Del Rosa Villa
2018 N Del Rosa Ave., San Bernardino, CA  92404
Citation Number: 240006458
Citation Date: 8/11/2009
Violation Date: 6/1/2009
Class: AA
Penalty: $ 90,000

On 6/11/09, a 52 year old resident wheeled himself outside after midnight and hung himself by his belt on the parking lot fence. His death certificate listed the cause of death as "hanging." The resident, who suffered from schizophrenia and suicidal ideation, had been admitted from a hospital in May 2009 after attempting to kill himself by throwing himself in front of a car. His care plan at Del Rosa Villa stated that he was to be on "suicide watch at all times." At least 2 nursing staff members observed him leave the facility shortly before his death but made no attempt to stop or monitor him. They and other licensed nurses and CNAs responsible for his care reported they did not know about the suicide watch or the resident's history of attempted suicides. The facility was cited for failing to implement the resident's plan of care, which led to his death.