Based on record review and staff interview, the facility failed to obtain labs services as ordered by a physician for 1 (R #64) of 4 (R #53, R #64, R #85, and R #116) residents reviewed for [MEDICATION NAME] treatment. R #64 had and order for blood monitoring dated [DATE] that was not followed, and on [DATE] he had bloody nose and was sent to the ER. This deficient practice could have led to his death on [DATE]. The findings are: A. Record review of the physician's orders [REDACTED]. Record review of the R #64's clinical record revealed no results for this test was found. B. Record review of the resident's Progress Notes revealed the following: 1. [DATE] at 4:19 pm and 4:24 pm revealed R #64 was bleeding from his nose and the doctor ordered that he be sent to the hospital. 2. …
F504
Administration Deficiencies
Provide or obtain laboratory services only when ordered by the attending physician.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The harm level
How severely F504 is cited
0.0% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2100.0% | E— | F— |
| No harm, potential for minimal | A— | B— | C— |
In the surveyor’s words
What an F504 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview, and record review, the facility failed to ensure laboratory testing was performed timely as ordered by the physician for one (Resident A) of three sampled residents. This failure resulted in delayed identification of a gastrointestinal infection which affected the provision of treatment causing further decline in Resident A's health status. Findings: On (MONTH) 12, (YEAR), at 11:35 a.m., an unannounced visit to the facility was conducted to investigate a complaint related to infection control issues. On (MONTH) 12, (YEAR), Resident A's record was reviewed. …
Based on surveyor review of the closed record and interview of facility staff and an attending physician, it was determined that the facility staff failed to obtain a laboratory test for resident #2 as ordered. This finding was identified during a complaint investigation MD 472, which is valid. The findings included: On 05-11-15, review of the closed record revealed that resident #2 was admitted to the facility in January 2015 following a hospitalization . Further review of the physician's orders [REDACTED]. The nursing staff signed off on the Treatment Administration Record (TAR) that the laboratory test was completed on 01-26-15. …
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