Based on the review of clinical records, facility documentation, facility policies, and interview with residents and staff, it was determined the facility failed to ensure a resident's environment was free of accident hazards, and failed to ensure hazardous materials were not accessible to one of nine residents (Resident R1). Staff failed to provide supervision for Resident R1 with documented history of suicidal ideation and who voiced suicidal thoughts. This failure resulted in Resident R1 obtaining a disposable razor and cutting her/his wrist. This failure placed Resident R1 at risk for serious injury and resulted in an Immediate Jeopardy situation for Resident R1. This deficiency is cited as past non-compliance. Findings Include: Review of facility policy Safety and Supervision of Residents dated August 2024, revealed Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assurance Improvement Plan) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Ensuring that interventions are implemented; and d. Documenting interventions. 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following: a. Bed Safety; b. Safe Lifting and Movement of Residents; c. Falls; d. Smoking; e. Unsafe Wandering; f. Poison Control; g. Electrical Safety; and h. Water Temperatures. i. Items that can have potential harm Review of facility policy Suicide Threats dated August 2024, revealed that Resident suicide threats shall be taken seriously and addressed appropriately. 1. Staff shall report any resident threats or alarming passive language of potential suicide immediately to the nurse supervisor/charge nurse. 2. The nurse supervisor/charge nurse shall immediately assess the situation and shall notify the charge nurse/supervisor and/or director of nursing services of such threats. 3. After assessing the resident, the nurse supervisor/charge nurse shall notify the resident's attending physician and responsible party, and shall seek further direction from the physician. 4. All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior immediately. 5. Staff will monitor the resident's mood and behavior and update care plans accordingly. 6. Staff shall document details of the situation objectively in the resident's medical record. Review of facility policy 1:1 (a facility staff individually providing observation to a resident) Supervision of Residents dated December 31, 2024, revealed Resident safety is a priority at Horsham Center for Jewish Life. Residents that are exhibiting behaviors that may cause harm, are placed on 1 :1 supervision until IDT (Interdisciplinary team) team meets and updates plan of care to ensure safety. The behaviors below are not all inclusive: o Active/passive suicidal ideation o Repeated or continuing attempts to seriously self-harm o Active exit-seeking-residents o Repeated aggressive behaviors o Acute psychotic episodes. Once resident is placed on 1 :1 the following steps are to be followed: o Staff who is assigned will be given report on resident. o Shift to shift report will be completed when changing shift with ongoing and off going shift. o If any of the above behaviors arise, the supervisor is to be notified immediately. o One to one will always be within arm's length as it relates to resident safety. Review of Resident R1's clinical record revealed that the resident was admitted to the facility with diagnoses of bipolar disorder with psychotic episode (a mental illness that causes extreme mood swings, often called manic-depressive disorder), major depressive disorder (major loss of interest in pleasurable activites), and generalized anxiety disorder. Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R1 dated December 3, 2024, revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 13 which indicated that the cognitive status of the resident was intact. MDS mood assessment indicated that the resident felt down, depressed or hopeless 7-11 days in two weeks. Resident stated yes to Feeling bad about yourself - or that you are a failure or have let yourself or your family down, with a frequency of 2-6 days in 2 weeks. Resident also indicated feeling lonely or isolated. Review of care plan for Resident R1 dated August 11, 2024, revealed the resident had a history of suicidal ideation and/or intent. Care plan interventions included, assess for any suicidal ideations, consult psychology and/or psychiatry as ordered, If resident having active suicidal ideations check and remove any items/objects in room that could potentially be used for self-harm and place resident on 1:1, if needed. Review of hospital record for Resident R1 dated December 24, 2024, revealed the resident admitted to the hospital from the facility for worsening depression. Resident continued to display symptoms of calling out, making statements of wanting to die and was referred for inpatient psychiatric stay. Review of physician's note for Resident R1 dated December 24,2024, revealed the resident had a recent stay at the hospital for uncontrolled anxiety and behaviors. Resident's diagnoses from hospital included depression, anxiety and bipolar disorder. The physician recommended to monitor resident closely. Review of nursing note for Resident R1 dated December 29, 2024, at 4:56 a.m., revealed the resident displayed signs of anxiety throughout the beginning of the shift. Review of nursing note for Resident R1 dated December 29, 2024, at 9:27 a.m., revealed that Nurse reports resident stated (she/he) is going to cut (his/her) wrists. 