RN 1 spoke with the resident's family member at 4:47 a.m.
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The resident arrived at her doctor's office on October 13 with wet dressings covering two open wounds on her left foot.
The breakdown in communication centered on Resident #1, whose scheduled bath days were Monday, Wednesday, and Friday.
She told inspectors the facility had no proof residents were receiving their scheduled baths.
The resident never returned from the hospital.
Federal inspectors found the practice violated requirements to provide activities that meet residents' individual needs and preferences.
During a November 26 interview at 2:29 p.m., she admitted she had not started any specialized training in infection prevention.
When inspectors questioned nurses about the missing orders, staff admitted they weren't sure if orders were needed.
The resident stayed outside until 1 AM on October 8, repeatedly telling staff he was "enjoying the fresh air" and wasn't ready to come inside.
Medication Aide G parked the Station A cart close to both the TV room and dining area at 9:52 a.m.
The November 25 discovery at Parklane West Healthcare Center revealed a fundamental breakdown in medication security.
The attack occurred on October 8 between two residents at Lone Star Ranch Rehabilitation and Healthcare Center.