Health inspection·November 16, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a need to alter treatment for 1 of 4 residents reviewed for physician notification. (Resident #1) The facility failed to immediately notify the physician on 9/24/25 when they were unable to draw the blood successfully on Resident #1 for labs. This failure could place residents at risk for delayed diagnosis or altered medical management.Findings included: Record review of an admission record, dated 9/30/25, indicated Resident #1 was a 68 year female who admitted on [DATE] and discharged home with home health services on 9/28/25 with diagnoses including acute kidney failure (when the kidneys suddenly stop functioning, leading to a build-up of waste products in the blood), arthropathic psoriasis (a form of inflammatory arthritis that can affect people with psoriasis, causing joint pain, swelling, stiffness, and fatigue), congestive heart failure (a condition where the heart muscle is damaged and cannot pump blood efficiently to meet the body's needs), anemia (a condition where the body lacks enough healthy red blood cells or hemoglobin, which can cause symptoms like fatigue, weakness, and shortness of breath), hypertension (or high blood pressure, a condition where the force of blood against artery walls is consistently too high), and hypothyroidism (a common condition where the thyroid gland in your neck does not make enough hormones). Record review of an active orders summary report, dated 9/16/25, indicated Resident #1 had admission Labs CBC, CMP, TSH, Vit.D one time only for one week post admission for two days follow up with results with an order date of 9/16/25, start date of 9/23/25, and end date of 9/25/25. Record review of Physician order detail report, dated 9/16/25, and completed by LVN B, indicated Resident #1 had verbal orders for admission labs: CBC, CMP on admission and one week post admission: CBC, CMP, TSH, Vit.D. This order was signed by Resident #1's Physician and dated 9/17/25. Record review of admission MDS assessment, dated 9/20/25, indicated Resident #1 had clear speech, was able to make her self-understood by expressing ideas and wants; had clear comprehension. She had a BIMS score of 12 out of 15 indicating she had moderate cognitive impairment with thinking and memory. She required supervision or moderate assistance with most ADLs. Record review of Resident #1's undated revised care plan indicated the following:-Focus (initiated 9/16/25): [Resident #1] respiratory risk related to respiratory conditions. Goal: Respiratory risks related to pulmonary conditions/function will be minimized with interventions. Intervention (initiated 9/24/25): Notify physician of change in status. -Focus (initiated 9/24/25): [Resident #1] was at risk for cardiac complications due to Hypertension. Goal: will have no cardiac complications through review date. Interventions: and monitor lab work as ordered by physician and report results.-Focus (initiated 9/24/25): [Resident #1] had potential for complications from chronic kidney disease. Goal: [Resident #1] will have minimized risk for progression of comorbidities due to CKD. Intervention: Monitor lab values per physician's orders.-Focus (initiated 9/24/25): [Resident #1] at risk for complications r/t Hypothyroidism (under active thyroid). Goal: No Page 1 of 2 676443 676443 11/16/2025 The Center at Grande 3219 East Grande Boulevard Tyler, TX 75707

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 676443 Page 2 of 2