The resident at Jefferson Manor Nursing and Rehab Center told state inspectors on September 3 that he wasn't pleased with his room's conditions.
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The facility's own policy required immediate updates following such events.
Normal oxygen saturation levels typically range from 95% to 100%.
The facility violated fundamental infection prevention measures that form the backbone of nursing home safety.
The resident, identified in records as Resident #2, was discovered at 7:50 a.m.
The resident had a physician's order for do-not-resuscitate status on file at Good Samaritan Society Sioux Falls Center.
The resident had been at the facility for more than two years and was previously considered safe to go outdoors independently.
The August 5 incident began around 8:30 pm when a medication aide couldn't locate Resident #1 for his evening medications.
The facility's own policy, last updated in September 2010, spelled out detailed requirements for when staff must wash their hands and use protective equipment.
The patient's fall risk score of 10 placed them in the facility's high-risk category, according to the nursing home's own fall prevention policy.
When both residents were inside, Resident #2 closed the door on Resident #3.
The facility received a phone call between 10:00 and 10:30 a.m.