**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to recognize a sudden change of condition which resulted in a delay of treatment for 1 of 3 resident (R1) reviewed with change condition. As a result R1 experienced chest pain was hospitalized and died. The immediate jeopardy (IJ) began on [DATE] when licensed nursing staff failed to comprehensively assess and monitor R1 after he voiced he was having chest pain. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 4:30 p.m. The IJ was removed on [DATE] but non-compliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: R1's face sheet dated [DATE], identified R1 admitted 7/24. R1 had diagnoses of non-st elevation myocardial infarction (heart attack that happens when part of your heart is not getting enough oxygen), atrial fibrillation (irregular heart rhythm in the heart's upper chambers), history of stroke (blood supply to part of the brain is blocked or reduced), nonrheumatic aortic stenosis (heart valve problem that affects the blood flow to the heart and body), and gastroesophageal reflux disease (GERD) (chronic condition where stomach acid flows back into the mouth from the esophagus). R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment. R1 had no impairments to upper or lower body and used a walker and wheelchair to move around the facility. R1 required substantial assistance to dress lower body, and supervision assistance with upper body, toileting, and transferring. R1 had an indwelling urinary catheter. R1's care plan dated [DATE], identified R1 had altered cardiovascular status and would remain free from cardiac complication. Interventions included to monitor vital signs and notify the medical doctor of significant abnormalities. R1's provider visit note dated [DATE], identified nonrheumatic aortic valve stenosis had caused recurrent chest pain, staff were to monitor for any signs of recurring chest pain, signs, or symptoms of fluid overload and to call provider if noted. During an interview on [DATE] at 10:41 a.m., licensed practical nurse (LPN)-C stated R1 was always good at telling her when something was wrong physically with him such as if he had a concern about his catheter or blood sugar readings. R1's progress note dated [DATE] at 8:47 p.m., identified R1 had 2+ pitting edema to bilateral lower extremities, crackles noted at base of lungs. R1 denied shortness of breath (SOB). Vital signs were blood pressure (BP) 132/75 (normal range 120/80), temperature (T) 98.2 (normal 95.9-99.5), pulse (P) 71 (normal 60-100), 95% oxygen (O2) room air (normal 95-100%), respirations (R) 18 (normal 12-20). On rounds to notify provider and put a message in Teams for nurse manager. R1's late entry progress note documented on [DATE] at 5:11 p.m. identified on [DATE] at 6:15 a.m., an aide reported R1 was complaining of chest pain. R1 was talking normally, did not complain of any radiating in his extremities. R1's vital signs were within normal limits (R1's record did not include recorded vital signs between 6:00 a.m. 7:00 a.m.). R1 had 2+ pitting edema to bilateral lower extremities (BLE) and wheezing in the lower lobes with a six-pound weight gain in a week and a half. Monitor R1 for increased chest pain, radiating, and difficulty breathing and address with provider when they are at the facility at 8:00 a.m. R1's late entry progress note documented on [DATE] at 5:40 p.m. for [DATE] at 7:11 a.m., identified R1 was sitting in recliner and did not appear to be distressed or anxious. R1 stated pain was in the center of his chest. R1 stated the pain was not radiating anywhere and he did not have pain anywhere else. R1 reported pain between 4-6/10. R1 had been to the bathroom prior to nurse entering room and R1 denied SOB or increased pain with movement. R1 had increased blood sugar (BS) of 204 (normal BS range is 80-130 before meals), which was noted to be high for R1. R1 complained of nausea and nursing assistant brought yogurt for R1 and he declined Tylenol. R1's late entry progress note documented on [DATE] at 5:40 p.m. for entry from [DATE] at 7:58 a.m., identified R1 had 1,000 milligrams (mg) of Tylenol for pain. R1's family member (FM)-A was present in room and R1 appeared calm and was sitting in the recliner. R1's late entry progress note documented on [DATE] and 5:40 p.m. for entry from [DATE] at 8:05 a.m., identified R1 was complaining of chest pain and nausea. R1 did not complain of increased pain with breathing and pain was not radiating. R1 did have a small, clear emesis with continued nausea. Continue to monitor symptoms and notified nurse manager and told her it was put on rounds for the provider to address when she arrived. R1's vital sign record on [DATE] at 8:15 a.m. were BP 115/71, T 97.5, P 61, R 16, 02 99% room air. R1's late entry progress note documented on [DATE] at 5:45 p.m. for entry from [DATE] at 8:29 a.m., identified R1's family member (FM-A) came to the nurse's