1:1 started, MD (physician) notified, VM (voice message) left for daughter, room searched for harmful objects. Resident is to have plastic silverware, dietary/nursing made aware. DON (Director of Nursing) notified. Review of nursing note for Resident R1 dated December 29, 2024, at 1:56 p.m., revealed the resident had signs and symptoms of anxiety. The resident was on 1:1 supervision for suicidal ideation. Resident to have plastic silverware. Resident displayed signs of anxiety throughout the shift. Review of facility investigation revealed a written statement provided by Employee E4, Registered Nurse, dated December 29, 2024 revealed the resident expressed that (he/she) wanted to cut (his/her) wrists. Resident was placed on 1:1. Employee E4 searched the tables, bathroom and the tray tables. Employee E4 removed scissors, pens, and a sharp rock painting off the wall. Review of physician progress note for Resident R1 dated December 30, 2024, revealed the practitioner recommended to continue 1:1 supervision for safety related to expressed concern. Review of Psychiatrist, Employee E8's note for Resident R1 dated December 30, 2024, revealed Continue 1:1 supervision for safety due to expressed concerns. Caution to discourage dependence on aide as secondary gain for attention in light of isolation. Review of facility investigation dated December 31, 2024, related to Resident R1 revealed Resident R1 had a vertical 1.5 inch scratch and three vertical 3 centimeters scratches medial to 1.5 inch. scratch to inner aspect of left wrist which occurred on December 31, 2024, around 5:40 a.m. Resident stated (he/she) attempted to cut (his/her) own wrist. Wound was cleaned with normal saline and covered with a dry dressing. Cleanse scratch on left wrist with normal saline and bacitracin applied then covered with Band-Aid until healed. Review of nursing note for Resident R1 dated December 31, 2024, at 6:26 a.m., revealed, At approximately 0540 (5:40 a.m.) signee received a call from the Nurse Aide assigned to 1:1 explaining the resident acquired a razor and was threatening to cut her wrist. At the time of the call the CNA (nurse aide) didn't feel the resident would willingly relinquish the razor. Signee went to the resident's room to find she had given up the razor after she had scraped her wrist, causing a superficial abrasion. Wound was cleaned with NSS (normal saline solution) and covered with a clean dry dressing. Spoke with the resident to find she was feeling very down and lonely. Meanwhile the Nurse Aide swept the room for items the resident could potentially use to harm herself. Following our conversation . Mental Health Practitioner on-call contacted, message left requesting call-back. Physician called, message left requesting call-back; email sent reporting the incident. Strict 1:1 maintained. Report given to oncoming nurse and 1: 1 Nurse Aide. Review of nursing note for Resident R1 dated December 31, 2024, at 6:26 a.m., revealed While on unit A, passing morning medication. This nurse was notified by supervisor that resident had attempted to cut (his/her) wrist. Resident had several harmful items in (his/her) room upon searching by aide. After assessment, the resident received a superficial cut on the left inner wrist as 1: 1 aide was able to take item from resident. The supervisor notified the resident family as well as the psych nurse. Supervisor dressed resident cut. This nurse notified that resident will not go out at this time but will be seen by doctor. Items removed by aide. Resident complained of pain during this shift and received PRN (as needed) medication. Resident pleasant during this shift, however had moment of seeking excessive validation. Resident out of bed during most of this shift with 1 :1 aide in room. Resident plan of care is ongoing. Review of facility investigation revealed a written statement provided by statement from Licensed nurse, Employee E5, obtained by the Director of Nursing dated December 31, 2024, revealed that she confirmed the resident was on 1:1 during 11-7 with the resident. She stated that the resident was on precautions for norovirus (contagious virus that causes diarrhea