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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056101 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056101 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Pointe Post-Acute 6041 Fair Oaks Blvd Carmichael, CA 95608 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)