Health inspection·December 29, 2025

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 interview and record review, the facility failed to ensure food allergies were honored for one of four sampled residents (Resident 1) when during the lunch meal on 12/21/2025 Resident 1 was served Banana Pie that contained a known allergen.This failure resulted in Resident 1 to have a potentially life-threatening allergic reaction.Findings:During a review of Resident 1's clinical record, Resident 1 was admitted in December 2025 with diagnoses that included chronic respiratory failure (a long-term condition where the lungs can't get enough oxygen in or remove enough carbon dioxide), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently), and oxygen dependence. Resident 1's allergies included banana causing anaphylaxis (severe, potentially life-threatening allergic reaction). During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 12/8/25, Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 1 had intact cognitive.During a review of Resident 1's nutritional assessment, dated 12/1/25, Resident 1's food allergies included banana.During a review of Resident 1's care plan, dated 12/1/25, the care plan indicated that Resident 1 has the potential for complications related to a history of allergic reactions/allergies. Resident allergic to . banana. Interventions included dietary department to review food allergy alerts.During a concurrent review of the facility menu for week three, December 15-21, 2025, and Resident 1's meal ticket for 12/21/25, the menu included banana cream pie for lunch and the meal ticket indicated Resident 1's allergy to banana.During a review of the Change of Condition (COC), dated 12/21/25, Resident 1 reported his throat was closing up after eating bananas. Licensed Nurse (LN) 2 documented Resident 1 was agitated and anxious due to anaphylactic episode, lungs with wheezing upon auscultation, short of breath, a flushed face, with hands on neck gesturing he is having a hard time to breathe. LN 2 documented the Medical Director ordered Epinephrine Injection (a life-saving medication used for the emergency treatment of severe allergic reactions (anaphylaxis) ) 0.3 milligrams (mg-a unit of measurement) intramuscular (IM- in the muscle) now for anaphylaxis. Resident 1 stated the banana dessert was on his lunch tray.During a concurrent review of physician orders, dated 12/21/25, and electronic medication administration record (eMAR) for 12/21/25, Resident 1 was administered Epinephrine 0.3 mg for anaphylaxis.During a review of the facility's kitchen document titled Duties and Responsibilities, undated, indicated that cooks one and two are responsible to tell the dietitian or supervisor for substitutions and alternate food for allergies. Dietary Aide three duties include ensuring all trays are correct per diet.During an interview on 12/29/25 at 1:28 p.m. with the Dietary Supervisor (DS), the DS stated each meal tray is checked against the list of resident allergies and the meal ticket in accordance with the cook and dietary aide job duties. The DS confirmed meal trays should not leave the kitchen with food items residents are allergic to. DS confirmed Banana Cream Pie was on the menu 12/21/25. DS stated she was not sure how Banana Cream Pie was served to Resident 1.During an Page 1 of 2 056101 056101 12/29/2025 River Pointe Post-Acute 6041 Fair Oaks Blvd Carmichael, CA 95608

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 12/29/25 at 2:15 p.m. with the Administrator (ADM), the ADM confirmed the expectation is not to serve resident foods they are allergic to. The ADM stated that an allergic reaction can range from a local reaction to life threatening reactions.During an interview on 12/29/25 at 2:23 p.m. with the Director of Nursing (DON), the DON stated the expectation for residents with food allergies is not to serve foods they are allergic to and for the process for checking trays is followed. The DON stated if aresident receives a food item that they are allergic to, and they experience an anaphylaxis reaction, they could die.During a review of the facility's Policy and Procedure (P&P) titled, Food Allergies and Intolerances revised August 2017, the P&P indicated, Residents with food allergies.Steps are taken to prevent resident exposure to the allergen(a) . 056101 Page 2 of 2