Gregory Ridge Health Care Center

In the surveyor’s words

From the most serious findings on record at Gregory Ridge Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 17, 2026

  Based on interview and record review, the facility failed to provide adequate supervision to one sampled resident (Resident #3) who had a known history of chronic suicidal ideations and self-harm. The facility failed to implement the facility policy and physician recommendation to provide one on one (1:1) supervision to a suicidal resident and the physician recommendation to remove all items from the resident space that he/she could self-harm with. On [DATE], 1:1 monitoring was not provided by a designated staff assigned to the resident and at 12:50 P.M., the resident was found in his/her resident room with a call light cord around his/her neck which hung from the ceiling. […]

• Immediate jeopardy, isolatedF689May 20, 2026

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure Resident #1's physical, mental, and psychosocial well-being in accordance with the resident's identified needs related to mental health care needs and substance use disorders. The facility failed to implement interventions to reduce known hazards and risks to the resident. Facility staff were aware of the resident's family's concern the resident needed a legal guardian to assist them in making health care decisions in September 2025. The facility was aware of behaviors that were escalating and becoming dangerous with the resident leaving the facility all day, taking illicit drugs and drinking alcohol. […]

• Immediate jeopardy, isolatedF689Nov 18, 2025

  Based on interview and record review, the facility failed to provide adequate supervision, when the facility staff did not provide ordered 1 on 1 supervision in direct line of sight per policy for one sampled resident (Resident #2) who had a known history of self-harm. On 9/19/25, the resident was able to self-harm by cutting him/herself on the left arm with scissors which resulted in a 7cm x 3-centimeter (cm) laceration. The resident was afraid because he/she could not get the bleeding to stop and the laceration required 8 sutures. The facility census was 108 residents.The Administrator was notified on 10/8/25 at 11:30 A.M. of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 9/19/25. […]

• Immediate jeopardy, isolatedF740Apr 15, 2025

  Based on observation, interview, and record review, the facility failed to provide appropriate treatment and behavioral health services for one sampled resident (Resident #204) who had a known history of self-harm. The resident admitted to the facility on [DATE], with a history of self-harm and recommendation of intensive monitoring. The facility staff failed to consistently implement recommendations made in the resident's Pre-admission Screening and Resident Review (PASRR) assessment and the plan of care related to behavioral health services to ensure highest practicable well-being. […]

• Immediate jeopardy, isolatedF600Dec 23, 2024

  Based on observation, interview, and record review, the facility failed to keep one sampled resident (Resident #9) free from abuse. On 12/8/24 Certified Nursing Assistant (CNA) K kicked at Resident #9. Resident #89 grabbed Resident #9 by the neck out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Abuse and Neglect policy dated 1/5/23 showed: -Physical abuse included purposely beating, striking, or injuring a resident. It included but was not limited to hitting and kicking. -Verbal abuse included using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples included yelling at a resident. […]