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 Page 1 of 2 055544 055544 01/23/2025 Harvard Creek Post Acute 519 W. Badillo St. Covina, CA 91722

F 0770 intervention for a resident. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Stool Specimen, revised October 2010, the P&P indicated, The purpose of this procedure is to collect a stool specimen for laboratory testing. The P&P indicated, Verify that there is a physician's order for this procedure . The following information should be recorded in the resident's medical record: Residents Affected - Few 1. The date and time the specimen was collected. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. The P&P indicated, Notify the supervisor if the resident refuses the procedure. Report other information in accordance with facility policy and professional standards of practice. 055544 Page 2 of 2