and vomiting), and (he/she) was using the bathroom throughout the night into the early morning as (he/she) continued with gastrointestinal (GI) issues. Employee E5 stated that she gave the resident privacy in the bathroom and since (he/she) had norovirus while (he/she) was having ongoing GI issues. Staff remained outside the bathroom door Employee E5 stated that the resident came out of the bathroom and stated that (he/she) had cut (his/her) wrist with a razor that (he/she) found in the bathroom drawer. Immediately Employee E5 went into the bathroom to look in the drawer and she took a razor out of the drawer. She said that resident picked up the other razor and when Employee E5 asked for (resident) to give it to her Resident R1 declined. Employee E5 told (him/her) again that staff need to take the razor and if (resident) didn't give it to her, she would call security. The supervisor was called, and the resident handed over the razor. Review of progress note for Resident R1 by the Director of Nursing (DON) dated December 31, 2024, revealed that she assessed resident's left wrist, scratch marks are noted vertically on the inside of the wrist. Band-Aid was in place, some redness noted. Resident stated to the Director of Nursing, she/he did that with a razor that she/he found in the back of the bathroom drawer, and it was stupid of him/her to do, and regreted it. Interview with Employee E6, Licensed Practical Nurse, on January 7, 2025, at 11:50 a.m., revealed that she was working on December 29, 2024, when resident first expressed suicidal ideation. Resident told her that she/he was going to cut her/his wrist. Employee E6 stated the resident was placed on 1:1. Employee E6 stated 1:1 supervision should be provided all the time including inside the bathroom. Employee E6 stated razors were kept in locked clean utility room and she was not sure how resident obtained razors. Interview with Resident R1's husband who was a resident at the facility, on January 7, 2025, at 11:55 a.m., revealed that Resident R1 had severe depression since childhood. Husband stated the resident received the razors from the facility, it was the kind the facility provided. Interview with the Unit Manager, Employee E7 on January 7, 2025, at 12:00 p.m., stated she found potentially hazardous items during a search after resident cut her wrist. She stated the call bell cord was not removed after resident made the first threat, she had vaseline, lotions, and other personal product liquids in her room. Employee E7 stated resident told her that she/he got the razor from the bathroom drawer. Employee E7 stated razors should not be kept with residents with suicidal ideation and staff should stay at arms length of resident at all times when on 1:1 watch. Staff should have visual of resident even including the bathroom. Interview on January 7, 2025, at 1:00 p.m., with Employee E5, Nurse Aide who provided 1:1 supervision on December 31, 2024 to Resident R1 at the time that the resident cut her/his wrist stated that when she started 1:1 suicide watch shift, the aide I relieved informed me that the resident had been experiencing diarrhea. The resident remained awake throughout the night, frequently using the phone and going to the bathroom about every hour. At around 5:30 a.m., the resident came out of the bathroom and informed me that she/he had cut herself/himself while I was in her room. Resident R1 stated she/he had used a razor, and upon inspection, three disposable razors were found. The resident had stayed in her/his room all night, and the bathroom door had been closed during the resident use, preventing Employee E5 observing what the resident was doing in the bathroom. Employee E5 stated, she had assumed the resident had been searched before being placed on 1:1 observation. Staff stated she did not conduct a room sweep at the start of her shift. Employee E5 also stated she did not have proper PPE (Protective personal equipment), such as a mask, which limited her ability to provide supervision in the bathroom. Employee E5 stated she did not ensure the bathroom was safe before the resident used the bathroom and closed the door. After the incident, she conducted a room search and discovered a screwdriver and scissors in the desk drawer, two packs of thumbtacks in the drawer and some on the wall, two additional razors in the bathroom vanity drawer. Interview on January 7, 2025, at 1:40 p.m., with Employee E4, Registered Nurse, who searched resident room on December 29, 2024, when the resident expressed suicidal ideation stated she checked the bathroom, countertop, and drawers that was close to resident's bed, but didn't find anything. When asked if she thoroughly checked the bathroom vanity closet she stated I'm fairly certain I opened them fully, but nothing was removed from the bathroom. She