The discovery at Winfield Rehab & Nursing prompted federal inspectors to interview seven staff members over two days in October.
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Staff must also use gowns and gloves during high-contact care activities like changing briefs, assisting with toileting, and wound care.
Despite facility policies requiring two-person assistance for high-risk residents, the assistant worked alone.
The resident told federal inspectors in September that he didn't receive his lidocaine patch roughly one day out of every five.
Country Care Manor blocked the resident's return after a hospitalization that began October 17, 2025, according to a federal inspection completed November 21.
The medication violation at Cross Timbers Rehabilitation and Healthcare Center exposed confusion among nursing staff about basic medication safety protocols.
The same stale information remained posted when they checked again an hour later.
The patient required substantial help with transfers due to complications from an ischemic stroke and arteriovenous malformation in her brain.
Resident #1 fractured his right femur sometime around September 29th.
The problems centered on how nursing staff handled incidents involving two residents in September and October.
The resident scores 9 on cognitive assessments, indicating moderate impairment, and requires total assistance with bowel and bladder incontinence.
Federal inspectors found the facility failed to ensure proper immunizations for two residents during a complaint investigation in November.