Health inspection·January 30, 2026

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a duplicate blood drawn was not conducted on one sampled resident (Resident 1) on 1/12/2026 when the order to obtain labs had already been completed on 12/26/2026. This deficient practice resulted in an unnecessary and duplicated blood draw on Resident 1 without an order from the physician to obtain blood work on 1/12/2026. This deficient practice had the potential to cause anemia, physical injury, and lack of physician oversight.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of a urinary tract infection ([UTI] an infection in the bladder/urinary tract). During a review of Resident 1's Minimum Data Set ([MDS] an assessment tool) dated 12/4/2025, the MDS indicated Resident 1's cognition was intact. During a review of Resident 1's Physician's Order dated 12/11/2025, the Physician's Order indicated for Resident 1 to have the following labs drawn: 1. A Basic Metabolic Panel ([BMP] a common blood test used to measure a person's overall health). 2. A Complete Blood Count ([CBC] a common blood test that measures the types and numbers of cells in the blood) During a review of Resident 1's Laboratory (lab) Results for 12/2025, the Lab Results indicated Resident 1's labs were collected on 12/11/2025 at 4:25 a.m., and the results were reported to the facility on [DATE] at 12:43 p.m. During a review of Resident 1's Nursing Progress note dated 1/13/2026, the Nursing Progress note indicated Resident 1 inquired about her lab results. The Nursing Progress note indicated the facility's lab binder was checked and it was discovered that the phlebotomist (PB) mistakenly drew labs from Resident 1 on 1/12/2026 based on a physician's order dated 12/11/2025, that had already been completed on 12/11/2025 with results dated 12/12/2025. During a review of Resident 1's Comprehensive Test Requisition with a collection date of 12/11/2025, the Comprehensive Test Requisition indicated it was signed and dated by the PB on 1/12/2026 to indicate a BMP and CBC were collected again without a new Requisition for 1/2026. During an interview on 1/29/2026 at 2:09 p.m., the Director of Nursing (DON) stated when a physician orders labs for a resident the lab requisition form, that consist of a yellow and white copy, is kept in the facility's lab binder. When the PB draws the resident's blood they remove the white copy and leave the yellow copy in the lab binder to indicate the lab drawn/completed. The DON stated the yellow copies are not removed monthly but are kept in the lab binder until the binder gets full. During an interview on 1/30/2026 at 8:57 a.m., the Assistant Director of Nursing (ADON) stated she spoke to the PB (date unknown) who told her she did not pay attention to the color of the forms in the lab binder and only looked at Resident 1's name on the lab requisition form, she (PB) stated she mistakenly drew Resident 1's blood on 1/12/2026. During an interview on 1/30/2026 at 3:25 p.m., the DON and ADON stated the previous lab requisition forms should have been removed from the lab binder which would have prevented the PB from mistakenly drawing Resident 1's blood. During an interview on 2/6/2026 at 11:12 a.m., the PB stated she remembered seeing both a white and yellow copy of the lab Page 1 of 2 555070 555070 01/30/2026 Southland 11701 Studebaker Road Norwalk, CA 90650

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requisition in the facility's lab binder (1/12/2026) and thought the white form was still in the lab binder because Resident 1 had refused or was not available when the lab was originally ordered (12/11/2025). The PB stated when the lab draw is completed the white copy should be removed from the lab binder and taken with the PB when they leave the facility, the yellow copy would stay in the facility's lab binder indicating the labs were drawn. The PB stated she did not clarify the date that was on the lab requisition with facility staff because there was nobody at the nurse's station. During a review of the facility's Policy and Procedure (P/P) titled Diagnostic Test Results Notification dated 4/2025, the P/P indicated it is the policy of the facility to obtain laboratory and radiology services when ordered by a physician. The P/P indicated laboratory and radiology services will be arranged and completed as ordered. The facility was not able to produce a P/P or practice to indicate what procedure the PB should follow when conducting blood draws. 555070 Page 2 of 2