stated she didn't search other cabinets and drawers other than the bedside table, where she only saw a pen and scissors. There was a sharp rock-like item on the wall which was removed. She stated she did not recall seeing a table or a cabinet next to the door. Employee E4 stated she didn't check other areas in the room, just the immediate area of the resident, and placed the resident on 1:1 supervision. Employee E4 stated the call bell cord was not removed as well. Employee E4 confirmed that the call bell cord should have been removed. Employee E4 stated resident was really anxious and a lot of time was spent calming the resident down. She stated she did not recall seeing any other items. Employee E4 also stated when residents were placed on 1:1, staff need to stay with the resident, keeping eyes on them at all times to monitor their actions. Interview with psychiatrist, Employee E8 on January 7, 2025, at 2:44 p.m. revealed that she ordered 1:1 supervision for safety related to suicidal ideation. Employee E8 stated due to resident's mental status she discouraged staff from providing companionship because she did not want resident to get used to it and to only use 1:1 for safety. Interview on January 7, 2025 at 1:40 p.m., with Employee E2, Director of Nursing, stated when resident who has a communicable disease is on isolation, staff should wear PPE and be with resident at all times. Staff should also thoroughly check the room for potentially dangerous objects when resident's express suicidal ideation. Director of Nursing confirmed that the staff did not thoroughly check Resident R1's environment when (he/she) expressed suicidal ideation on December 29, 2024, and did not provide 1:1 supervision consistently as ordered which resulted in resident obtaining razor and cut her wrist. An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 7, 2025, at 3:55 p.m. for the facility's failure to ensure that resident's environment was free of accident hazards, and failed to ensure that hazardous materials were not accessible to a resident. Staff failed to provide 1:1 supervision for Resident R1 with documented history of suicidal ideation and voiced suicidal thoughts two days prior to the indicent. This failure resulted in Resident R1 obtaining a disposable razor and cutting her/his wrist. The facility's failure placed Resident R1 who had a history of suicidal ideation at risk for serious injury and resulted in immediate jeopardy situation. An IJ Template was presented to the facility on January 7, 2025, at 3:55 p.m. The facility submitted a written plan of action on January 7, 2024, at 6:10 p.m. and implemented the plan of action which included: Resident's room was searched for all potentially dangerous objects and were removed. Documentation revealed 1:1 supervision continued, December 31, 2024, and remains in place. Review of residents with SI (suicidal ideation) was conducted on December 31, 2024, no other residents on December 31, 2024, were being observed for SI. The facility reviewed and implemented policies on December 31, 2024, to ensure that the residents with suicidal ideation/ behaviors that can lead to self-harm, do not have access to potentially dangerous objects such as sharp objects, medications, hazardous chemicals and staff provide appropriate 1:1 supervision when indicated. Education was started on December 31, 2024, for staff responsible for overseeing room searches on the policy of ensuring no sharp objects, medications, hazardous chemicals are accessible to the resident. December 31, 2024, achieving >77% and continued on January 1, 2025, with the facility completing >90%. Education will continue for any staff not educated, upon their return, prior to their 1:1 shift, until reaching 100%. Education was provided to staff providing 1:1 on ensuring that residents with SI are always within arm's length as per the supervision policy. Education was started on December 31, 2024, achieving >77% and continued on January 1, 2025, with the facility completing >90% and will continue upon their return for any staff not educated prior to their 1:1 shift until reaching 100%. Audit completed December 31, 2024, and continues Q (every) Shift for the resident on 1:1 for SI to ensure safe environment. QAPI meeting was conducted on December 31, 2024, with the IDT and will continue to be reviewed with the committee to determine if further action is needed. On January 8, 2024, at 4:45 p.m. the action plan was reviewed, observations were made of all nursing units and resident rooms. Interviews were conducted with staff to confirm that the in-service education was completed. Observation was completed to ensure consistent 1:1 observation was provided. Review of facility documentation revealed that the corrective plan was immediately developed and initiated on