Health inspection·January 23, 2025

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow a physician's order to collect a stool sample for one of three sampled residents (Resident 1). Residents Affected - Few This deficient practice had the potential for a delay of care and services to Resident 1. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 3/25/2024, and recently admitted Resident 1 on 11/27/2024, with diagnoses of acute respiratory failure with hypoxia (a serious medical condition that occurs when the body does not have enough oxygen in its tissues), end stage renal disease (irreversible kidney failure), and dependence on renal dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are no longer functioning properly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/2/2024, the MDS indicated Resident 1 was understood by others and had the ability to usually understand others. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, showering/bathing self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 was always incontinent (unable to voluntarily control) of urinary and bowel. During a review of Resident 1's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note (SBAR), dated 12/12/2024, untimed, the SBAR indicated Resident 1 was having signs and symptoms of loose stools (diarrhea). The SBAR indicated Resident 1 had two episodes of loose stools during the morning (AM) shift. During a review of Resident 1's Physician and Telephone Orders (PO), dated 12/13/2024, timed at 12:20 pm, the PO indicated Resident 1 had an order for stool for c. difficile (C. diff - a test that looks for toxins produced by the clostridioides difficile bacteria in a person's stool) to be collected. During an interview on 1/23/2025 at 2:41 pm with the Assistant Director of Nursing (ADON), the ADON stated it was important to follow the physician's order (to collect stool to test for C. diff) so the facility staff could have started the treatment and interventions for Resident 1 right away. The ADON stated the order for Resident 1's stool sample to be collected was not completed. During an interview on 1/23/2025 at 3:55 pm with the Director of Nursing (DON), the DON stated it was important to follow a physician's order so the facility staff could provide the proper care and (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: 055544 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 055544 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722 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)