In March 2011, a patient committed suicide in bed at the Two Rivers Behavioral Health System facility. The patient had not been placed on 1:1 observation even though staff knew patient was suicidal and agitated the day before death. Staff failed to conduct appropriate 15 minute checks to make sure the patient was breathing while asleep. When staff checked the patient for 5:00 a.m. vital signs, they found that she was not breathing and had a nylon strap from a medical device and a stretchy rubber toy wrapped around her neck. It took staff several minutes to begin resuscitation procedures and cut the items from around the patient’s neck. CMS declared that this was a case of unabated Immediate Jeopardy from a March 2011 visit. When the facility was found not to have abated the condition of immediate jeopardy by April 2011, CMS terminated Two Rivers from Medicare and Medicaid programs. CMS later agreed to terminate the rescission on that condition that Two Rivers submit an acceptable plan of correction and engage various experts to develop implementation plans for meeting the conditions of participation, which the facility ultimately did.