**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation, the facility staff failed to A) remove known hazards (long cords) from a resident's private room after a suicide attempt by strangulation and during active verbalizations of suicidal ideation for one Resident (Resident #12) in a sample of 27 residents and; B) the facility staff failed to supervise and monitor Resident #12 after he expressed recurring thoughts of death that resulted in a suicide attempt resulting in psychosocial harm. On 01/23/2019 at 4:20 PM, immediate jeopardy was called. On 01/23/2019 at 5:00 PM, immediate jeopardy was abated and was lowered to a level 3 isolated due to the failure of staff to supervise and monitor Resident #12 prior to his suicide attempt on 04/20/2018. The findings include: Resident #12, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses include but not limited to bipolar disease, anxiety, depression, diabetes, hypertension, severe strokes, hemiparesis, hemiplegia, and contractures of right leg and right arm/hand. Resident's #12's most recent quarterly Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 10/30/2018. Resident #12 was coded with a Brief Interview of Mental Status (BIMS) score of 13 out of 15 indicative of intact cognition. Total severity score for mood was 15 out of possible 27 indicative of moderately severe depression. Psychotic behavior was coded as not occurring. Behavioral symptoms such as scratching self was coded as occurring 1 to 3 days. Psychotherapy by any licensed mental health professional was coded as being administered 1 day out of 7. Comparatively, the total severity score for mood dated 10/30/2018 demonstrated increased depressive symptoms (sleep disturbances) from MDS quarterly assessment with an ARD of 03/14/2018 which was just prior to documented suicidal ideations and suicide attempt on 04/20/2018. The most recent quarterly MDS assessment for functional status for locomotion on unit in a wheelchair was coded as requiring oversight, encouragement, or cueing from staff and support from staff for set up only. Functional status for bed mobility was coded as requiring extensive assistance from staff. Toileting and personal hygiene activities were coded as total dependence and full staff performance. Functional status for eating was coded as requiring limited assistance from staff indicating Resident was highly involved in the eating activity. Functional status for dressing was coded as Resident involvement in activity but requiring extensive assistance from staff for support. On 01/23/2019 at 12:17 PM, Resident #12 was observed in dining area seated upright in his wheelchair. When asked about any concerns regarding the care received at the facility, the Resident stated I don't want to be here anymore. The Resident had a kerlix wrap covering his left forearm from the elbow to the wrist. When asked about the dressing, the Resident stated the staff put it there because I'm scratching. The Resident's fingers on right hand were in a flexed position consistent with contractures. On 01/23/2019 at approximately 2:00 PM, Resident #12 was observed in the hall propelling self in wheelchair, with his left foot on the floor, to the dining room and stated he was available for an interview. The kerlix wrap was no longer on Resident #12's left forearm and when asked about it, the Resident stated the staff removed it to let it open to air. There were open areas on the left lateral forearm consistent with nail scratches. At the base of the scratch marks, there were approximately 4 red, open wounds with an estimated diameter of 1 cm and no perceivable depth. Resident #12 re-stated he did not want to be at the facility anymore. When asked why, Resident #12 stated I'm not happy here. I can't walk anymore and they stopped working with me. Resident #12 also stated they have to feed me because the right hand and arm don't work. Resident #12 demonstrated partially moving right arm in an upward motion but limited distance. The fingers on his right hand were flexed and, when asked, Resident #12 was able to demonstrate the ability to actively, partially extend fingers on his right hand away from palm. Resident #12 stated he could feed himself with the left hand if he had a special fork. Resident #12 was asked if he could move his left arm and he demonstrated ability to fully extend fingers on the left hand and Resident #12 lifted his left arm to the level of his chin. Resident #12's nails appeared trimmed and skin on bilateral palms was intact. When asked if he had been hospitalized recently, Resident #12 stated he was sent to the hospital because he tried to kill himself. When asked how he tried to kill himself, Resident #12 stated he tried to strangle himself with the call bell cord. Resident #12 also stated he does not feel happy; he feels depressed and the medication for depression isn't working. When asked if he still had thoughts of suicide, Resident #12 stated he always thinks about killing himself, even today but does not have a plan of how to carry it out. On 01/23/2019 at approximately 2:45 PM, Resident #12's room was quickly surveyed for ligature risk. It was a private room. The