The resident, identified as R901 in state inspection records, had been admitted to the facility following hospitalization for a left ankle fracture. Their medical conditions included intellectual disabilities, pneumonia, and anxiety disorder. They had been living in a group home before the hospitalization and had a family member serving as their guardian.
On August 18, 2025, a physician ordered multiple lab tests for the resident: a urinalysis with culture and sensitivity to rule out infection, a complete blood count, and a B-type natriuretic peptide test to rule out heart failure. None of these tests were ever performed.
Two days later, on August 20, an interdisciplinary team note documented "no new orders, no new labs." The resident's electronic medical record contained no lab results for any of the tests ordered on August 18.
On August 24, the resident fell at the facility and was transferred to the hospital.
The Director of Nursing acknowledged the facility's failure during an October 8 interview with state inspectors. "The DON reported that the facility has missed to draw the lab as ordered for R901 and they had identified that the facility was not compliant after R901 was transferred to the hospital," according to the inspection report.
The nursing director explained that staff only discovered their mistake while reviewing the resident's medical records after the August 24 hospital transfer. At that point, they initiated what's called a Past Non-Compliance process to address the violation.
A complainant contacted state authorities about the missed lab work, confirming the facility's failure to follow through with the physician's orders during an October 3 phone interview.
The facility's own protocol, last revised in March 2014, clearly outlines the process: physicians identify and order diagnostic testing, staff process the requisitions and arrange for tests, and laboratories report results back to the facility. None of these steps occurred for this resident's August 18 orders.
The missed tests were particularly concerning given the resident's medical complexity. Urinalysis with culture and sensitivity testing is standard for detecting urinary tract infections, which can cause serious complications in elderly residents and those with intellectual disabilities. The B-type natriuretic peptide test helps diagnose heart failure, a potentially life-threatening condition requiring immediate intervention.
The facility held an emergency Quality Assurance and Performance Improvement meeting on August 24, the same day the resident was hospitalized. They set a compliance date of August 25 to correct the violations.
According to the facility's Past Non-Compliance report, they were not following their own lab policy between August 18 and August 24 - exactly the period when the resident's ordered tests should have been completed.
State inspectors found the facility had implemented corrective actions and was maintaining compliance during their October visit. The facility continued conducting audits to monitor their lab processes.
The violation was classified as causing "minimal harm or potential for actual harm" to residents. However, the failure occurred during a critical period when the resident's condition was apparently deteriorating, culminating in the fall that required emergency hospitalization.
The case highlights how administrative oversights in nursing homes can leave vulnerable residents without necessary medical monitoring. For a person with intellectual disabilities who may not be able to communicate symptoms clearly, timely lab work becomes even more crucial for detecting infections or other medical problems.
The facility's acknowledgment that they only caught their mistake after reviewing records following the hospitalization raises questions about their daily monitoring systems. The six-day gap between the physician's orders and the resident's fall suggests no staff member checked whether the lab work had been completed during that critical period.
While the facility has since implemented corrective measures and demonstrated compliance to state inspectors, the resident experienced nearly a week without the diagnostic testing their physician deemed necessary for their care.
The inspection was conducted as part of a complaint investigation, indicating concerns about the facility's lab practices had reached state authorities through outside reporting.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villa At Green Lake Estates from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for The Villa At Green Lake Estates
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