The September incident at Advanced Center for Nursing & Rehabilitation left doctors unaware that critical lab work had gone undone for nearly two weeks. Federal inspectors found similar problems with a second resident whose blood tests simply vanished from the medical record.
Resident #5 arrived with a cascade of serious conditions. Pneumonia ravaged her lungs while acute and chronic respiratory failure starved her tissues of oxygen. Congestive heart failure weakened her heart's ability to pump blood. Anemia left her with too few healthy red blood cells to carry what oxygen remained. Severe fluid buildup swelled tissues throughout her body, and her blood calcium levels had dropped dangerously low.
On September 10, her physician ordered a Basic Metabolic Panel and Complete Blood Count with differential to be drawn two days later. The tests would have revealed crucial information about her kidney function, electrolyte balance, and blood cell counts — all critical for someone fighting multiple life-threatening conditions.
The blood was never drawn.
Nobody documented why. Nobody recorded that Resident #5 had refused the procedure. The tests simply didn't happen, and her medical record contained no explanation.
For nearly two weeks, her physician remained unaware that the ordered lab work had never been completed. Only when the doctor wrote a new order on September 25 — this time for a Comprehensive Metabolic Panel and CBC to be drawn the following day — did anyone obtain her blood. Those results showed no significant abnormalities.
But inspectors found no record of what her condition might have been during those missing two weeks, when her multiple serious diagnoses went unmonitored.
Regional Nurse Licensed Practical Nurse #5 told inspectors on September 30 that he couldn't locate any documentation showing the blood work had been obtained for Resident #5. He explained that the blood work should have been drawn according to the physician's order, or the provider should have been notified so the test could be rescheduled with a new order.
The facility's own policy, last updated in 2018, requires that all blood work be obtained and processed to ensure "resident safety, accuracy, timeliness and professional standards of quality." Results must be returned to the ordering physician and entered into the resident's medical record. Nursing staff must promptly review results and notify physicians of abnormal or critical values.
None of that happened for Resident #5.
The pattern repeated with Resident #11, whose medical history included alcohol abuse, hypothyroidism, and peripheral vascular disease. The thyroid condition meant his body wasn't producing enough hormone to regulate metabolism. His peripheral vascular disease had narrowed blood vessels due to deposit buildup, reducing blood flow to his limbs.
On August 30, his physician ordered a Basic Metabolic Panel and Complete Blood Count with differential to be drawn on September 3. Like Resident #5, his blood work never materialized. Inspectors found no documentation that the tests were completed and no record that Resident #11 had refused them.
The missing lab work left his physician without crucial information about how his multiple conditions were progressing. Blood tests could have revealed whether his thyroid medication was working properly, whether his kidney function remained stable, and whether his blood cell counts suggested any complications from his other conditions.
LPN #5 told inspectors he couldn't locate documentation showing Resident #11's blood work had been obtained either. The same nurse who couldn't explain what happened to Resident #5's tests also couldn't account for Resident #11's missing lab work.
When inspectors interviewed the Nurse Practitioner on October 2, he expressed surprise at learning the blood work had never been completed for either resident. He told inspectors that physician's orders should have been followed, or he should have been notified that the blood work wasn't obtained so he could place new orders.
The Nurse Practitioner explained that nursing staff should have documented in the clinical record why the blood work wasn't obtained, whether they had notified the provider, and any follow-up orders that resulted.
But the medical records contained none of that documentation.
The facility's Laboratory and Blood Work Services policy explicitly states that blood work services must be provided "in accordance with physician's orders, resident rights, federal regulations and Connecticut Public Health code standards." The policy promises that results will be returned to ordering physicians and entered into residents' medical records.
For both residents, the facility violated its own written procedures.
The inspection, completed October 2, found that Advanced Center failed to ensure blood work was obtained per physician's orders for two of twenty-one randomly selected residents. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
But the impact extended beyond the two residents whose tests went missing. The breakdown in basic laboratory procedures meant physicians were making treatment decisions without complete information about their patients' conditions.
Resident #5's multiple serious diagnoses — from heart failure to respiratory problems — required careful monitoring through regular blood tests. The missing two weeks of lab data created a gap in her medical care that could have affected treatment decisions.
Resident #11's thyroid condition and vascular disease similarly needed ongoing laboratory monitoring. Without the ordered blood work, his physician couldn't assess whether his treatments were working or if his conditions were worsening.
The facility's own nursing staff couldn't explain what had happened to either set of missing tests. The Regional Nurse responsible for overseeing laboratory procedures had no documentation to show the work was done. The Nurse Practitioner treating both residents remained unaware that his orders had gone unfollowed for weeks.
Advanced Center's failure to follow physician orders for basic blood work left two vulnerable residents with serious medical conditions unmonitored during critical periods of their care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Center For Nursing & Rehabilitation from 2025-10-02 including all violations, facility responses, and corrective action plans.
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