The nurse, identified as LVN A in inspection records, broke sterile protocol while caring for a resident on enhanced barrier precautions.
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Federal inspectors cited the nursing home for violations that posed immediate threat to resident health and safety following the October 22 incident.
But when federal inspectors arrived for a complaint investigation in November, they found the mat stored away from her room.
The resident was on a "nothing by mouth" diet due to difficulty swallowing.
The medication error at Karcher Post Acute was one of seven drug mistakes documented by federal inspectors during a November complaint investigation.
Federal inspectors found that nursing assistants repeatedly witnessed delays in colostomy care during a November complaint investigation.
The unnamed administrator told investigators she thought her predecessor would notify the state when he left.
The incident occurred on July 12, 2025, at Seneca Health Care Center.
Resident 1, who required a strict 1,440ml daily fluid limit due to heart failure, was given a large blue cup containing 360ml of water each night shift.
The resident's behavior deteriorated dramatically after he started smoking in September 2025.
The same resident's September records showed missing documentation for the steroid cream on four separate dates.
The facility's last Quality Assurance committee meeting occurred on July 17, 2025.