December 31, 2024. Audits were initiated to ensure that no sharp objects, medications, hazardous chemicals are accessible to the residents with suicidal ideation and residents with SI are always within arm's length as per the supervision policy. The facility reviewed and updated their policy related to 1:1 supervision. Additionally, the facility educated all staff to the updated facility policy. Interviews were conducted with Nurse Aides, Licensed nursing staff and Registered Nurses regarding trainings and competencies related to ensuring that no sharp objects, medications, hazardous chemicals are accessible to the residents with suicidal ideation and residents with SI are always within arm's length as per the supervision policy. Staff also stated that they received sufficient trainings from the facility. The facility alleged compliance with their plan of correction as of January 1, 2025. The Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on January 8, 2025, at 4:45 p.m. This deficiency was identified as Immediate Jeopardy past non-compliance. 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3)(5) Nursing services 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.18(b)(1) Management

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical records and facility documentation, it was determined that the facility failed to ensure that adequate supervision was provided to a resident who verbally expressed to nursing staff that she wanted to kill herself, which resulted in an Immediate jeopardy to Resident R1 who ingested acetaminophen, was transferred out to the hospital, had elevated blood levels of acetaminophen, and received treatment for intentional acetaminophen overdose (Resident R1). Findings include: Review of the August 2024 physician orders for Resident R1 included the diagnoses of hypertension (high blood pressure); chronic kidney disease (a gradual loss of kidney function that can lead to kidney failure); cerebral infarction (a stroke); muscle weakness; anxiety (excessive, persistent and uncontrollable worry and fear about everyday situations) and depression (a mood disorder that cause persistent feelings of sadness and loss of interest). Review of the resident's annual Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated July 23, 2024 indicated that the resident was assessed with a BIMS (Brief Interview of Mental Status) score of 15, which indicated that the resident was cognitively intact. Review of a note written by the psychologist dated April 2, 2024, at 12:21 p.m. documented that the village leader (unit manager) called the psychologist and informed the psychologist that the resident left her (unit manager) several voicemails overnight reporting thoughts of being better off dead. The note also indicated that while meeting with the resident at the unit manager's request, the resident endorsed having felt overwhelmed with the thoughts of being better off dead last evening, but denied thoughts of self-harm then or in session. The psychologist reported that the resident stated that she was still having thoughts of being better off dead but denied suicide ideation. Review of a note written by the psychologist dated May 3, 2024, at 4:04 p.m. indicated a session with the psychologist where resident reported . thought of being better -off dead; she denied SI (suicidal ideation) on my interview . Review of a note written by the psychologists dated June 24, 2024, at 10:55 a.m. indicated a session with the psychologist .thoughts of being better off dead; she denied SI on my interview . Review of a nursing note dated August 3, 2022 at 10:20 p.m. by Licensed nurse, Employee E3 documented that while doing her rounds at the start of her shift (3:00 p.m. -11:00 p.m.), Resident R1 stated, I am going to kill myself. Licensed nurse, Employee E3 stated that she redirected the resident and the resident stated, know what to do and will do it. Licensed nurse, Employee E3 reported that she notified the supervisor, vitals were obtained, and she gave the report to the upcoming nurse for follow-up (11:00 p.m.-7:00 a.m.). Review of an interview conducted by the facilty on August 6, 2024, with Licensed nurse, Employee E3 revealed that the resident told her that she wanted to kill herself because she was upset at the care she received Friday night related to having a bowel movement after drinking prune juice and the call bell response time. Licensed nurse, Employee E3 reported that she contacted the Nursing Supervisor, Employee E5 asking that the nurse assess the resident, but reported that nursing supervisor, Employee E5 never came to the floor. Licensed nurse, Employee E3's statement also indicated that when she completed her first medication administration on her shift, the resident's assigned nurse aide, Employee E6 came to the nurses station with