Health inspection·February 2, 2024

F 0808 Level of Harm - Minimal harm or potential for actual harm Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to provide fortified diet (diet enhanced to increase caloric content) as ordered by the physician for 19 out of 102 residents requiring fortified diet. Residents Affected - Some This deficient practice had the potential to result in decrease caloric intake and lead to undesirable weight loss. Findings: During an observation of the tray line service for lunch on 2/2/2024 at 12:15 PM, residents who were on fortified diet received the same food as those residents who did not have an order for fortified diets. Dietary Aide (DA1) did not communicate the fortified diet orders written on the meal tickets during the observation of the facility's tray line for lunch service. A concurrent review of the tray or meal tickets on the meal cart indicated the orders for each resident's fortified diet. During the observation, DA 1 did not read out loud the fortified diet and the cook (Cook1) did not add any additional food items to the resident's meal trays with orders for fortified diet. During an interview with [NAME] 1 on 2/2/2024 at 12:40 PM, [NAME] 1 stated he has melted butter for fortified diets. [NAME] 1 stated he did not add any melted butter today during lunch service. [NAME] 1 stated the tray line staff (DA 1) did not read out the fortified diets. [NAME] 1 stated the fortified diets are for residents who are losing weights and it ' s a physician order. [NAME] 1 stated fortified diets get additional butter on the vegetable or starch. During a concurrent interview with DA 1 and Dietary Supervisor (DS) on 2/2/2024 at 1:10 PM, DA 1 stated that she saw the orders for fortified diets but did not read them out for [NAME] 1 to serve extra butter. The DS stated fortified diets are orders from the physician. The DS stated that fortified diets are for residents who have decrease intake and needs the extra calories to maintain nutritional status. The DS stated the residents with fortified diets receives either butter or gravy to increase caloric intake. During the same interview, the DS stated Fortified diets are recommended by the registered dietitian as part of the nutritional assessment and then ordered by the physician. The DS stated that today [2/2/2024] the residents on fortified diets did not receive fortified food for lunch. A review of facility policy titled Fortified Diet (not dated) indicated, The fortified diet is designed for residents who cannot consume adequate amounts of calories and or protein to maintain their weight or nutritional status. The amount of calorie increase should be 300-400 per day. Examples of Page 1 of 2 055845 055845 02/02/2024 Leisure Glen Post Acute Care Center 330 Mission Road Glendale, CA 91205

F 0808 adding calories may include Extra butter, gravy .etc. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055845 Page 2 of 2