The resident had been admitted to The Center at Grande on September 16 with conditions requiring careful monitoring. Her care plan specifically targeted complications from hypothyroidism and high blood pressure, with goals of preventing complications over the next 90 days through lab monitoring and physician reporting.
One week after admission, the facility was supposed to draw blood for CBC, CMP, TSH, and Vitamin D tests. Staff C attempted the blood draw on September 24 but failed twice. The next day, Staff C approached LVN D on the second floor, who had helped with difficult draws before.
LVN D also couldn't successfully draw the blood.
After multiple failed attempts by two different staff members, the resident refused to allow any more tries. The required lab work was never completed.
A handwritten statement provided by the facility and dated September 29 documented Staff C's version of events. The statement described the unsuccessful attempts but revealed no communication with supervisors or the ordering physician during the five-day period when the labs should have been drawn and reported.
The facility's Director of Nursing said during a November 16 interview that she wasn't aware of Staff C's failed attempts until after the resident had already been discharged. She confirmed that the one-week post-admission labs were never completed.
"Staff C and LVN D should have told her or the resident's doctor," the DON said.
The resident's physician, who had written the orders for the laboratory tests, said during a telephone interview that he had never been made aware the labs weren't completed. He said he hadn't been notified of the unsuccessful attempts to collect the specimen.
"He would have expected Staff C to inform her nurse manager or for the facility to contact him directly, so the matter could have been addressed," according to the inspection report. The physician stated that not doing the lab work "would never be an option" and said he wished he had been notified.
The DON acknowledged the facility didn't have a system in place to verify labs were completed, saying that hadn't been an issue before to her knowledge. She said the facility used its own staff to draw blood because everything was handled in-house rather than contracted out.
She described Staff C as competent, with no complaints, and said Staff C had been trained on how to draw laboratory specimens.
The facility provided an education record dated September 29 and signed by both the DON and Staff C. The training emphasized that if Staff C was unable to obtain blood from a patient, Staff C must immediately notify the charge nurse and the DON.
This training occurred five days after the initial failed attempts and three days after LVN D's unsuccessful try.
When inspectors attempted to interview LVN B, the staff member who had entered the lab orders, the telephone number provided by the facility wasn't working. No interview was obtained.
Staff C also didn't answer when inspectors called, and although they left a message with a callback number, no interview was completed.
The facility's laboratory services policy, revised in April 2024, requires staff to provide laboratory services when ordered by physicians and promptly notify ordering physicians of results that fall outside clinical reference ranges. The policy makes no mention of notification requirements when labs cannot be completed.
During the DON's interview, she initially said the one-week post-admission labs were "a mistake made by the staff when entering the order." Later in the same interview, she confirmed the labs were ordered correctly but were never drawn.
The resident's care plan had specifically identified the need to monitor lab results per physician's orders and report results to physicians as part of managing her thyroid condition. For her blood pressure management, the plan called for obtaining and monitoring lab work as ordered and notifying the physician of any changes in condition.
Neither monitoring goal could be met without the blood work that was never successfully drawn.
The inspection found the facility failed to ensure laboratory services were provided as ordered, affecting the resident's ability to receive appropriate medical monitoring during a critical post-admission period when baseline values needed to be established for ongoing care management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Center At Grande from 2025-11-16 including all violations, facility responses, and corrective action plans.