Gregory Ridge Health Care Center

During an interview on 10/7/25 at 12:30 P.M., CNA B said:-When sitting as one-to-one staff observation, he/she was to be within arm's length with the resident always in his/her sight.-He/she was never to close the resident's door unless he/she was in the room with the resident. -If the resident got up and walked around, he/she was to follow the resident wherever they went.-He/she was to converse with the resident, encourage the resident to use their coping skills if escalating and interact with the resident.

During an interview on 10/7/25 at 2:07 P.M., CNA C said:-He/she had sat one-to-one with the resident in the past.-The staff was to always keep the resident close, preferably within arm's length.-Staff were to at least keep them within close sight, 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 staff were never to close a resident's door unless they were in the room with the resident and close by the resident.-If the resident acted like they wanted to talk, the staff was supposed to talk with them, engage them in activities to keep them busy.-If the resident did not want to talk, the staff was not to force them.

During an interview on 10/7/25 at 3:36 P.M., the Psych NP said:-Resident #2 had been doing so well for so long, he/she was really upset that the resident self-harmed.-He/she had not been working with the resident for long as he/she just picked up the facility in August 2025, but he/she had seen him/her recently and the resident was very proud of going so long without self-harming.-The resident had a small behavior and the Psych NP saw him/her on 9/19/25 briefly, just to let the resident vent.-The resident had been using his/her coping mechanisms well, drawing and voicing his/her feelings to staff.-He/she did not see anything alarming when they spoke the day of 9/19/25.-He/she did not make a note that day as they just spoke briefly, and things seemed to be good.-The staff did notify him/her of the incident.-He/she was not aware the CNA sitting one-to-one with the resident on 9/19/25 kept the door shut during the night.-He/she would have expected the CNAs keep the door open and be able to see the resident at all times, documenting per the policy.

During an interview on 10/8/25 at 1:45 P.M., the facility Administrator and DON said:-CNA A was sitting with the resident on the night he/she self-harmed and knew better than to keep the door closed.-CNA A should have followed the resident out of the room when he/she left the room to go get help from LPN A.- LPN A and CNA A did not handle the situation or the resident as expected and were both terminated. -The expectation was that CNA A remained inside the resident's room at all times during one-to-one staff observation, followed the resident out of the room when he/she left the room, and that LPN A would 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. -Given the resident had told LPN A he/she was in distress, the DON and Administrator would have expected LPN A to have noticed the resident had a pillowcase wrapped around his/her arm and immediately intervened instead of preparing a PRN medication.-CNA A had been educated on staying with the resident inside the room and never closing the door when on one-one staff observation.

There was no reason CNA A should have closed the door and/or not had the resident within his/her sight at all times. MO002621570

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