Federal inspectors identified it during a complaint inspection at Care One at Newton completed September 3, 2025.
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Eleven days later, the doctor's order to treat the resident's bone condition still hadn't been entered into her medication record.
The resident, identified in inspection records only as R303, was admitted to Optalis Health and Rehabilitation of Troy in April 2025.
That was one of the findings federal inspectors documented during a September 4 complaint inspection at the Burke County facility.
Federal inspectors cited the 247 E.
The inspection, triggered by a complaint and conducted September 3, 2025, centered on an incident that occurred August 28 at Thryve of Burbank.
Not a phone call to the attending physician.
The first incident involved Resident 1 and Resident 2.
On August 10 alone, the resident received doses at 12:30 a.m., 4:00 a.m., and 8:00 p.m.
The violation, cited at a level of minimal harm or potential for actual harm, affected a small number of residents.
He left a message to pass along in the morning report.
The sequence of events, reconstructed from the inspection report, began in the early morning hours when transport picked R1 up from the facility.