Other·March 11, 2026

§483.50(a)(2) The facility must- (i) 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. (ii) 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. §72523 Patient Care Policies and Procedures (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/15/2026, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1) had blood drawn for laboratory (lab) services without a physician's order, as well as having her hand roughed up when the blood was drawn. On 1/29/2026, the CDPH conducted an unannounced visit at the facility to investigate the complaint allegations. During the investigation, the CDPH determined Resident 1's blood was drawn twice based on the same physician's order placed on 12/11/2025. The facility failed to: 1. Ensure Resident 1 did not have her blood drawn on 1/12/2026 when the order to obtain labs had already been completed on 12/12/2025, per a physician's order dated 12/11/2025. 2. Ensure there was a policy and procedure (P/P) in place and/or a recognized practice that indicated what procedure the phlebotomist should follow when conducting blood draws. 3. Follow its Policy and Procedure (P/P) "Diagnostic Test Results Notification" dated 4/2025, that indicated to obtain laboratory and radiology services when ordered by a physician. These deficient practices 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. Resident 1, a 77 year old female, was admitted to the facility on 7/29/2025 with diagnosis of a urinary tract infection ([UTI] an infection in the bladder/urinary tract). A review of Resident 1's Minimum Data Set ([MDS] an assessment tool) dated 12/4/2025, indicated Resident 1's cognition was intact. The MDS indicated Resident 1 required set up or clean-up assistance with eating, oral hygiene and personal hygiene, supervision or touch assistance with upper body dressing, partial/moderate assistance with toileting hygiene, lower body dressing and putting on/taking off footwear. A review of Resident 1's Physician's Order dated 12/11/2025 indicated the following labs to be drawn for Resident 1. 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) A review of Resident 1's Laboratory Results for 12/2025 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 12/12/2025 at 12:43 p.m. A review of Resident 1's Nursing Progress Note dated 1/13/2026 indicated Resident 1 inquired about her lab results. The Nursing Progress Note indicated the facility's lab binder was checked and it was discovered 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. A review of Resident 1's Comprehensive Test Requisition with a collection date of 12/11/2025 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, 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 the white copy is removed and the yellow copy is left in the lab binder to indicate the labs were drawn/completed. The DON stated the yellow copies are not removed monthly but were kept in the lab binder until the binder becomes 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 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, the yellow copy stays 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. A review of the facility's P/P titled "Diagnostic Test Results Notification" dated 4/2025 indicated it was 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 that indicated what procedure the PB should follow when conducting blood draws. The facility failed to: 1. Ensure Resident 1 did not have her blood drawn on 1/12/2026 when the order to obtain labs had already been completed on 12/12/2025, per a physician's order on 12/11/2025. 2. Ensure there was a policy and procedure (P/P) in place and/or a recognized practice that indicated what procedure the phlebotomist should follow when conducting blood draws. 3. Follow its P/P "Diagnostic Test Results Notification" dated 4/2025, that indicated to obtain laboratory and radiology services when ordered by a physician. These deficient practices 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. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security and welfare of Resident 1.