Verdugo Valley Skilled Nursing & Wellness Centre
2635 Honolulu Avenue, Montrose, CA 91020
Citation Number: 920006159
Citation Date: 6/11/2009
Violation Date: 2/28/2009
Class: AA
Penalty: $ 100,000

On 2/28/09, a resident died after putting a fire extinguisher in his mouth and discharging it. The resident, who had diagnoses of mental retardation and mental illness, had a recent history of suicide attempts. Twice earlier in February 2009 the resident put the fire extinguisher in his mouth and discharged it in an attempt to kill himself. Additionally, on 2/3/09, the resident wheeled his wheelchair into the middle of the street with a suicidal plan to be hit by a car. In response to the initial suicide attempts, the facility developed a care plan to monitor the resident frequently. However, there was no evidence how often the resident would be monitored or who would do the monitoring. At the time of the resident's admission in January 2009, the Regional Center reported to the facility that the resident required one-to-one supervision due to suicide attempts and serious behavioral problems. The facility was cited because it admitted and retained the resident despite not having an adequate plan to provide for his safety. This failure led to his death.
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