Resident 35 arrived at Shoreline Healthcare Center in March with a left hip fracture and small heel blisters.
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Cook [NAME] pulled broccoli, carrots, zucchini and cauliflower from the failing freezer at Beachside Post Acute at 4:00 a.m.
The insulin was supposed to be given before meals.
On July 20, 2024, staff attempted to change the dressing around the catheter site.
The first resident, identified as R10, had been diagnosed with pneumonia and respiratory failure according to her December 2024 assessment.
The violation centered on the facility's systematic failure to verify and implement hospital discharge orders when residents returned from medical treatment.
The drug can destroy infection-fighting blood cells, making regular monitoring critical for patient safety.
The resident's care plan specifically required two staff members for all turning and repositioning in bed.
The scene at The Rehabilitation Center on Pico revealed a medication crisis that federal inspectors called immediate jeopardy.
By the time a federal inspector arrived six weeks later, the medical director said he had never heard of the recommendation.
She eventually required emergency hospitalization on January 27 with an infected amputation site and "intractable pain," hospital records show.
The resident at Care One at Millbury had developed a large genital slit from his long-term catheter.