furniture in the room consisted of two wardrobes and one dresser with a TV on it against the right wall. There was one bed in the room positioned near the window. On the left wall of the room, there were two wall lights and one of them had a long light cord (accessible to the Resident when he was up in his wheelchair) hanging down and nearly touching the floor. The wall light directly behind Resident #12's bed did not have a light cord attached to it. The window blinds had 2 sets of cords. The function of the cords on the left were for blind tilt control and appeared inaccessible to the Resident. The lift cords on the right side of the blinds were beyond the foot of the bed and accessible to Resident #12 while he was in his wheelchair. On 01/23/2019 at approximately 2:50 PM, the provider notes were reviewed. An admission History & Physical form completed by an MD (medical doctor) dated 05/14/2018 documented, This is a 56yrs [sic] old man, a [facility] resident with hx [history] significant for major depression and bipolar disorder tried to kill himself by strangulating his head with his call bell cord on 04/20/2018 morning and was admitted to a hospital for suicidal attempt. He is back at facility on 05/11/2018. On this same form under Family History, it was documented, mother had depression died of suicide The nurse's notes were reviewed. A nurse's note dated 03/18/2018 at 12:28 PM documented, Resident was extremely irritable. Aides asked he [sic] if he wanted to get up and he declined their care and still proceeded to yell that he needed help and he wanted to get out of bed. Resident hollered help I went into the resident room and found him on the floor halfway under his bed with his head facing at the end of the bed. I asked resident what happened and how he got there. Resident stated I threw myself down here, if you put me back in that goddamn bad I will do it again. Resident has no apparent injuries from fall and vital signs obtained. Blood pressure: 165 / 75 pulse 83 respirations 19 oxygen saturation 95% on room air temperature 97.4 orally. Resident has calmed down now is in a more rational state of mind. I encourage resident to call for assistance using the call bell provided and explained to him the potential risk factors of his behaviors such as injuries related to him purposely falling from his bed. MD aware and resident is self representative. A nurse's note dated 03/29/2018 at 7:32 PM documented, Resident has been having angry outbursts since 3 p.m. Resident screaming as loud as possible help, help, help because he stated he wanted to get in bed. The CNA and I put him in the bed at 4 pm. Resident began screaming again help, help, help at 5:30 p.m. Resident now stated he wanted to get back up and then his chair. Resident stated if you don't get me the hell out of this bed I will get out of my goddamn self I don't give a damn if I get hurt I will fall. To avoid him trying to purposely fall out of bed I got him out of bed and back into the wheelchair and brought him in the dining area near the nurses station so he could eat his dinner. Resident started hollering and yelling at staff calling them names. Resident repeatedly pushed the dining room table with his wheelchair almost tipping his chair over with him in it. Resident then proceeded to go up the hallway to the main dining room looking for the receptionist and hollering her name. I explained she had went home for the day. He stated She better not have, I need my money, she has my money, I don't give a damn. Leave me the hell alone. Resident then starts screaming help again and literally threw himself out of his wheelchair onto the floor where he hit his head. I asked resident why did he do this? Resident stated because I can who gives a damn it's my goddamn head. Resident has a 0.5cm by 2 cm lesion to the forehead which I cleaned and dressed. Resident was picked up off the floor with the Hoyer lift after complete physical assessment was performed. Resident asked to go to bed so we put him in bed. Neuro checks implemented and initial vitals obtained after fall at 6:15 p.m. Blood pressure: 127/74 pulse: 80 respirations: 19 oxygen saturation: 97% on room air temperature: 97.1 orally. Pain level: 4. Resident states his head hurts. Resident had been given his 6 p.m. pain medication and Ativan which were effective at pain relief of head pain. A nurse's note on 03/29/2018 at 11:37 p.m. documented, Resident refused all neuro check vital signs. Continue to holler help and threatened to throw himself in the floor. Performed dressing change three times to the open lesion on the forehead substained [sic] from the fall and each time resident rips off dressing cussing and scratches open the lesion making it bleed then wiping his hands all over his face and onto blankets. Resident attempted to wipe blood on me. A nurse's note on 03/30/2018 at 2:06 PM documented, Resident having crying episodes-stating he wanted to die. Stated he wanted to kill himself. Telephoned NP [nurse practitioner]- NP gave new order for Seroquel 50 mg [an antipsychotic]. Resident representative aware. The next nurse's note entry on Resident #12 is 6 days later dated 04/05/2018 at 