Health inspection·January 7, 2026

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (1) of four (4) sampled residents (Resident 1) was provided with a breakfast tray that did not contain food that the resident was allergic to. This failure had the potential to result in Resident 1 experiencing an allergic reaction such as anaphylaxis (a severe, whole-body allergic reaction that happens quickly and can be life-threatening).During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of syncope (fainting or passing out, caused by a temporary lack of blood flow and oxygen to the brain) and collapse (to fall down) and autoimmune thyroiditis (when the immune system mistakenly attacks its own thyroid gland [a small, butterfly-shaped endocrine gland in the front of the neck that produces hormones to control the body's metabolism, energy use, growth, and other vital functions such as heart rate and digestion] causing inflammation [swelling]). Resident 1's admission Record also indicated Resident 1 had multiple allergies with one being to gluten (a protein found in grains like wheat, barley and rye that acts like a natural glue, giving dough its stretchy elastic quality, helping bread rise, and holding foods together). During a review of Resident 1's admission assessment dated [DATE], Resident 1's admission Assessment indicated Resident 1 had an allergy to gluten (a substance present in cereal grains, especially wheat, that is responsible for the elastic texture of dough). During a review of Resident 1's Diet Order and Communication dated 12/21/2025, Resident 1's Diet Order and Communication indicated Resident 1 had a food allergy to gluten.During a review of Resident 1's Care Plan dated 12/22/2025, Resident 1's Care Plan indicated Resident 1 was at risk for nutritional imbalance due to requiring assistance with mobility and having an allergy which included gluten. Resident 1's Care Plan also indicated interventions that included to honor resident's reasonable food preferences and to offer substitutes for meals as needed. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/27/2025, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) with cognitive skills for daily decision making. Resident 1 needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with walking 10 and 50 feet, chair/bed-to-chair transfers (the ability to transfer from a bed to a chair (or wheelchair), putting on/taking off footwear and lower body dressing (the ability to dress and undress below the waist). Resident 1 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with upper body dressing (the ability to dress and undress above the waist), personal hygiene and eating. During an interview on 1/7/2026 at 7:33 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 12/22/2025 Resident 1's breakfast tray contained eggs and sourdough toast and Resident 1 had told him that the resident was allergic to gluten and could not eat what was on the breakfast tray which is the sourdough toast.During an interview on Page 1 of 2 555338 555338 01/07/2026 Brighton Care Center 1836 N. Fair Oaks Ave Pasadena, CA 91103

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1/7/2026 at 8:03 AM with Dietary Supervisor (DS), DS stated on the morning of 12/22/2025 the morning cook was not aware that Resident 1 had a gluten allergy and mistakenly gave Resident 1 sourdough toast on the resident's breakfast tray. DS stated it was an error on the kitchen's end since the resident was admitted overnight. DS further stated the risk of a resident receiving something they are allergic to on their meal tray is the possibility of the resident having a life-threatening reaction. During an interview on 1/7/2026 at 8:12 AM with DS, DS stated when a resident is admitted , the Registered Nurse Supervisor confirms the resident's allergies and notifies the kitchen with a dietary communication slip. DS stated he believes for Resident 1, the process was followed but somehow Resident 1'sallergy was missed since the resident received sourdough toast on the resident's breakfast tray on 12/22/2025 and Resident 1 should not have received the breakfast tray with food the resident was allergic to. During an interview on 1/7/2026 at 1:15 PM with the Director of Nursing (DON), the DON stated when a resident is admitted to the facility, their allergies are recorded in their admission record/ facesheet and the staff complete a dietary communication slip and hand it to the dietary department to notify them of the resident's allergies. The DON stated Resident 1's dietary slip was submitted to the kitchen on 12/21/2025 when she was admitted , however, Resident 1 received sourdough toast on her breakfast tray on 12/22/2025. The DON stated Resident 1 should not have received that breakfast tray because it placed Resident 1 at risk for a possible allergic reaction. During a review of the facility's policy and procedure (P&P) titled, Food Allergies and Intolerances, revised August 2017, the P&P indicated, Resident with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to allergen(s). The P&P also indicated: Meals for residents with severe food allergies are specially prepared so that cross-contamination with allergens does not occur. Residents with food intolerances and allergies are offered appropriate substitution for foods that they cannot eat. 555338 Page 2 of 2