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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.

His care plan from May 2024 specifically required assistance from two staff for bed mobility and transfers.

The hospital had discharged the patient specifically to continue intravenous Avycaz treatment through January 13.

The February inspection at Riverview Healthcare Center revealed systematic breakdowns in food safety and infection control that put residents at risk.

Resident 35, who had undergone craniotomy and required a tracheostomy, received heparin injections twice daily to prevent blood clots.

The facility violated reporting requirements in five of 27 abuse cases reviewed during a June 2024 complaint inspection.