealed that Occupational Therapy Assistant (OTR) 1 had delivered a tray of food to R89. Review of the dietary card on the meal revealed that this tray of food belonged to R65, not R89. Observation of the meal tray which was incorrectly delivered to F89 revealed that the food was a regular texture, not the pureed texture that R89 was supposed to receive. Further observation of the meal tray revealed that the tray included two foods to which the resident was allergic - Cajun fish filet, and chocolate brownie. No staff were present at the table with R89. Due to immediate surveyor intervention, R89 did not ingest any of the food and the tray was taken away. At 12:25 PM, the DON was immediately notified that R89 did not receive the correct diet. The DON stated that she had checked the diet tray against the food provided, and it was correct for the resident listed on the diet card. The DON next stated that she told OTR1 that this tray was to be delivered to the hall where the resident (R65) was in their room. Interview with OTR1 on 08/05/22 at 12:30 PM revealed that he did not hear the DON say that R65 was in a room on the hall, waiting for their meal. OTR1 stated he thought that the DON had told him that the resident was right over there, and as a result, he delivered the tray to the resident whom he thought the DON had indicated. OTR1 confirmed he failed to correctly identify the resident prior to delivering the tray of food. 3. Record review revealed the facility had additional residents with either food allergies and/or orders for a modified food consistency whose cognitive abilities could prevent them from identifying risks if they received the wrong food or diet: a. Review of the Dashboard in the EMR revealed that R19 was admitted on [DATE], with diagnoses including; pneumonitis (infection of the lungs) due to inhalation of food and vomit, altered mental status, dysphagia (difficulty swallowing) and aphasia (inability to speak) following nontraumatic cerebral hemorrhage (bleeding in the brain not related to trauma), and cognitive communication deficit. R19 had orders for a regular pureed diet as well as enteral feeds (feeds by gastrostomy tube, which is a tube surgically placed directly into the resident's stomach). Further review of the Dashboard, as well as the resident's care plan, revision date 05/10/22, revealed R19 was allergic to eggs. Review of the Spring/Summer 2022 Kld (menu) for the week of 07/31/22, revealed that it included egg-based foods, including scrambled eggs with peppers and onions on 07/31/21, cheese omelet on 08/03/22, Quiche [NAME] on 08/04/22, and Eggs Florentine on 08/05/22. R19's Quarterly MDS, with an ARD date of 05/03/22, revealed the resident was assessed as severely cognitively impaired in cognitive skills for decision making. Per the MDS, R19 required extensive assistance with one-person physical assistance with eating. b. Record review of R63's Dashboard revealed the resident was admitted on [DATE], with diagnoses including multiple sclerosis and glaucoma. Review of the Orders tab revealed the resident had a current order, with a start date of 03/30/22, for a pureed diet. Per the Dashboard, R63 had an allergy to chocolate. Review of the Spring/Summer 2022 Kld (menu) for the week of 07/31/22, revealed that it included chocolate foods including chocolate-chip cookie on 08/02/22, and a chocolate brownie on 08/05/22. R63's Quarterly MDS, with an ARD date of 06/19/22, reflected a BIMS score of 1/15, indicating the resident was severely cognitively impaired. Per the MDS, the resident required a mechanically altered diet, and total dependence with one-person physical assistance with eating. c. Record review of the Dashboard in the EMR revealed that R62 was admitted on [DATE], with diagnoses including; sequelae (symptoms following) cerebral infarction, hemiplegia and aphasia following cerebral infarction, Diabetes Type Two (2) without complications, and other seizures. Per the Dashboard, R62 had allergies to shellfish and beans. Review of R62's care plan revealed that since 12/26/17, it included the resident's allergies of shellfish and bean. Per the Orders tab, as of 05/17/20, R62 had orders for a mechanical soft diet. Review of the Spring/Summer 2022 Kld (menu) for the week of 07/31/22, revealed that it included green beans on 08/01/22, Italian green beans on 08/03/22, and navy bean soup on 08/05/22. R62's Annual MDS, with an ARD date of 06/18/22, reflected a BIMS score of 3/15, indicating the resident had severe cognitive impairment, and required supervision with one-person physical assistance with eating. d. Record review of the Dashboard revealed that R91 was admitted on [DATE], with diagnoses including dementia and Diabetes Type Two (2) without