Columbia Manor Health & Rehabilitation sent the resident to the hospital on August 27 for fluid leakage from their skin.
Nursing Home News — Page 731
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Federal inspectors found the resident had dried feces on her buttock and a brief fully saturated with urine and feces.
Quarter-sized holes in the foam sealing around the units allowed daylight to stream through, compromising the rooms' environmental controls.
Resident 4 told inspectors he often had to monitor his room's entrance to prevent Resident 1 from entering.
The resident in question had been assessed as having full decision-making capacity in a June medical examination.
Federal inspectors who visited in September found the facility had substantiated both incidents as abuse but failed to implement adequate protections.
Her care plan documented impaired decision-making, memory loss, and a history of falling.
Licensed practical nurse #5 told the surveyor she believed the resident was on "enhanced barrier precautions" because of a catheter.
The resident's oxygen saturation had dropped to 80 percent at 9:20 a.m.
The temperature violated the facility's own policy requiring hot foods to reach at least 120 degrees at the point of service.
The electronic devices monitor residents' movements and can trigger alarms if they attempt to leave designated areas.
"It had been hot and muggy, and they did not want to smell," the resident told inspectors on September 5.