The September 19 incident at Gregory Ridge Health Care Center occurred during what's called one-to-one staff observation, where an aide is supposed to stay within arm's length of a suicidal resident at all times. Instead, CNA A closed the door and positioned themselves in the hallway outside.
The resident had been doing well for months without self-harming and was proud of that progress, according to the facility's psychiatric nurse practitioner. Earlier that day, the resident had experienced what staff described as a "small behavior" and briefly spoke with the psych NP to vent feelings.
Around 11:30 that night, the resident left their room and approached LPN A at the nurses' station, saying they were "in distress." The licensed practical nurse told the resident to return to their room while she prepared a PRN medication.
The resident went back to the room, where CNA A was supposed to be providing constant supervision.
What happened next revealed the breakdown in the facility's suicide prevention protocols. CNA A had closed the resident's door and was sitting outside in the hallway. The resident, alone inside the room, wrapped a pillowcase around their arm.
When the resident emerged from the room bleeding, they found LPN A in the hallway and told her what had happened. Only then did LPN A notice the pillowcase wrapped around the resident's arm and intervene.
"He/she was so glad the resident followed directions to go to the nurse for help as he/she was afraid the resident could have bled out had the resident not gotten scared of the bleeding," LPN A later told investigators.
The psychiatric nurse practitioner was upset when notified of the incident. The resident "had been doing so well for so long" and had been effectively using coping mechanisms like drawing and talking to staff about feelings.
"He/she was really upset that the resident self-harmed," investigators noted. The psych NP had only recently begun working at the facility in August 2025 but had observed the resident's pride in going so long without self-injury.
Federal inspectors interviewed multiple staff members about the facility's one-to-one observation policies. CNA B explained the requirements: stay within arm's length with the resident always in sight, never close the door unless inside the room with the resident, follow the resident wherever they go, and engage them in conversation or activities.
CNA C, who had previously provided one-to-one observation for the same resident, described similar protocols. Staff were supposed to keep residents "close, preferably within arm's length" and "close enough that if the resident tried to harm themselves or escalated to the point of self-harm they were to have been able to stop the resident."
The psychiatric nurse practitioner told investigators he was unaware that CNA A had kept the door shut during the night shift. He expected CNAs to "keep the door open and be able to see the resident at all times."
Both the CNA and LPN involved in the incident were terminated, according to the facility administrator and director of nursing. They said CNA A "knew better than to keep the door closed" and should have followed the resident out of the room when they left to seek help.
The administrator and DON criticized LPN A's response as well, saying she should have "shown more urgency when the resident stated he/she was in distress, including asking questions of the resident, providing non-pharmacological interventions and more closely assessing the resident's physical state."
They noted that given the resident's statement about being in distress, LPN A should have immediately noticed the pillowcase wrapped around the person's arm instead of focusing on preparing medication.
The facility's own policies required CNA A to stay inside the room at all times during one-to-one observation and never close the door. "There was no reason CNA A should have closed the door and/or not had the resident within his/her sight at all times," administrators told investigators.
Federal inspectors classified the violation as immediate jeopardy to resident health and safety. The resident who had been proud of months without self-harm was left bleeding in their room while the person assigned to protect them sat outside a closed door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gregory Ridge Health Care Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
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