1:09 AM documented, resident very restless and agitated scratching at forehead cursing and yelling at staff attempting to get out of bed with no assist medications given as ordered resident continues with behaviors. There were no nursing note entries between 03/30/2018 2:06 PM and 04/20/2018 07:52 AM that showed assessing, monitoring for suicidal ideations, or determining if Resident #12 had a plan to commit suicide. A nurse's note on 04/20/2018 at 07:52 AM documented, At about 6:10 AM this morning, staff reported to this nurse that resident was actively trying to kill himself by strangulation. Resident was seen with the call bell wrapped around his neck tightly. I removed the call bell from around his neck. Resident stated, 'I want to die' & 'I wanted to get out of this place.' 1 on 1 given to resident at the time of the incident & repeated 1 on 1 and close observation since then. Resident was assisted up into wheelchair & has been calm with bouts of crying noted when asked about the incident. Resident is on continued monitoring. Resident has visible redness around his neck. Resident expressed a personal tragedy that occurred in his family. Oncoming staff made aware. Close monitoring will continue. A nurse's note on 04/20/2018 at 8:21 AM documented, Given in report that resident attempted suicide by attempting to strangle himself with his call bell cord. Resident reportedly had a bluish tent [sic] to skin tone when found. Resident has been given one on one care since the incident occurred at 6:10 AM. Resident very upset visibly crying. Attempted to console resident and provided emotional support. Resident sent to [hospital] for psychiatric evaluation. Resident left in ambulance via stretcher at 8:12 AM. On 01/23/2019 at 3:30 PM, the Administrator was asked to provide any service concerns, incident reports, or any investigations regarding Resident #12 from January 2018 to January 2019. The Administrator presented a copy of a facility-reported incident dated 01/24/2018 and stated that was the only investigation he had for Resident #12. The attempted suicide by this Resident on 04/20/2018 was not reported to the state agency. On 01/23/2019 at approximately 3:45 PM, Surveyor D made the following observation. Surveyor D went to Resident #12's room to observe the environment for any ligature risks. Resident #12 was observed sitting in his wheelchair in his room. He was dressed in sweat pants and shirt. The sweat pants were visibly wet in the front. Resident #12 had, in his hands a fanny Pack with a plastic clip on it. Resident #12 held one part of the clip in his left hand and maneuvered the other part into the clip with his right hand. Resident #12 was able to clip the belt of the fanny pack and place it over the end of the bed rail. His left arm was exposed and there were scabbed areas with reddened open areas from wrist to elbow. When asked what happened to his left arm he stated I scratch it until it bleeds. When asked do they put a bandage on it, he responded 'They wrap it sometimes but they leave it open sometimes too. The blinds in Resident #12's room had double cords on each side, and the overbed light on the opposite side of room hand plastic coated cord with metal tabs at the end hanging from the light. On 01/23/2019 at 4:15 PM, the state agency supervisor was notified. After consultation with the state agency supervisor, on 01/23/2019 at 4:20 PM, immediate jeopardy was called. On 01/23/2019 at 4:40 PM, the Administrator was notified of immediate jeopardy for Resident #12 due to ongoing accessibility to ligatures in the Resident's room that could be used for strangulation. On 01/23/2019 at approximately 4:45 PM, Surveyor D and this surveyor entered the Resident's room for closer examination of ligatures. The cord hanging from the wall light was unobstructed and accessible to Resident #12 when he was in his wheelchair. It measured 57 inches long (144.78 cm) and 1/16 inch (0.15 cm) thick. According to product description provided by the Administrator, the cord is made from a nylon center core and encased in ABS (acrylonitrile butadiene styrene) plastic. There was a hard, plastic, bell-shaped cuff at the terminal end of this pliable cord suitable for anchoring a knot in the ligature. The diameter of the bell measured 0.55 inches (1.4 cm). The other end of the light cord had a metal device on it that fastened to a metal chain hanging down from the wall light. The window blinds had 2 sets of cords. The function of the cords on the left were for blind tilt control and appeared inaccessible to Resident #12. The lift cords on the right side of the blinds were beyond the foot of the bed and accessible to Resident #12. When the blinds were partially opened, the lift cords measured 53 inches (134.62 cm) long and 1/16 inch (0.15 cm) thick. The lift cords were connected by a hard plastic-appearing bead to create a loop in the upper portion of the cords. The bead could not advance down to the terminal end of the cords due to a knot in the connection. The knot was 17 inches (43.18 cm) from the terminal end of the cords. The diameter of the hard plastic-type bells at the ends of the lift cords measured 0.70 inches (1.8 cm). On 01/23/2019 at 4:53 PM, the Administrator stated that staff removed the call bell from the room when it happened but they did not remove other items in the room that were ligatures. On 01/23/2019 at 5:00 PM, the blinds and light cord and stated all cords were removed from the Resident's room. On 01/23/2019 at 5:00 PM, immediate jeopardy was abated. On 01/23/2019 at approximately 5:30 PM, the review of the clinical record continued. A nurse's note entry dated 01/23/2019 at 5:05 PM documented, New order received from MD to send resident to ER (emergency room) for eval and treatment for suicidal ideations with past attempt of killing himself. 