Health inspection·March 5, 2025

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide special dietary need of one of two sampled residents (Resident 1) by failing to ensure Controlled Carbohydrate Diet (CCHO diet, a dietary approach designed to manage blood sugar levels) that is recommended by Registered Dietitian (RD, is a healthcare professional who specializes in food and nutrition) was communicated and order obtained from the resident's primary physician. This deficient practice placed Resident 1 at risk for developing high blood sugar that can lead to hospitalization and/ or death. Findings: During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and acute kidney failure (a sudden loss of kidney function). During a review of Resident 1's care plan, focusing on DM, initiated on 2/17/2025, indicated an intervention for dietary consult for nutritional regimen and ongoing monitoring. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 2/21/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision making was moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 1 was independent with eating and oral hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues; resident completes activity) with toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with shoer/bath. The MDS also indicated Resident 1 was on a therapeutic diet (a specialized meal plan designed to treat or manage specific medical conditions), on admission and while a resident in the facility. During a review of Resident 1's Order summary report dated 3/5/2025, timed at 3:57 PM, indicated no added Salt (NAS) mechanical soft diet (consists of foods that are soft, easy to chew and swallow, often requiring minimal chewing, and are designed for individuals with difficulty chewing or swallowing) - chopped texture (food prepared into bite sizes), ordered on 2/23/2025. The order did not indicate to start resident on CCHO diet, snacks twice a day (BID) and nephrovite (multivitamins) daily. Page 1 of 3 055818 055818 03/05/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's food and nutritional assessment completed by RD, dated 2/24/2025, timed at 11:36 AM, indicated Resident 1 is currently on NAS diet, it indicated Resident 1 is at risk of altered nutrition due to diabetes and kidney disease. The assessment indicated the following nutrition intervention/prescription/recommendation: Discontinue diet (current diet order) and change to CCHO NAS mechanical soft chopped thin liquid diet (watery and easy to pour like water, juice, milk or broth). Snacks BID. Nephrovite daily. During a concurrent observation and interview on 3/5/2025 at 2:30 PM with Resident 1, in Resident 1's room, Resident 1 asked surveyor for another cup of juice because she just finished a cup of juice and showed surveyor that it is now empty. Resident 1 stated she does not know if the juice is sugar free or not. During an interview on 3/5/2025 at 2:37 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 has DM. During a concurrent record review and interview on 3/5/2025 at 2:42 PM with Kitchen Supervisor (KS), Resident 1's diet card was reviewed. KS showed surveyor Resident 1's diet card which indicated NAS diet. KS verified Resident 1's current diet card did not indicate CCHO. KS stated when a resident has diagnosis of DM, CCHO is usually ordered by doctor (resident's primary physician) and it will generate in their diet card that resident's diet should be CCHO, which is a diet that has lesser sugar than normal diet. During a concurrent record review and interview on 3/5/2025 at 2:45 PM with Registered Nurse (RN), Resident 1's medical records dated from 2/24/2025 to 3/5/2025 were reviewed. RN stated Resident 1 was seen by RD sometime in February of this year (2025). RN stated RD recommendations are being reviewed by licensed nurses and communicated to the resident's primary physician and if the physician is agreeable with RD recommendation the licensed nurse obtains the physician's order and will carry out the order (implement). RN stated Resident 1's food and nutrition assessment by RD dated on 2/24/2025 was not reviewed by licensed nurses, and was not and should have been communicated to Resident 1's primary physician. RN added he was not aware of Resident 1's food and nutrition assessment done by RD on 2/24/2025, RN stated it was his first time reviewing it today. During a concurrent record review and interview on 3/5/2025 at 3:34 PM with Director of Nursing (DON), Resident 1's medical records dated 2/24/2025 to 3/5/2025 were reviewed. Resident 1's medical records did not indicate Resident 1's primary physician was informed of the RD's recommendation on 2/24/2025 to placed resident on CCHO diet. The DON verified Resident 1 has diagnosis of DM, and the expected diet order should include CCHO to control blood sugar. The DON verified Resident 1's current diet order is NAS mechanical soft diet - chopped texture, ordered on 2/23/2025. The DON verified Resident 1's food and nutrition assessment done by RD on 2/24/2025 has nutrition intervention/ prescription/ recommendation to discontinue diet and change to CCHO. The DON stated providing CCHO diet to a resident who has DM is important to control blood sugar. The DON stated high blood sugar can lead to hospitalization and/or death. The DON stated a resident who has DM, and uncontrolled blood sugar can experience fruity smell, unresponsiveness, and can go to diabetic coma (a life-threatening, reversible state of unconsciousness in people with diabetes, caused by either dangerously high or low blood 055818 Page 2 of 3 055818 03/05/2025 Royal Gardens Healthcare 2339 W. Valley Blvd. Alhambra, CA 91803

F 0800 sugar levels). Level of Harm - Minimal harm or potential for actual harm During a review of Facility's Policy and Procedure (P&P), titled Therapeutic diets, revised October 2017, indicated therapeutic diets are prescribed by the attending physician (Doctor/ primary physician) to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The P&P indicated interpretation and implementation indicated the following: Residents Affected - Few A therapeutic diet must be prescribed by the resident's attending physician (or non -physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. Diet order should match the terminology used by the food and nutrition services department. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record. During a review of Facility's P&P, titled Nutrition Care, dated 2018, indicated unclear or questionable diet orders should be clarified by the RD, licensed nurse, Director of Food and Nutrition Services and physician as soon as possible. 055818 Page 3 of 3