The resident, identified in inspection records only as R117, had been at Haralson Nursing & Rehab Center for less than two weeks when the error occurred.
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Care plans are meant to be living documents, revised as a resident's condition changes.
He said he had asked for a new mattress multiple times.
The resident at Patapsco Healthcare had a sacral wound that had gotten worse.
The resident was sent to the emergency room by ambulance.
Federal inspectors arrived at the facility on September 10, 2025, responding to a complaint.
The required checks were not complicated.
The housekeeper looked at it and said she believed it was getting up under the floor tiles.
The incident at Mulder Health Care Facility happened on September 9, 2025.
It means inspectors concluded that the problem was not theoretical.
The dumpster doors and lids had been left open.
A nursing assistant had watched a colleague say terrible things to residents.