Health inspection·October 29, 2025

F689 Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72523, Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to ensure Resident 1, who had a history of major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life) was properly and adequately monitored in accordance with the facility's policies and procedures (P&P), titled, “Security Wand 15-Minute Room Checks” and “Zoning and Supervision.” This failure resulted in Resident 1 gaining the opportunity to hang himself to attempt suicide (the act of intentionally causing one's own death) while being inside Resident 1’s room (Area 2). The failure resulted in resuscitation (to revive from apparent death or from unconsciousness) and a transfer to the General Acute Care Hospital (GACH) where Resident 1 was declared brain dead two days later. A review of Resident 1’s Admission Record (AR) indicated, Resident 1 was a 31-year old male who was admitted to the facility on 3/8/23 with multiple diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior), bipolar (extreme mood swings between periods of mania [elevated mood] and depression) type, other psychoactive substance abuse (the harmful or hazardous use of drugs that alter brain function, affecting mood, perception, cognition, and behavior), uncomplicated, and major depressive disorder, recurrent, unspecified. A review of Resident 1’s History and Physical (H&P), dated 3/12/25 indicated, Resident 1 had a flat affect (lack of emotional expression), was confused, and with tangential thought process (a pattern of thinking where a person's thoughts frequently stray from the main topic of conversation or question). A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 6/3/25, indicated Resident 1’s cognition was intact.  The MDS indicated Resident 1 had potential indicators of psychosis behavior (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality).  The MDS indicated, Resident 1 was assessed independent in activities of daily living and was taking antipsychotic and antidepressant drugs and had one day of psychological therapy (any licensed mental health professional). A review of Resident 1’s Order Summary Report (OSR), dated 7/20/25, the OSR indicated a transfer Resident 1 via 911 (emergency response system) ambulance to the GACH ER (Emergency Department) r/t (related to) being found unresponsive m/b (manifested by) resident attempting suicide by hanging. A review of the GACH’s ED Note Physician (EDN), dated 7/20/25, timed at 7:56 AM, indicated, Resident 1 was found in cardiac arrest (the heart suddenly and unexpectedly stops beating) at the facility, LKW (last known well) between 6:30 AM and 6:40 AM, found at 6:59 AM hanging from a sprinkler head and had ligature marks (a type of pressure mark or abrasion on the neck caused by a ligature [the act of binding or tying up with a cord or other material in cases of hanging or strangulation around neck]).  The EDN indicated EMS (Emergency Medical Services) reported Resident 1 was cyanotic (a bluish discoloration of the skin caused by a shortage of oxygen in the blood) and unresponsive in full cardiac arrest upon EMS’s arrival at the facility and Resident 1’s initial heart rhythm was asystole (flatline – when the heart’s electrical system fails entirely causing the heart to stop pumping).  The EDN indicated EMS was able to obtain ROSC (Return of Spontaneous Circulation - the moment when a patient in cardiac arrest regains their own heartbeat and blood flow) in the field but Resident 1 had another cardiac arrest.  A review of Resident 1’s Progress Notes (PN), dated 7/20/25, timed at 8:38 AM, indicated, at approximately 7 AM the Licensed Psychiatric Technician (LPT) was called on the radio (walkie-talkie device) by a staff (unnamed) to Area 2.  The PN indicated that the LPT entered Area 2 and observed Resident 1 hanging from the water sprinkler by a sheet and a code blue (an emergency code for a patient needing resuscitation) was called. A review of the GACH’s Discharge Summary (DS), dated 7/23/25, timed at 18:48 PM, indicated Resident 1’s multiple discharge diagnoses included strangulation via asphyxiation (when a person doesn't get enough oxygen in the body) resulting in cardiac arrest.  The DS indicated, Resident 1’s prolonged downtime (an extended period during which a patient experiences cardiac arrest) and evidence of cerebral edema (swelling of the brain) on the head CT (computed tomography – a diagnostic imaging test) showed findings and clinical examination consistent with brain death.  