a bottle of Tylenol. Nurse aide, Employee E6 told Licensed nurse, Employee E3 that the resident said that she took 25 pills. Licensed nurse, Employee E3 indicated in her statement that she called the Nursing Supervisor, Employee E5 by phone, did not get an answer, so she contacted the Unit Manager, Employee E7 and asked her what she should do. Licensed nurse, Employee E3 reported that the Unit Manager, Employee E7 told her to contact the nursing Supervisor, Employee E5. Licensed nurse, Employee E3 reported that the nursing supervisor came to the floor for the first time between 8:30 p.m. and 9:00 p.m. and instructed her to take vitals and keep an eye on her. Licensed nurse, Employee E3 reported that she checked on the resident frequently throughout her shift approximately every 25-30 minutes and that she thought that the resident should have a 1:1 instead. Licensed nurse, Employee E3 reported that she gave the resident her 9:30 p.m. medications and that the resident's assigned nurse aide checked on the resident throughout his shift. Employee E3 reported that the resident was asleep at 9:00 p.m. During an interview with Licensed nurse, Employee E3 on August 19, 2024, at 3:43 p.m. the statement that Employee E3 provided to facility administration on August 6, 2024 was reviewed with her, and she confirmed that it was an accurate account of what occurred. Employee E3 reported that the resident's assigned nurse aide for the 3:00 p.m. through the 11:00 p.m. nursing shift (Employee E6) also informed her (Employee E3) that when he went to conduct rounds at the beginning his shift, the resident also told him that she wanted to kill herself. Employee E3 notified the nursing supervisor, but he did not come up. Employee E3 reported that she also notified the licensed supervisor (Employee E5) when the assigned nurse aide (Employee E6) notified her that the resident reported that she took Tylenol. Employee E3 reported that the nursing supervisor did not come up, so she called the Unit Manger (Employee E7) on day shift (7:00 a.m. through 3:00 p.m.) that the resident reported that she wanted to kill herself, and that the resident told her nurse aide (Employee E6) that she took 25 Tylenol, and that the nurse supervisor was notified, but he did not come to see the resident yet. Employee E3 reported that the Unit Manager told her to walk to the nurse supervisor's office to find him. Review of a written nurse aide statement obtained during an interview conducted with Nurse aide, Employee E6 (assigned nurse aide for 3:00-11:00 p.m. shift) on August 6, 2024, indicated that the nurse aide reported that at the start of his shift at 3:00 p.m. the resident also told him that she wanted to kill herself because she was unhappy with the way that she is taken care of. The nurse aide reported that he notified licensed nurse, Employee E3 who then went to see the resident. The nurse aide reported that she told the nurse I am [AGE] years old. I don't know why I am still alive. The nurse aide reported that when he brought the resident her dinner tray she did not want to eat and stated that she wanted to kill herself. The nurse aide reported that he checked on her at approximately between 5:00 p.m. and 6:00 p.m. and that is when the resident told the nurse aide that she took 30 pills of Tylenol and showed the nurse aide the bottle which he brought to Licensed nurse, Employee E3. Continued review of the nurse aide's statement indicated that the nurse supervisor came to the floor later and took vital signs. The nurse aide, Employee E6 explained that he was not assigned to be a 1:1 for the resident but stated that he checked on her throughout his shift. During an interview with Employee E6 on August 19, 2024 at 12:04 p.m. the statement that Employee E6 provided to facility administration on August 6, 2024 was reviewed with him, and he confirmed that it was an accurate account of what occurred. Employee E6 also reported that the resident's statements about wanting to kill herself occurred during the beginning of his shift. He stated that he checked on her throughout his shift and that when he went to deliver the resident's dinner to her, she was lying in her bed. He reported that he was not told that the resident had to have a 1:1 (a staff member assigned to monitor a resident at all times due to medical or safety concerns.) Employee E6 reported that when he went back to the resident's room to retrieve her dinner tray, she told him that she did not want anything to eat and stated to him again that she wanted to kill herself. Unit manager, Employee E7 (3:00 p.m. 11:00 p.m. shift) reported that Licensed nurse, Employee E3 contacted her at 5:43 p.m. on August 3, 2024, was frantic, and reported that the resident had suicidal ideations. Unit manager, Employee E7 reported that she told Licensed