The facility's dietary manager had conducted a November training session titled with the resident's name, specifically instructing staff not to put tomatoes on their food. Three cooks and two dietary aides signed acknowledgment forms.
But the violations continued.
On December 24, when a cook aide became sick and left work, the dietary aide who took over food preparation served the resident tomatoes. The aide told inspectors she was "horribly mistaken and apologetic" for the emergency error.
Three days later, on December 27, kitchen staff served the same resident sliced ham containing pork — another documented allergen.
The dietary manager blamed agency staff for the ham incident, telling inspectors that temporary workers "were giving residents the wrong trays, and trays were having to be re-made that day." She said agency workers were "only to blame on that one occurrence."
The resident's allergies weren't unknown. Multiple staff members told inspectors they were well aware of the restrictions because the resident "would often write things on her meal tickets and send them back to the kitchen."
The dietary aide who prepared food on Christmas Eve said she had been trained about resident preferences a month earlier and knew how to check resident tickets before making side dishes. She acknowledged being "well aware" of the resident's allergy.
Despite this knowledge, the facility had already counseled staff twice about meal accuracy. Employee counseling records from November 27 and December 10 show the dietary manager educating a dietary aide about reviewing meal tickets before trays left the kitchen.
The assistant director of nursing told inspectors the December 27 pork incident "should not have left the kitchen" because staff knew about the resident's allergies. He said nursing staff and kitchen staff were all aware of the restrictions.
The dietary manager, who became supervisor in October after working as a cook for five years, said she was "in the process of doing every resident's food preference while also learning her role." She acknowledged that honoring allergies was crucial because violations "could affect the resident's health."
The facility's own policy requires that food service staff "inspect food trays to ensure that the correct meal is provided to each resident." The policy states that each resident should receive meals that consider "the preferences of each resident."
But the dietary manager told inspectors they had only started a process "about a couple weeks ago, ensuring plates were accurate before sending out."
The assistant director emphasized that following dietary restrictions was "a resident right" and that adhering to allergies would "prevent adverse health reactions."
The dietary manager provided inspectors with copies of employee counseling she had conducted with a new cook aide who "may have been responsible for passing tomatoes" to the resident on multiple occasions.
The repeated violations occurred despite the facility having established procedures and conducting specific training sessions. The November in-service bore the resident's name and explicitly addressed their tomato allergy, yet staff continued serving the prohibited food.
The dietary manager said nurses sometimes sent communication slips about diet changes, and she was working to complete food preference documentation for all residents while learning her supervisory duties.
The Christmas Eve incident highlighted staffing challenges when regular employees become unavailable. The dietary aide said the sick cook aide's departure created an emergency situation that led to the dietary error.
For the December 27 pork service, the dietary manager deflected responsibility to temporary agency staff, suggesting they mixed up meal trays and caused remakes that day.
The assistant director acknowledged that the facility had conducted previous training on meal service accuracy, indicating this wasn't the first time dietary errors had occurred.
The inspection found that some residents were affected by the facility's failure to serve meals according to documented dietary restrictions and preferences, despite staff knowledge of the requirements and multiple training sessions addressing the specific violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At Western Hills from 2025-12-29 including all violations, facility responses, and corrective action plans.