911 phones at this time. A nurse's note dated 01/23/2019 at 5:13 PM documented, Resident interviewed. In regards to self harm, resident stated, I always have had thoughts of suicide, but I'm not actually going to do it. Throughout the conversation, resident denied having an active plan for self harm. Initiated one-to-one sitter. Primary nurse notified. NP notified. New order received to send to ER for evaluation of suicidal ideations. On 01/23/2019 at approximately 6:00 PM, a Resident Transfer Form was given to Surveyor B by Employee H. It was the Transfer Form (for Resident #12) completed by the nurse on day shift that documented on 04/20/2018 at 8:21 AM Resident left in ambulance via stretcher at 8:12 AM The vital signs on the form on 04/20/2018 at 7:56 AM were blood pressure: 112/71 Pulse: 68 Respirations: 18 Temperature: 97.2 Oxygen saturation: 98%. This form had a date on the top left corner of 01/23/2019 6:00 PM. On 01/23/2019 at 6:10 PM, Surveyor A, Surveyor C, and this Surveyor were present when Surveyor B and the DON were looking together at Resident #12's Vital Sign Report on the computer. The DON stated that This program pulls all of the vital signs from any and all vital signs in the clinical record that were documented on 04/20/2018. If it was documented on that day, it is in this report. The DON was then asked by Surveyor B, Why is the Resident Transfer Form given to me by Employee H a few minutes ago have a blood pressure on it and this doesn't? The DON stated, I don't know why that is. The Resident Vital Sign Report, with a print date of 01/23/2019 6:09 PM, documents vital signs report was completed by the same nurse on day shift with a capture date/time of 04/20/2018 at 6:52 AM. The Pulse: 68, Pulse oximetry 98%, Respirations: 18, Temperature: 97.2. No blood pressure was recorded on the report. The nurse on night shift that removed the call bell from around Resident #12's neck on 04/20/2018 did not document vital signs in the narrative note, the Vital Signs Record, or the Resident Transfer Form. The oncoming nurse documented on the clinical notes, Vital Sign Record, and the Resident Transform Form but there is a discrepancy in the record with the time and blood pressure. On 01/23/2018 at 6:30 PM, the care plan was reviewed. An intervention for the problem of history of falls documented, Keep call bell and personal items within reach. When the DON was asked about still having a call bell for the Resident on the care plan, she stated, It could mean the chime. On 01/24/2019 at 8:30 AM, Employee G from the maintenance department was asked about the blinds, he stated they look like a metal composite with a nylon rope. Employee G carried blinds and walked with this surveyor to the facility scale. Employee G placed blinds on scale and CNA B weighed blinds at 16 pounds. The length of the blinds measured 70.25 inches and the slats are 2 inches wide. With the blinds fully retracted, the lift cords measured 60 inches from where they exited the headrail to the terminal end of the cords at the bottom of the bells. On 01/24/2019 at 10:20 AM, CNA A was asked about Resident #12's feeding activities. CNA A stated Resident was able to feed himself finger foods. Also stated Resident used a special fork and spoon to feed himself but would also need staff to help with eating. On 01/24/2019 at 10:22 AM, LPN C was asked about the open areas on Resident #12's left forearm. LPN C stated the open areas are self-inflicted scratch marks. When asked why he scratches himself, LPN C stated Resident said he did it when he felt nervous and when he felt itchy. On 01/24/2019 at 10:25 AM, the first Plan of Correction (POC) by the facility was received, reviewed, and discussed among survey team members. On 01/24/2019 at 10:52 AM, survey team met with Administrator and corporate staff to inform them the POC was rejected, why it was rejected, and to record their questions. On 01/24/2019 at 11:35 AM, an interview with Staff B, a licensed clinical social worker (LCSW), was conducted. Surveyors A, B, C, D, and this surveyor were present. Staff B stated she has worked with Resident #12 for close to a year and that Resident #12 is seen weekly to offer therapy for depression. When asked if she assesses Resident #12 for thoughts of suicide during the visits, she stated, I gauge him for suicidal ideation on a scale from 1 to 5 where 5 is the worst, and I ask him 'how depressed are you?' Staff B stated she does not put are you suicidal? and does not ask Resident #12 if he has a