Consumer NZ is calling for an independent inquiry into rest homes after an elderly resident soiled herself while waiting almost three hours to go to the toilet.
Freda Love was also found by son Robert Love in her urine-soaked bed on many occasions at St Kilda Care Home in Cambridge.
In one instance on October 24 last year the 92-year-old was shivering under a thin shawl in a urine-soaked bed with the window open and the call bell out of reach.
Tauranga resident Robert Love said his mother could not walk but she had enjoyed robust health until moving to the Bupa Care facility last year.
She died in Waikato Hospital in February.
"On average every 11 days a significant, serious incident took place which either caused her pain and suffering or put in jeopardy her health and wellbeing," he said.
Love won a Disputes Tribunal case against Bupa Care Services which has been ordered to pay him $10,000 for failing to deliver reasonable standards of care.
He documented 14 incidents, largely concerning the indwelling catheter [IDC] Freda Love wore for bladder control.
Love said the drainage tube was often not taped to his mother's leg which would dislodge the tube and pull an inflated balloon from his mother's bladder, leading to pain and wet beds.
He also said she had a sticking plaster put on raw skin on her buttocks and had been moved every two hours in the night to prevent pressure sores, which caused great discomfort.
Another problem was the design of the premium room Love had paid a higher amount for, because in the summer months it reached up to 30C in the middle of the day.
Love bought a portable airconditioning unit and a fan, and Bupa installed a sun filter which made the room dark, but these did not help.
He said it resulted in his mother suffering respiratory difficulties, dehydration and fungal infections and the tribunal referee accepted Freda Love lived in dark, hot and humid conditions.
On November 14 Freda, who lived at St Kilda Care Home for five months, needed to use the commode but because of insufficient staff available she waited two hours and 50 minutes.
By the time she was attended to her bowels had moved. The tribunal decision said Bupa accepted Freda should have been toileted without delay and apologised to Robert Love, however it was "unaware she had been left sitting in faecal matter".
Robert Love said it was not an isolated incident.
"People might ask why did I allow this to take place for so long? They kept offering me assurances things would change but they didn't."
Bupa was ordered to refund Love the $8112 he paid for the premium room and money for travel and expenses associated with having to travel to St Kilda to help his mother.
The tribunal found the room was not fit for purpose, the ratio of one staff to every 10 residents was not suitable, that Bupa had breached its obligations under the Consumer Guarantees Act to provide services with reasonable care and skill, and that it breached its contract with Love.
Consumer NZ chief executive Sue Chetwin said rest homes received significant public funding and when they failed to deliver services to required standards, they needed to be held accountable.
A Bupa spokeswoman said it "regrets distress the resident endured and apologises to the family".
"The care of our residents is our highest priority, and we treat these matters very seriously."
Bupa was continuing to review the ruling and acknowledged there were some instances and aspects where it should have done better, she said.
"We have installed shading to skylights in the home to minimise heat from the sun, which is currently being monitored.
"We have worked to put better practices and policies in place for our residents, including improved management of continence care.
"We realise that these improvements to practice in no way make up for the standard of care delivered in this instance, but we are taking all possible steps to demonstrate learnings from this incident."
The Health and Disability Commission said it had dealt with two complaints from Robert Love about his mother's care in 2015 and 2016 but they did not relate to St Kilda Care Home.