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.
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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.
The incident occurred November 14 during a transfer at Las Alturas Nursing & Transitional Care.
Federal inspectors found the facility failed to maintain accurate, comprehensive care plans for residents during a December 30 complaint investigation.
The facility's infection control nurse told inspectors on December 30 that she replaces the missing signs "at least once a week" because they routinely vanish.
San Marcos Rehabilitation and Healthcare Center failed to update its nurse staffing posting for 11 consecutive days, from December 19 through December 29.