plan in place to carry out a suicide. Staff B stated she uses the Geriatric Depression Scale and will get the psychologist involved as necessary. Staff B stated that all the sessions were held in the dining room and that she does not know what his room looks like. When asked if she made any recommendations to the facility regarding Resident #12, she stated, no. When asked if she was aware there were long ligatures accessible to Resident #12 in his room, she stated Resident #12's environment should have been evaluated for safety and the cords should have been removed from his room. She also stated it would have been prudent for her to look at the Resident #12's environment. When asked if she attends care plan meetings, she stated she does not usually attend care plan meeting unless there are behavior problems but never here at this facility. Staff B went on to say that as a result of this meeting, she was going to totally change what I am doing. She stated she will be going to residents' rooms, she will be asking if (residents) are suicidal, and she will ask them if they have a plan. On 01/24/2019 at 2:10 PM, the 2nd POC was received, reviewed, and discussed among the survey team members. On 01/24/2019 at 2:46 PM, the survey team met with Administrator and corporate staff to inform them the 2nd POC was rejected, why it was rejected, and to record their questions. The meeting ended at 3:03 PM. On 01/24/2019 at 3:54 PM, the revised (3rd) POC was received, reviewed, and discussed among survey team members. On 01/24/2019 at 4:06 PM, the final POC was accepted. On 01/25/2019 at approximately 9:40 AM, CNA D was asked what Resident #12 kept in his fanny pack and CNA stated sometimes he would keep his glasses or his money/loose change in there. She also stated that Resident #12 was able to feed himself finger foods such as chicken nuggets, a sandwich, or French fries. On 01/25/2019 at 9:47 AM, Staff C, an occupational therapy assistant that has worked at the facility for five years, was interviewed. Staff C stated she has worked with Resident #12 in relation to wheelchair positioning and how to move better in the wheelchair. She also worked with Resident #12 with the gorilla grip build up fork, spoon, and big washcloth so he can wash his face. She also stated in the past year, she has seen Resident #12 use his upper extremities to wheel himself in the wheelchair at will. When asked if the Resident's strength and dexterity has declined over the past year, she stated she thinks he has maintained the same strength and dexterity. On 01/25/2018 at approximately 11:00 AM, the kitchen staff provided a sample plate of frozen french fries typically served at this facility. The Administrator provided the two types of call bells used at the facility. The call bell cords measured a thickness of 0.23 inches (0.6 cm). Comparatively, the call bell cords are thinner than the diameter of the bell at the terminal end of the light cord (1.4 cm), the bells on the terminal end of the lift cords (1.8 cm), and the French fries (1 cm) that Resident #12 is able to pick up and feed himself. On 01/25/2019 at 12:45 PM, an interview with the facility's social worker was conducted. Staff A has worked at the facility for 18 years and has her Bachelor's degree in Psychology. When asked if she was aware Resident #12 expressed he wanted to kill himself, she stated not in recent times. When asked to share what she knows about him, she stated, I talk to him routinely, at least every quarter. She stated he likes to be involved in activities; he prefers to get up early. When asked about the cause for his current condition, she stated, I'm not sure if he had a stroke in the past. When asked about what should be done when a resident verbalizes suicidal ideations, she stated nursing should report it to her so she would be aware of it. When asked who is responsible for making referrals to psychiatry, she stated it was the DON's responsibility. When asked if she saw Resident #12 between 03/30/2018 and 04/20/2018 (the time frame when the Resident verbalized suicidal ideations to the morning he attempted suicide), Staff A looked at the electronic health record during the interview and verified she did not see him in that time period. Her first visit with Resident #12 when he returned to the facility was 05/16/2018 at 5:27 AM. When asked if she received an in-service on the topic of suicide recently, she stated she receive training on 01/24/2019 about the process of what to do, to monitor resident, and who to notify. When asked what she thinks should have been done (when Resident #12 verbalized suicidal ideations), she stated, Staff should be monitoring, he has ongoing depression. When asked to define 'monitoring, Staff A stated visiting consistently, frequently. Staff A stated Resident #12 would go to the lobby to get change to purchase snacks such as chips or diet soda. Staff A also stated Resident #12 can get money into his fanny pack independently and zip it back up. When asked about the suicide attempt on 04/20/2018, Staff A stated she was surprised by it. She stated, He was turning blue when found and it was looped around his neck a few times. Staff