complications. Per the Dashboard, R81 had an allergy to shellfish. R91's Annual MDS, with an ARD date of 07/05/22, reflected a BIMS score of 5/15, indicating severe cognitive deficit, and the requirement for limited assistance dependence with one-person physical assistance with eating. e. Record review of the Dashboard in the EMR reflected that R6 was admitted on [DATE] and readmitted on [DATE], with diagnoses including; Alzheimer's disease, Diabetes Type Two (2) with hyperglycemia (high blood sugar), seizures, and sepsis (major infection). Per the Dashboard, R6 was allergic to seafood. Review of R6's care plan, revealed that on 08/04/22, the care plan was initiated to also show an allergy to seafood. Review of the Spring/Summer 2022 Kld (menu) for the week of 07/31/22, revealed that it included tomato basil fish on 08/01/22, breaded fish on 08/02/22, and Cajun fish filet on 08/05/22. R6's Significant Change MDS, with an ARD date of 07/14/22, reflected a BIMS score of 3/15, indicating the resident was severely cognitively impaired, Per the MDS, the resident required limited assistance with one-person physical assistance with eating. 4. Review of the facility policy titled, Resident Food Preferences, revised 10/01/21, revealed Upon the resident's admission the dietitian or nursing staff will identify a resident's food preferences. When possible, this will be done by direct interview with the resident. The Dietitian will discuss resident food preferences with the resident when such preferences conflict with a prescribed diet . The resident's clinical record (orders, care plan, or other appropriate locations) will document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions. The Dietitian will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. Review of the facility policy Displaying the Menu, revised 10/15/21, revealed, 1. Planned written menus will be posted by staff in a clear, obvious area that is easily viewed by all individuals. 2. Daily menus will be clearly posted near dining area. Review of the Spring/Summer 2022 menu, dated for the week of 07/31/22 through 08/06/22, revealed it listed main entrees and alternatives for the lunch and supper meals. During an interview on 08/02/22 at 11:03 AM, R104 stated that the facility staff, including nursing and dietary, did not ask him his food preferences and he would often be served foods he did not like. R104 stated that he asks for and receives a tuna salad sandwich on his lunch and dinner trays so that in the event he is served a food he does not like, he would have something to eat. During an interview on 08/04/22 at 9:50 AM, R104 stated that he did not know that there were preplanned menus and alternatives from which he could choose. R104 stated that he rarely leaves his room and was not aware that the menus were posted outside of the dining room. R104 stated he does not like gravy but is served gravy on his food. During this interview, R104 verified that no menu was posted in his room. Review of R104's tray ticket dated 08/02/22, revealed no food preferences listed. Further review of R104's tray ticket dated 08/02/22, revealed a tuna salad sandwich was listed in addition to the main entrée. Review of the electronic medical record (EMR) Resident Dashboard, dated 08/04/22, revealed R104 was admitted to the facility on [DATE], with diagnoses which included a stroke. Review of the quarterly MDS, with an ARD of 07/11/22, revealed a BIMS score of 12/15, indicating R104 had moderate cognitive impairment. Review of the EMR Care Plan tab revealed a Nutritional Risk care plan, revised on 07/12/22, with goals to meet nutrition/hydration needs and weight maintenance with an intervention to honor food preferences, noting the resident, Likes pudding, oatmeal, tuna and egg salad. Review of the Nutritional Notes, and Nurses' Notes, located in the EMR Progress Notes tab and dated 12/02/20 through 08/05/22, revealed no documentation by the dietitian or nursing staff of food preferences for R104. 5. During an interview on 08/02/22 at 11:33 AM, R15 stated no facility staff, including nursing or dietary, had asked him his food preferences and he would often be served foods he did not like. R15 stated that he asks for and receives a peanut butter and jelly sandwich on his lunch and dinner trays so that in the event he is served a food he does not like, he would have something to eat. R15 stated he does not like pasta but gets pasta all the time. Observation of R15's lunch tray on 08/02/22, revealed spaghetti and meat sauce as the entrée along with a peanut butter and jelly sandwich. During an interview at the time of this lunch observation, R15 stated, I had pasta last night [beef macaroni casserole was listed on the menu for dinner on 08/01/22]. During