Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure resident (1) who had an allergic reaction that required the administration of an antihistamine due to a shellfish allergy was identified by the dietary staff before being served shrimp Alfredo. Findings include: 1. Review of the provider's 8/16/2024 SD DOH FRI revealed: *On 8/16/24, the provider served shrimp [NAME] for lunch. The nurse had looked up residents who had shellfish allergies and reminded the certified nursing assistants (CNA) to be careful of cross-contamination. The nurse then questioned resident 1's meal and confirmed that resident 1 was served the pureed shrimp Alfredo. Resident 1 was then taken to the nurses' station for assessment where she started to develop a rash around the mouth and redness in her mouth and throat. The nurse obtained orders to administer Benadryl. The Benadryl was administered to resident 1 once it had been received. 2. Observation on 8/21/24 at 11:30 a.m. of the lunch service with [NAME] E and [NAME] F revealed: * [NAME] E and [NAME] F referred to the resident's tray ticket for the resident's preferences for each meal. *The food tray ticket included the resident's diet, diet texture, adaptive equipment, allergies, and menu preference. *Cook F referenced the tray tickets and placed food items on the resident's plate. 3. Interview on 8/21/24 at 11:45 a.m. with [NAME] E and [NAME] F revealed: *On 8/16/24 [NAME] F served shrimp [NAME] to resident 1. *Cook F admitted that she had missed the documented shellfish allergy on resident 1's tray ticket on 8/16/24. *Cook F felt that a resident's food allergies should be highlighted on the tray ticket, and stated it would make dietary staff more aware of the resident's food allergies. *Cook F stated that nursing staff should have made dietary staff aware when they had known that shellfish was on the menu, and there were residents with a documented shellfish allergy. *Cook E stated nursing did not communicate with them until the food was already served to resident 1. *When asked about substitutes for residents with food allergies, [NAME] E stated that residents on puree diets did not have a choice because the menu does not offer pureed food and most residents with puree diets cannot communicate their preferences. *Cook E stated that the dietary staff would go to each resident's room and would ask them if the resident wanted the main meal being served or if they would want a substitute food item. However, they would not do this for residents on puree diets because there was not a puree option on the menu. She felt this may have been why they would have not looked at resident 1's tray ticket as closely on 8/16/24. *When asked what she would do if she had realized that resident 1 had a shellfish allergy, [NAME] F stated she would have made something else for her to eat. 4. Interview on 8/21/24 at 12:30 p.m. with Certified Dietary Manager (CDM) C and Director of Culinary Services (DCS) D revealed: *Tray tickets were printed three times a week. There is a specific section where allergies are listed. *It is the responsibility of staff to reference the tray tickets regarding resident's food allergies. *The shrimp [NAME] was permanently taken off the menu and replaced with chicken Alfredo. *Dietary staff should be offering residents on a puree diet an alternative food option when needed. *The menu substitution lists referred to the 5/27/2020 Offering Food Replacements at Meal Times Policy was not currently available to the dietary staff in the kitchen. 5. Review of Resident 1's electronic medical record revealed: *Resident had a documented shellfish allergy. 6. Review of resident 1's 8/16/24 nursing progress note revealed: *Nursing was advised that dietary was serving shellfish (shrimp Alfredo) for lunch. Nursing reviewed which residents with shellfish allergies. Nursing reminded staff the certified nurse aides (CNA) to be careful of cross contamination and residents who have allergies. The resident was recently switched to a puree diet. The nurse observed the table where resident one was being assisted by staff and questioned the meal resident one was provided and was currently eating. It is reported that the dietary cook had given the resident the pureed shrimp Alfredo. Resident was immediately brought to the nurses' station for examination and monitoring. It was noted that the nurse was able to see resident 1 started to develop a rash on the corners of her mouth. It was also noted that resident 1's mouth and throat were red. Resident 1 was able to speak one-word answers during the examination. Orders for Benadryl and an epinephrine injection were obtained. The Benadryl was given when it arrived. It was noted that the Benadryl was effective, and the epinephrine injection was not needed. 7. Review of the provider's 2/2024 job description for a Licensed dietary cook revealed: *Job duties included: -Reviewing menus before food preparation and following recipes. -Inspecting special diet trays for accuracy. -Coordinating dietary services with other departments. -Assuming authority, responsibility, and accountability of the cook. -Processing and following diet changes and new diets received from nursing services. -Preparing food for therapeutic diets in line with planned menus and standardized recipes. 8. Review of the provider's 5/27/2020 Offering Food Replacements at Mealtimes Policy revealed: *If an individual is not eating (or foods) served, the Nursing Associates in responsible for asking why and for verbally offering a suitable food replacement. (Please see the Menu Substitution Lists in the Menus/Therapeutic Diets Section.) The individual is encouraged to give input for his/her choice of substitution. A minimum of three substitutions should be offered. *For those on special diets, be sure the food replacement offered are appropriate for the therapeutic and mechanically altered diet order.