The violation centered on Resident #1, who required enhanced barrier precautions due to an infectious condition.
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Federal inspectors discovered the abandoned cart at Lone Star Ranch Rehabilitation and Healthcare Center on December 29 at 8:19 AM.
The nurse's progress notes stated: "Respiratory: Difficulty breathing noted.
Three cooks and two dietary aides signed acknowledgment forms.
Employee 1, a certified nursing assistant working through a staffing agency, put Resident 1 to bed around 2 PM on December 15, 2025, at Homeland Center.
The resident told the ombudsman he wanted to return to the nursing home.
When asked why the drainage bag shouldn't touch the floor, the registered nurse caring for the patient said she didn't know how to prevent it.
The incident at Autumn Creek Post Acute involved a resident with stroke-related left side weakness who needed assistance with care.
Staff must do all the work for his toileting, lower body dressing, putting on shoes, showering, and turning in bed.
The missing document contained the resident's explicit instructions about resuscitation efforts.
The form is supposed to tell residents and families exactly how many nurses are working each shift each day.
The resident, who depends on staff for all daily care and mobility needs, kept a plastic container filled with over-the-counter medications within arm's reach.