The Center At Grande
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
complications related to hypothyroidism over the next 90 days. Interventions: Monitor lab results per physician's orders and report results to physicians.-Focus (initiated 9/24/25) [Resident #1] had blood pressure. Goal: No complications related to high blood pressure over the next 90 days. Interventions: Obtain and monitor lab work as ordered by physician. Notify physician of any change in condition. Record
review of Resident #1's clinical records from 9/16/25 to 9/28/25 reflected no one week post admission: CBC, CMP, TSH, Vit.D. documentation or results. Record review of a handwritten statement, dated 9/29/25, provided by the facility, completed by Staff C indicated the following: On September 24, 2025, I [Staff C] attempted to draw blood from [Resident #1] for her one-week labs. Unfortunately, [Staff C] was unsuccessful after two attempts. So, on the next day [Staff C] went to [LVN D] that worked on the 2nd floor who had helped [Staff C] before on several occasions. However, [LVN D] was also unable to draw the blood successfully. At the next attempt to draw blood [Resident #1] refused because of so many failed attempts.
Record review of education/in-service record, date 9/29/25, and signed by the DON and Staff C, indicated
the following: If [Staff C] was unable to obtain blood from the patient, [Staff C] must immediately notify the charge nurse and either DON. During an interview on 11/16/25 at 4:00 p.m. the DON said the one-week post admission labs for CBC, CMP, TSH, and Vit.D. were a mistake made by the staff when entering the order. During an interview on 11/16/25 at 5:23 p.m. the DON said Resident #1's one week post admission CBC, CMP, TSH, Vit.D labs were not done. The DON said she was not aware of what [Staff C] did until after [Resident #1] discharged . The DON said Staff C and LVN D should have told her or the resident's doctor.
The DON said they did not have a system in place to verify labs were done because that was not an issue before, to her knowledge. The DON said the facility used its own staff to draw blood because everything was in-house and not contracted. She said Staff C was good, no complaints, and DON trained Staff C had been trained on how to draw laboratory specimens. On 11/21/25 at 12:55 p.m., attempted to interview LVN B, the staff who entered the orders, the telephone number provided by facility was not a working number and no interview was obtained. On a telephone interview was attempted with Staff C, regarding the unsuccessful lab attempts for Resident #1. Staff C did not answer, and although a message with a call back telephone number was left, the interview was not obtained. During a telephone interview on 11/21/25 at 12:57 p.m., Resident #1's physician who wrote the order for one-week post-admission laboratory tests said
he had not been made aware that the labs ordered were not completed. He said he had not been notified of Staff C's unsuccessful attempts to collect the lab specimen. Resident #1's Physician stated 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. He further stated that not doing the lab would never be an option and expressed that
he wished he had been notified. Record review of revised facility laboratory services policy, dated 4/2/24, indicated, The facility stall: 1. Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws. 2.Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
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THE CENTER AT GRANDE in TYLER, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TYLER, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE CENTER AT GRANDE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.