A stated she was aware the call bell cord releases from the wall when it's pulled. When asked if she made any recommendations to the facility about room safety, Staff A stated, not specifically. When asked for the Social Work department policy concerning behaviors, Staff A stated she didn't know if there was a written policy and added, I just do my job. A copy of her job description was requested. On 01/25/2019 at 2:10 PM, the facility DON was interviewed. When asked about what she would expect to see on the care plan of a Resident who expressed suicidal ideations, she stated she would expect to see mood, if they were expressing depressive symptoms and thoughts and feelings of harming self. The DON stated interventions would include psychiatry consult, meds if applicable, and one-to-one therapeutic communication as needed. She stated there should also be resident-specific interventions such as activities to encourage. When asked about her expectation when a Resident verbalizes suicidal ideations, she states she would provide one-to-one monitoring and notify MD (medical doctor). This surveyor and the DON reviewed the nursing note entry dated 03/30/2018 at 2:06 PM. When asked what her expectation is of staff when a Resident verbalizes thoughts of suicide, she stated she would expect to see vital signs and more details about what was going on. She also stated that after the assessment and caring for the Resident, she would expect that EMS (emergency medical services) would be called. She stated she would also expect she would be notified as well as ADON and the Administrator. When asked if she was notified about the attempted suicide, she stated she didn't remember but she's sure she was. When asked what she would have done in the event she was notified, she stated she would refer Resident #12 to psychiatry. She also stated that if she would make a referral to psychiatry, she would write a note about it in the clinical record. However, after reviewing the electronic record, the DON did not find evidence of her referral or that the psychiatrist was notified of Resident #12's suicidal ideations from 03/30/2018. The DON stated she could not see it in the computer and would check the hard chart. She also stated that, in general, it's a good idea for social worker to be notified when residents make depressive statements. On 01/25/2019 at 2:30 PM, the corporate DON stated, The official title is 'social worker' in reference to Staff A. A copy of Resident Coordinator Job Description was presented. Responsibilities listed include but not limited to, develops social histories on residents through information obtained from referral sources, appropriate social agencies, residents and family members or friends. Documents same, and updates as needed. Evaluates resident's social situation; incorporates into the resident's overall care plan as assessment of resident needs, goals, and progress. Helps resident understand his need for the Center's care and assists in dealing with fears, resentments, loneliness. Assists resident in acceptance of placement. Works closely with other services involved in total health care of the resident in assisting with restoration of health, slowing disease process and preventing complications. On 01/25/2019 at 3:40 PM, the Administrator was interviewed. When asked about the investigation pertaining to Resident #12's suicide attempt on 04/20/2018, he stated he did not have an investigation and added there was nothing to investigate because we knew what happened. When asked if he thinks an investigation should have been done, he stated, Looking back, I should have - it would be the thing to do. When asked why he thinks it's important to do investigations, he stated to be able to look back at the cause and the notes. A copy of the ombudsman notification was requested. On 01/25/2019 at 4:05 PM, the Administrator stated the ombudsman was not notified when Resident #12 was transferred to the hospital for attempted suicide on 04/20/2018. The physician's orders were reviewed. There were no orders for behavior monitoring pertaining to suicidal ideations/plans found from 03/30/2018 to 04/20/2018. Orders from the Nurse Practitioner (NP) for behavior monitoring the day Resident #12 returned to the facility dated 05/11/2018 (discontinued on 06/28/2018) documented target behaviors to be monitored were verbally abusive towards staff, crying outbursts and withdrawn. There were no orders for monitoring for suicidal ideations/plans or assessing/monitoring environment for safety risks. Orders from an internist MD for behavior monitoring for Resident #12 dated 06/28/2018 (still active) documented target behaviors to be monitored were verbally abusive towards staff, crying outbursts, and withdrawn. There were no orders for assessing/monitoring for suicidal ideations/plans or environmental safety checks. A psychological services form completed by Staff B (LCSW), listed the date of service as 03/30/2018 and time was 12:55 PM to 1:15 PM (the service time was less than one hour prior to nursing entry of resident crying and verbalizing wanting to die and wanting to kill himself). Under Current Risk[TRUNCATED]