Resident 1 was declared brain dead on 7/22/25 at 2:55 PM. During an observation on 9/12/25 at 9:08 AM with the Program Director (PD) while inside Area 2, Area 2 was a 2-bed occupancy room with both beds having designated drapes (privacy curtains).  Area 2 had ceiling mounted sprinklers (pendent fire sprinklers - water sprinkler that sticks out from the ceiling) above both beds and in the restroom.  The sprinkler heads stuck out 4 to 5 inches from the ceiling.  During an interview on 9/12/25 at 9:36 AM with Certified Nursing Assistant (CNA) 2, CNA 2 stated CNA 2 entered Area 2 before 7 AM on the day of the incident when CNA 2 found Resident 1 hanging with a bed sheet (CNA 2 gestured around neck), with head down, eyes closed, both knees slightly bent, and both feet slightly on the floor.  CNA 2 stated, CNA 2 tried to wake Resident 1 up and called for help using CNA 2’s radio.  CNA 2 stated, CNA 3 and the Licensed Vocational Nurse (LVN) 2 came in “right away” and unhooked Resident 1, who was “dangling with the sheet.’’ CNA 2 stated staff started CPR (cardiopulmonary resuscitation - an emergency, life-saving technique used when a person's heart has stopped and is not breathing) until the paramedics (medical professionals who specialize in emergency treatment) arrived.  CNA 2 stated, per the facility’s policy, staff were to conduct room checks and observe the residents (in general) inside the resident’s room. During an interview on 9/12/25 at 10:15 AM with CNA 3, CNA 3 stated, CNA 3 heard CNA 2 on the radio calling out the Licensed Psychiatric Technician (LPT) and calling a code blue.  CNA 3 stated, CNA 3 immediately went to Area 2 and saw Resident 1 hanging from the sprinkler and Resident 1 was positioned slightly slumped over, head down, both knees slightly bent and both feet slightly on the floor. CNA 3 stated Resident 1 was “more pale white” in color.  CNA 3 stated, the distance between Resident 1’s neck to the sprinkler was about a foot long.  CNA 3 stated CNA 3 pulled Resident 1 up while LVN 2 and CNA 2 released the sheet around Resident 1’s neck, placed Resident 1 on the floor, and started CPR immediately.   A review of the surveillance video footage (SVF), on 9/12/25 at 11:28 AM, titled, Conference Room, dated 7/20/25, timed from 6:39 AM to 7:33 AM with the Director of Staff Development (DSD) indicated, CNA 2 was sitting on a chair at Area 3’s (room located next to Area 2) doorway while monitoring the Area 1 (west unit nursing station) hallway.  The SVF indicated the following timeline: 6:39:00 AM, Area 2 had 2 white chairs outside of Area 2 and CNA 1 was seated at Area 3’s doorway. 6:43:09 AM, Resident 1 came out of Area 2 with both hands inside Resident 1’s pant pockets and walked toward Area 1’s hallway passing CNA 1. 6:43:54 AM, Resident 1 turned around and entered Area 2.  CNA 1 remained seated at Area 3’s doorway. 6:50:45 AM, CNA 1 knocked on Area 2’s door and did not enter Area 2. 6:59:26 AM, CNA 2 entered Area 2. 7:00:32 AM, CNA 2 came out to Area 2’s doorway and flagged staff for help. 7:00:51 AM, LPT entered Area 2. 7:00:56 AM, CNA 4, LVN 2, and CNA 3 entered Area 2. 7:07:28 AM, Paramedics arrived and headed toward Area 2. 7:33:09 AM, Resident 1 was on a gurney being transported and taken by paramedics. During a concurrent interview and record review on 9/12/25 at 2:35 PM with the DSD  The DSD stated the facility has a Q 15-minute room check P&P (Security Wand 15 Minute Room Checks) indicating staff must enter each room to check and scan a device mounted inside the room by using a security wand (device used by staff to scan the mounted device located in the resident’s room that indicates Q 15-minute room checks were conducted). The DSD stated staff has to physically walk inside the rooms to check on the residents for the safety and wellness of the resident. During a concurrent interview and record review on 9/12/25 at 3:24 PM with the DSD, CNA 1’s Personnel Action Request (PAR), dated 7/25/25, was reviewed.  The PAR indicated, CNA 1 was terminated from the facility for violating company policy regarding safety.  The PAR indicated, CNA 1 failed to follow responsibilities [pertaining to] Q15 room check.  The PAR indicated on 7/20/25 from 6:00 AM to 7:00 AM Q15 minute room check must be done at least four times within the hour, and CNA 1 did not do [Q 15-minute [room] checks] all four times.  The PAR indicated the following timeline: 6:11 AM, [CNA 1] positioned himself in the doorway of Area 3. 06:15 AM, still sitting in the doorway of Area 3 (did not perform Q15 minute room check). 6:23 AM, went into Area 2 and came back to sit down in the doorway of Area 3. 6:30 AM, still sitting in the doorway of Area 3 (did not perform Q15-minute room check). 6:45 AM, still sitting in the doorway of Area 3 (did not perform Q15-minute room check). 