On 9/17/2019, during an investigation of an unrelated complaint, a 59 year old male resident with mental illness was observed in the facility pacing with bleeding from the left side of his face and body. The resident had been left unsupervised on a patio for smoking and fell while trying to pick up discarded cigarette butts. The resident was known to be at risk for falls and required one-person assistance while walking and supervision while smoking. On 9/17, the resident was left alone by a nurse who “had a tendency to leave the facility before the end of her shift” and before other staff could provide needed supervision to residents. The resident was sent to the hospital for treatment and the facility was cited for failing to: implement the resident’s care plan, provide adequate supervision, and perform “routine resident checks” to maintain resident safety and well-being.
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