Resident #6 was eating lunch on June 5, 2025, when they lifted the chicken from their plate and discovered mushrooms underneath. They immediately felt itching in their throat and notified nursing staff.
Registered Nurse Supervisor #1 entered the room at 1:20 PM while the resident was still eating. The resident picked up the chicken and showed the supervisor the mushrooms hidden beneath the chicken and pasta. The resident reported their tongue felt tingly and both arms were itching.
Staff observed the resident's arms were slightly red with a raised rash.
The meal ticket attached to the tray clearly stated the resident had allergies and dislikes to mushrooms. Certified Nursing Assistant #2 checked the ticket after the resident reported feeling weird and confirmed it documented the mushroom restriction.
The resident's mushroom allergy had been documented in their care plan since April 21, 2025. Yet somehow the kitchen served them chicken prepared with mushroom sauce on June 5.
Dietician #1 explained that when Resident #6 was first admitted on July 18, 2024, they stated during an interview that they were not allergic to anything. In January 2025, the resident told dietary staff they did not like mushrooms.
The dietician said they became aware of the actual mushroom allergy only after the June incident occurred. They acknowledged being unsure about the care plan that documented the mushroom allergy starting April 21, 2025.
"The electronic medical record does not generate an alert for allergy unless the resident is a readmission or new admission," the dietician explained. "The allergy should have been verbally discussed with them."
The meal ticket was updated to include the mushroom allergy only after the incident occurred.
According to facility protocol, the Dietary Supervisor is responsible for ensuring meal tickets match what gets served on residents' trays.
But the Director of Nursing later disputed whether the resident even had a legitimate mushroom allergy. During a September interview, they stated their investigation concluded the alleged allergy was not verified.
The director noted that on admission, the resident had only expressed a dislike for mushrooms, and hospital records contained no documentation of mushroom allergies. They said the allergy notation was updated in March 2025 but couldn't explain why the system failed to update meal tickets accordingly.
Physician #1 added another layer of confusion to the incident. During a November interview, they stated that while nursing staff documented several attempts to contact them about the allergic reaction, they had no recollection of being contacted.
The physician said nursing staff ultimately reached another physician who put orders in place. They acknowledged that mushroom allergy was documented in the resident's chart, but questioned whether the facility actually served mushrooms to the resident.
"I do not believe Resident #6 received mushroom from the facility because Resident #6 buys food from outside routinely," the physician stated.
However, when the physician evaluated the resident on June 6 or 7, the resident specifically reported receiving mushrooms from the facility. By that point, the resident's symptoms had already cleared.
The incident reveals a breakdown in communication between dietary staff, nursing supervisors, and physicians. Despite having a documented allergy in the care plan since April, the resident was served the exact food they were allergic to.
Registered Nurse #1 confirmed they observed mushrooms on the meal tray that was still in the resident's room and immediately reported the situation to their supervisor.
The facility's electronic medical record system appears to have significant gaps. While it can track allergies for new admissions and readmissions, it failed to alert dietary staff when an existing resident's allergy status was updated in March 2025.
The incident occurred despite multiple staff members being involved in meal preparation and delivery. The dietary department prepared chicken with mushroom sauce, kitchen staff plated it, and nursing staff delivered it to a resident whose meal ticket clearly documented mushroom restrictions.
Staff only discovered the error after the resident began experiencing symptoms and showed them the mushrooms hidden under their chicken.
The resident's physical reaction included throat itching, tongue tingling, arm itching, and a raised red rash on both arms. These symptoms developed immediately after consuming the meal and required medical evaluation over the following days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clove Lakes Health Care and Rehab Center, Inc from 2025-11-18 including all violations, facility responses, and corrective action plans.
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