The 43-bed Tabor Manor Care Center has struggled with a failing call light system since mid-December, federal inspectors found during a February visit.
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Her medical conditions include depression, muscle wasting, and being unsteady on her feet.
When the family member arrived at the facility and walked past staff in the hallway, they found the resident needed to be changed and required a new gown.
The physician ordered 20 repetitions, three sets each, five days per week.
When the nursing assistant tried again to put the sock on, the resident screamed and pulled her left leg away, telling the assistant not to touch her leg.
The aide changed gloves twice during the procedure without washing her hands, creating potential for cross-contamination.
The Activity Director reported to the Director of Nursing that a student had been touched inappropriately, with another student witnessing the incident.
The nurse never changed gloves.
Instead, they found metformin, a diabetes medication.
The violations centered on two residents with serious medical conditions requiring enhanced barrier precautions.
The facility's own policy requires staff to answer call lights immediately, but no longer than five minutes.
The 83-year-old resident arrived at the facility on a Tuesday with a drain tube inserted in her abdomen following surgery for a perforated duodenal ulcer.