6:50 AM, calling residents for breakfast in Area 1, but did not check Area 2. 6:55 AM, [CNA 1] left his area unattended.  The DSD stated the facility’s SVF showed CNA 1 did not get up to check Area 2 and that was the main reason why CNA 1 was terminated.   During a telephone interview on 9/15/2025 at 8:14 AM with CNA 1, CNA 1 stated “I got let go [terminated]” by the facility for not doing the routine Q 15-minute room check on Resident 1.  CNA 1 stated the last time CNA 1 entered Area 2 on 7/20/25 before 6:30 AM to answer the call light that came on from Area 2.  CNA 1 stated, Resident 1 and Resident 2 did not say anything [express any concerns] when CNA 1 answered the call light.   During a concurrent interview and record review on 9/15/25 at 10:47 AM with the DSD, the facility’s SVF, dated 7/20/25, timed at 6:00 AM to 6:43 AM was reviewed.  The SVF indicated the following timeline: 6:00:00 AM, CNA 1 walking in Area 1’s hallway. 6:05:33 AM, CNA 1 passed by Area 2. 6:13:13 AM, CNA 1 was seated in Area 3’s doorway. 6:23:34 AM, CNA 1 entered Area 2. 6:24:00 AM, CNA 1 came out of Area 2, looked up at the call light above door. 6:24:10 AM, CNA 1 went back to sit in Area 3’s doorway. The DSD stated, the last time CNA 1 entered Area 2 was at 6:23:34 AM.  The DSD stated, CNA 1 only went inside Area 2 once when CNA 1 should have at least entered Area 2 four times in “that hour window (6:00 AM to 7:00 AM)” to check on Resident 1 and Area 2.     The DSD stated, staff (in general) should physically enter the resident’s room to ensure residents are safe and sound, that “they’re (residents) breathing,” and to check the surrounding.  During an interview on 9/15/25 at 12:18 PM with CNA 2, CNA 2 stated, on 7/20/25, Resident 1’s privacy curtains were drawn (closed) around Resident 1’s bed up to the middle of the bed’s footboard when CNA 2 found Resident 1 hanging.  CNA 2 stated the staff had to visibly check “see them with your eyes,” the residents Q 15 minutes for the safety of the residents.   During an interview on 9/15/25 at 12:36 PM with the Director of Nursing (DON), the DON stated, to ensure resident safety, staff were supposed to check and locate the resident for the Q 15-minute room checks. The DON stated staff “must get up” and go inside the room to check on the residents even if the room was empty.  The DON stated, CNA 1 was terminated from the facility for not following the facility’s policy titled, Security Wand 15 Minute Room Checks. The DON stated CNA 1 did not get up to check Area 2 and staff was supposed to get up and “really” check the resident’s room. During an interview on 9/15/25 at 1:15 PM with the LPT, the LPT stated, the LPT heard CNA 2 call the LPT on the radio to come to Area 2.  The LPT stated the LPT saw Resident 1 hanging with a sheet tied to the sprinkler located on the ceiling and the LPT called for a code blue.  The LPT stated, CNA 1 was supposed to have “eyes on” Resident 1 for the Q15-minute room checks for Resident 1’s safety.  The LPT stated staff had to physically go inside the resident’s room during the Q15 room checks. A review of the facility’s P&P titled, “Security Wand 15 Minute Room Checks,” dated 2021, the P&P indicated, room checks included for the staff to knock before entering the room, checking bathrooms (open the door after knocking), and pulling curtains back to visually see the resident.   A review of the facility’s P&P titled, “Resident Rights to Humane Care,” revised date 2021, indicated, residents must be provided with the highest quality of care and dignity and the right to be free from abuse, neglect, and harm.   A review of the facility’s P&P titled, “Zoning and Supervision,” updated 5/1/23, indicated, the monitoring allowed the staff to account for each person and made sure that each resident was free from distress.  The P&P indicated, to check the rooms as scheduled and check the residents who were asleep to assure they were free of distress and for the NOC (night) shift to supervise surroundings and to be alert and pay attention to resident activity for the entirety of shift while on duty.   The facility failed to ensure Resident 1, who had a history of major depressive disorder was properly and adequately monitored in accordance with the facility's P&P titled, “Security Wand 15-Minute Room Checks” and “Zoning and Supervision.” This failure resulted in Resident 1 gaining the opportunity to hang himself to attempt suicide while being inside Area 2. The failure resulted in resuscitation and a transfer to the GACH where Resident 1 was declared brain dead two days later. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.