Health inspection·April 11, 2024

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observation, interview, record review and review of facility policy, the facility failed to ensure residents with food allergies and/or food intolerances did not receive those foods at meals. This affected one resident (#15) out of three residents reviewed for food allergies/intolerances. The facility identified ten residents (#7, #8, #15, #41, #42, #44, #47, #60, #64, and #79) as having known food allergies. The facility census was 96. Findings include: Review of medical record for Resident #15 revealed an admission date of 11/29/21. Diagnoses included type two diabetes with foot ulcer, chronic systolic (congestive) heart failure, essential hypertension (high blood pressure), and unspecified protein-calorie malnutrition. Resident#15 was on a regular diet with mechanical soft/dental soft texture. Resident #15 was cognitively intact and required setup or cleanup assistance for eating. Resident #15 had a known allergen to cheese. Review of care plan, initiated 02/28/24, revealed the Resident #15 had a potential for allergic reaction with a known allergy to cheese with a goal the resident would not receive substances known to cause an allergic reaction. Observation during lunch on 04/10/24 at 12:50 P.M. revealed Resident #15, who was allergic to cheese, was served mechanical soft chicken, lima beans and au gratin potatoes. The au gratin potatoes appeared untouched. Observation of Resident #15's meal ticket on the lunch meal tray revealed no indication of Resident #15 having a cheese allergy. Interview at the time of observation on 04/10/24 at 12:50 P.M. with Resident #15 confirmed his allergy to cheese with Resident #15 stating I told them and my sister told them I am allergic to cheese, and I get cheese items all the time. Observation of Resident #15's meal tray and interview on 04/10/24 at 12:55 P.M. with Licensed Practical Nurse #361 confirmed Resident #15 had received au gratin potatoes. Review of the facilities Fall and Winter week one menu for 2023 and 2024 revealed golden brown chicken, au gratin potatoes, buttered lima beans, and iced lemon sugar was to be served for lunch on 04/10/24. Review of the facility concern report, dated 03/13/24, initiated by Resident #15 revealed he was allergic to cheese and was still receiving cheese. The facility follow up on the concern report indicated the tray card had been updated. Page 1 of 2 365658 365658 04/11/2024 Cardinal Woods Skilled Nursing & Rehab Ctr 6831 Chapel Road Madison, OH 44057

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/10/24 during kitchen observation between 1:06 P.M. and 1:15 P.M. with Regional Dietary #374 revealed food allergies were loaded into the tray ticket system, and food allergies were indicated on the tray tickets. Periodically the food service manager would cross-reference the food allergies listed in the electronic medical record to ensure the two matched. Interview on 04/10/24 at 1:15 P.M. with Dietary [NAME] #376 confirmed the tray tickets were how dietary staff knew of a food allergy. Observation of Resident #15's lunch tray ticket for 04/10/24 and cheese allergy notation in the electronic medical record and interview on 04/11/24 at 9:29 A.M. with the Administrator, Regional Nurse #373, and Regional Dietary #374 confirmed Resident #15's food allergy to cheese was not listed on his tray card as it should be, and staff would have no idea Resident #15 was allergic to cheese. Review of the manufacturer box of Basic American Foods Au Gratin Potatoes Reduced Sodium (the au gratin potatoes which were served the previous day for lunch) with Regional Dietary # 374 revealed cheddar cheese was listed in the ingredient list and interview on 04/11/24 at 9:50 A.M. with Regional Dietary #374 confirmed au gratin potatoes should not have been served to a resident with a cheese allergy. Review of facility policy Food Allergies and Intolerances, revised October 2008, revealed residents with food allergies and/or intolerances will be identified upon admission and steps will be taken to prevent resident exposure to the allergen(s). This deficiency represents non-compliance investigated under Complaint Number OH00152203. 365658 Page 2 of 2