On his fourth day in the facility, the man was visited by family members who raised concerns that his urine was dark.
The family said staff had confirmed the presence of blood in the urine, but then changed the bag used to an opaque bag.
On the fifth day the man's son complained about his father's standard of care.
"The dissatisfaction with [the man's] care included his family members finding him in soiled clothing, and his being unable to reach his call bell for assistance."
The report found the nurses showed poor judgement and lack of nursing skill, and also failed to adequately document the care the man required.
"I consider that [the Ultimate Care Group Ltd] did not did not provide sufficient support for staff or take sufficient steps to ensure that [the man] was provided with appropriate care."
The report recommended that the company, nurses and the rest home apologise to the man's family and that they make changes to ensure its standard of care was improved.