Health inspection·December 26, 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 review of facility policies, clinical records, and facility documentation, and staff interview, it was determined that the facility failed to ensure that one resident reviewed with food allergies (Resident R1) was free from exposure to a food allergen resulting in an allergic reaction. Findings include: The facility policy entitled, Nutrition Services Communication Form dated June 2016 revealed that it will be used to enhance communication between nursing and dietary of the need to change in diet or for nutritional interventions. The facility policy entitled Food Allergen Awareness dated January 2018, revealed that food allergies will be identified by a common name of the food or any part of the food that contains a food allergen with the purpose to prevent an allergic reaction. Resident R1's clinical record revealed an admission date of 9/15/2019, with diagnoses that included anemia (iron deficiency), major depression, and anxiety disorder. Resident R1's clinical record included a diet that identified a food allergy to fish. Facility documentation revealed that on 11/11/2024, Resident R1 was served dinner with his/her son present with a meal tray ticket that specified breaded pork patty. When Resident R1's son questioned the food item and the meal tray, a staff member read the ticket and said it was a pork patty. Resident R1 ate a portion of the patty and began to develop a rash. The patty was then determined to actually be a breaded fish patty. Facility documentation verified that there was an error in the provision of an alternate food item related to a food allergy. During an interview on 12/23/2024, the Nursing Home Administrator, confirmed that the facility did not follow the physician's orders to not provide a food allergen to Resident R1 that resulted in an allergic reaction to fish. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies Page 1 of 2 395650 395650 12/26/2024 Warren Manor 682 Pleasant Drive Warren, PA 16365

F 0806 28 Pa. Code 211.12(c) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395650 Page 2 of 2