an interview and observation of the dinner meal on 08/05/22 at 5:45 PM, it was revealed that R15 received chicken parmesan served over spaghetti. During an interview on 08/04/22 at 9:55 AM, R15 stated that he did not know that there were preplanned menus and an alternative selection for the entree. R15 stated he rarely leaves his room and does not receive a menu. R15 stated that food preferences were discussed with him on admission, way back in October, but had not been discussed since then. R15 stated he does not eat pork but was served pork right after his admission to the facility. R15 stated that pork is the only food preference listed on his tray ticket. During this interview, R15 verified that no menu was posted in his room. Review of R15's tray ticket dated 08/02/22, revealed pork as an allergy, but no food preferences were listed. Further review of R15's tray ticket dated 08/02/22, revealed a peanut butter and jelly sandwich was listed in addition to the main entrée. Review of the EMR Resident Dashboard, dated 08/04/22, revealed R15 was admitted to the facility on [DATE], with diagnoses which included a stroke. Review of the EMR quarterly MDS, with an ARD of 05/14/22, revealed a BIMS score of 15/15, indicating R15 had no cognitive impairment. Review of the EMR Care Plan tab revealed a Nutritional Problem care plan for weight gain, revised on 05/11/22, with interventions to honor food preferences. Review of the Nutritional Notes, and Nurses' Notes, located in the EMR Progress Notes tab and dated 10/26/21 through 08/05/22, revealed no documentation by the dietitian and nursing of food preferences for R15. During an interview on 08/03/22 at 1:40 PM, the Dietary Manager (DM) stated that when a resident is newly admitted to the facility, the nurse completing the admission assessment asks the resident about food preferences. The nurse writes out a dietary communication sheet that the DM enters into the computer system. The DM stated, I try to go to every new admission and ask for their food preferences. Review of dietary communication sheets with the DM revealed most of the sheets included the diet order but no food preferences. The DM was unable to locate a dietary communication sheet for R104 and/or R15. During an interview on 08/05/22 at 10:05 AM, Licensed Practical Nurse (LPN) 2, who was also the unit manager for the third floor, stated that the admission nurse sends the diet order to the kitchen and may ask for food preferences. LPN2 stated that the dietitian follows up on the food preferences with the resident and/or family. During further interview on 08/05/22 at 10:05 AM, LPN2 stated she was not aware that R104 and R15 were unaware that there were menus and alternatives. LPN2 stated that the third floor had a selective menu list. LPN2 explained that a staff member takes a week's menu to the resident and/or their representative for menu selection and then give that list to dietary. Review of the selective menu, provided by dietary and dated 08/05/22, revealed neither R104 nor R15 were on the list. On 08/05/22 at 10:10 AM, LPN2 verified that the selective list included five residents on the third floor and did not include R104 or R15. During a telephone interview on 08/05/22 at 3:10 PM, the Dietitian stated that food preferences are obtained on admission by the nursing staff and also by the DM. The Dietitian stated that on the initial nutritional assessment and quarterly nutritional review, she reviews the food preferences for the residents. The Dietitian stated that she assesses food preferences for the residents on the second floor more often than the residents on the third floor because the second floor is short term rehabilitation [with a shorter stay in the facility] and the third floor is long-term care. Review of the Nursing policy titled, Resident Nutritional Services, and revised 10/1/21, revealed Nursing personnel will ensure that residents are served the correct food tray as per diet order and allergies .When serving the food tray nursing personnel must check the tray card to ensure that the correct food tray is being served to the resident. If an incorrect meal has been delivered nursing staff will immediately remove and report it to the food service manager so that a new food tray can be issued. Review of the facility's undated policy titled, Accuracy and quality of tray line service, revealed that the meal is checked against the therapeutic diet spreadsheet . staff will refer to the meal ticket for . allergies substitute appropriately for those items, problems with meal accuracy are resolved immediately, ongoing problems are brought to the attention of the food service manager. NJAC 8:39-17.1(c) NJAC 8:39-17.2(d) NJAC 8:39-17.4(a)(1)(2) NJAC 8:39-17.4(e)