nurse, Employee E3 to notify the nurse supervisor and that Licensed nurse, Employee E3 told her that the supervisor was not answering her phone. Unit manager, Employee E7 reported that she told Licensed nurse, Employee E3 to physically go try to locate the nurse supervisor. Unit manager, Employee E7 reported that she contacted Licensed nurse, Employee E3 at 6:37 p.m. and told her that the nurse supervisor came. During an interview with Employee E7 on August 19, 2024 at 4:45 p.m. the statement that Employee E7 provided to facility administration on August 6, 2024 was reviewed with her, and she confirmed that it was an accurate account of what occurred. Employee E7 reported that she was not working when she was contacted by Licensed nurse, Employee E3 and told Employee E3 to go physically find Employee E5 (nurse supervisor) since he had not coming up to the floor regarding what she reported to him regarding the resident stating that she wanted to kill herself and telling her assigned nurse aide that she took Tylenol. Review of a statement obtained from Nursing Supervisor, Employee E5 indicated that he came to see the resident, he did not notice any changes with the residents and that he took the resident's vitals. Nursing Supervisor, Employee E5 reported that he went to assess the resident around 5:00 p.m. regarding her behavioral threat and the resident told her that she wanted the police and that she was not happy. Nursing Supervisor, Employee E5 reported that he assessed the resident again at approximately 10:00 p.m. and that the resident did not tell him that she took medication to kill herself but told him that she wanted the police. The nurse supervisor reported that he instructed Licensed nurse, Employee E3 to monitor the resident and inform him of any changes. Review of an interview conducted with Licensed nurse, Employee E4 indicated that Employee E4 reported that at the start of her shift, she was notified by Licensed nurse, Employee E3 that the resident took Tylenol and that the bottle was taken from her room. Licensed nurse, Employee E4 reported that Licensed nurse, Employee E3 told her that the nurse Supervisor, Employee E5 stated that she does not need a 1:1 but to monitor her every hour. Licensed nurse, Employee E4 reported that she questioned as to why the resident was not on a 1:1. Licensed nurse, Employee E4 reported that she checked on the resident and that she was sleeping when she received a call from the security office on the first floor informing her that the resident called 911 (Emergency Meidcal Services). Licensed nurse, Employee E4 reported that the resident told her that she took the pills before lunch and then told her that she took them at 6:00 p.m. Licensed nurse, Employee E4 also indicated in her statement that the resident reported that she was unhappy here and this is nowhere [sic} to live. Resident was transported to 911 and Licensed nurse, Employee E4 reported that she went into the resident room with the police present and the nurse supervisor for her shift present (Employee E8) and found another bottle of tylenol and eyedrops and removed them from the room. Review of a nursing note dated August 4, 2024 at 12:45 a.m. documented that the resident reported to Licensed nurse, Employee E4 ( 11:00 p.m. - 7:00 a.m.) that she called 911 because she took 25-500 milligram of Tylenol because she does not want to live here anymore. Licensed nurse, Employee E4 reported that 911 personnel transported the resident to the hospital and that Licensed nurse, Employee E4 left a voicemail message for the physician and contacted one of the resident's daughters. Review of an interview conducted with Nursing Supervisor, Employee E8 revealed that at the start of her shift she did not receive any information from the 3-11 p.m. nursing Supervisor, Employee E5 that the resident was having suicidal ideations. Nursing Supervisor, Employee E8 reported that the resident stated that she took 25 pills of Tylenol and told the Emergency Medical Technician and the police officer that she wanted to kill herself when she was assessed. Nursing Supervisor, Employee E8 reported that she told Licensed nurse, Employee E4 to search the resident's room for any other medications and that Licensed nurse, Employee E4 conducted the search and returned with a bag of medication that she found. Nursing Supervisor, Employee E8 was not available for interview with State Survey agency. Review of the resident's hospital records with the Director of Nursing on August 8, 2024 at 2:30 p.m. indicated that the resident's admitting diagnosis was intentional acetaminophen overdose and Cluster B personality disorders (a group of mental disorders that involve unpredictable dramatic or intensely emotional responses to things) and that the resident was treated with N-ACETYLCYSTEINE (also known as N-acetylcysteine (NAC), a medication that is used to treat paracetamol overdose, also known as acetaminophen overdose). Continued review of the hospital records indicated that the resident's acetaminophen level was 103.5 micrograms per milliliter (mcg/mL) of acetaminophen in her blood. A blood level of acetaminophen in the range of 10 to 20 mcg/mL is considered safe (Haldeman-Englert, Foley, [NAME], 2022). Review of the resident's clinical record did not show evidence that she was adequately supervised and interventions were implemented to ensure resident safety for a resident who verbally expressed to at least two facility staff that she wanted to kill herself, and then acted upon it by ingesting a large quantity of Tylenol pills. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on August 8, 2024 at 5:30 p.m. it was discussed that there was no information in the clinical record to show evidence that the resident was adequately supervised by staff to prevent self-harm. The facility failed to ensure that adequate monitoring and supervision was provided to a resident who expressed to nursing staff that she wanted to kill herself. The facility's failure to ensure that the resident received adequate monitoring and supervision resulted in the resident ingesting acetaminophen at the facility as an attempt to kill herself, being transferred out to the hospital, where she was assessed with an elevated blood level of acetaminophen, and received medical treatment for intentional acetaminophen overdose. Based on the above findings, an Immediate Jeopardy to the safety of the resident was identified to the Nursing Home Administrator (NHA) on August 19, 2024, at 10:53 a.m. for failure to adequately monitor and supervise a resident who verbally expressed to nursing staff that she had a desire to kill herself. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator and Director of Nursing on August 19, 2024, at 10:53 a.m. On August 19, 2024 at 3:18 p.m. the facility provided the following corrective action plan: 1. A facility sweep was completed to ensure that there is no medication in the rooms of residents who don't have a physician's order, or not approved for self-administration. 2. ROBO was made to all families on 8/4/2024 to remind them that if they are bringing in any medication for their loved ones, that they give it to the nurse's station to ensure that it is handled properly. 3. Touchdown (Closed Circuit TV) was updated on 8/4/2024 to add a message stating that medications must be received at the nurses' station and not directly to the resident's room. 4. All staff were educated on notifying the DON, NHA, and nursing supervisor that when a resident mention thought of self-harm and if medications are ever in a resident's room, they must notify the nurse supervisor to ensure that the resident has been approved to have the medications. Educations were completed for all staff working in the building on 8/5/2024. Ninety percent completion for overall staff was reached on 8/9/2024. 5. A minimum of 90% of licensed staff were in-serviced on immediately notifying the physician if a resident mentions thoughts of self-harm and to place the resident on 1:1 to ensure safety. 6. The policy regarding suicidal threats was updated to reflect any alarming language that might lead to potential suicide. All staff in the building will be educated today (8/19/24), or prior to coming in contact with any residents. 7. A random audit was conducted to ensure staff understood the above educations. These audits will continue weekly x 3 and monthly x 3. 8. The facility will continue to conduct random audits of resident rooms to ensure that there are no medications in the rooms of residents who don't have a physician's order, or who are not approved for self-administration of medications. Theses audits will continue weekly x3 and monthly x3. 9. A whole house audit has been completed for all residents that triggered for suicidal ideations to ensure that all interventions are in place and care plans were updated. Audits will continue and will include new admissions, weekly x3 and monthly x3. 10. Audit results will be reviewed at QAPI X3 months. 11. Facility will educate residents who have a history of suicidal ideation/intent that incoming packages will need to be checked, with their permission, for any items that could potentially be used for self-harm. 12. Supervisor was suspended pending the investigation. Following verification of the implementation of the immediate action plan and review of staff education documentation, the Immediate Jeopardy was lifted on August 20, 2024, at 5:32 p.m. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(b) Resident care policies 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 28 Pa. Code 211.11(a) Resident care plan