station after the provider recommendation to be sent to the emergency room. Nurse asked FM-A if they wanted to transport R1 or if the facility should call the ambulance. R1's late entry progress note documented on [DATE] at 5:43 p.m. for [DATE] at 8:30 a.m., identified LPN-B called provider about R1's symptoms and physician requested R1 be sent to the emergency room. In review of R1's record on [DATE], the record did not identify continuous monitoring of R1's condition and did not include a comprehensive assessment of R1's cardiac status. R1's Interact Transfer to Hospital form dated [DATE] at 8:30 a.m., identified most recent vital signs were on: [DATE]- BP 133/72, R 18, T 98.7, P 80, 02 97%, [DATE], vital signs were not recorded, Pain level 6 R1's progress note dated [DATE] at 8:38 a.m., identified R1 stated pain was 4-6, not radiating and not worse when he takes a deep breath or with exertion. Vitals within normal limits and 2+ pitting edema to BLE. R1 stated Tylenol was not effective, provider notified and recommended to send to emergency room. Ambulance called and FM-A was with R1. R1's late entry progress note dated [DATE] at 8:45 a.m., identified ambulance was dispatched to facility. Fire department arrived and said the ambulance was approximately 45 minutes out. R1 complained of pain radiating in the upper extremities to the fire department. R1's progress note dated [DATE] at 9:37 a.m., identified R1 discharged to the hospital on [DATE] at 9:00 a.m. R1's hospital records dated [DATE], identified on [DATE], R1 had an electrocardiogram performed which showed acute anterior STEMI (severe type of heart attack that affects the lower chambers of the heart and can cause permanent damage or death). R1 had a surgical procedure however after procedural intervention, R1 suffered complications that included cardiogentic shock and pulmonary hemorrhage (acute bleeding from the lung).R1 transferred to comfort cares and expired on [DATE] at 7:50 p.m., with preliminary cause of death listed as cardiac arrest. During an interview on [DATE] at 11:42 a.m., licensed practical nurse LPN-A stated on [DATE] an aide came to her around 6:00 a.m. and informed her R1 had chest pain. LPN-A stated R1 had never had chest pain before. LPN-A stated she went and did a little check on him. LPN-A examined his legs and noted they were bigger than she had seen them before. LPN-A listened to R1's lungs and noted wheezing in the lower lobes and heard it more in the left than the right. LPN-A asked R1 if the pain radiated, any SOB or hurting with taking a deep breath, and took a set of vital signs. R1's vital signs were as close to perfect as anyone could get which did not seem like they would be for someone in distress. However, LPN-A could not recall what R1's vital signs were that she had collected. At that point she left the room and told R1 to call if he had any questions and she would be back to check on him. LPN-A told LPN-B of her findings and they both felt the R1's symptoms were associated with the six-pound weight gain in 1.5 weeks and made sure that R1 was on the rounding sheet for physician to see him later that morning. Sometime before before 8:00 a.m., R1 had an emesis bag in his hand and had spit up of clear fluid, no frothiness. LPN-A reported R1's emesis to LPN-B who told her it is something that would happen with fluid build-up in the lungs. At 8:00 a.m. LPN-A informed the nurse managers (NM) of R1's condition and R1 was on rounds for later that morning. Around 8:25 a.m., NM-A came over with R1's family member (FM)-A and asked her what we were doing with the situation. LPN-A explained to FM-A that they were waiting for physician rounds. NM-A then told LPN-A to call the provider and not wait. LPN-B called provider while LPN-A called the ambulance. During an interview on [DATE] at 2:43 p.m., LPN-B indicated on [DATE] at approximately 6:00 a.m., during morning shift report LPN-A mentioned R1 had chest pain and she assessed him, so LPN-B began the medication pass. LPN-B entered R1's room around 7:00 a.m. and checked his blood sugar. R1 and LPN-B discussed the high reading and the new symptom of nausea. LPN-B did not see any emesis in the emesis bag and did not listen to his lungs. LPN-B stated R1 explained the pain was above the belly button at the center of his chest and not worse with movement and not radiating. LPN-B had R1 eat a yogurt because he had a diagnosis of GERD; the yogurt would coat his stomach lining and relieve his nausea. She offered R1 Tylenol for the chest pain but R1 declined. He did request the Tylenol a short time later when his family member was present. A short time later R1' FM-A came out of R1's room and told her the Tylenol was not working and the pain had increased. LPN-B went straight to the phone and called the physician who ordered R1 to be sent to the hospital urgently. During a phone interview on [DATE] at 4:10 p.m., family member (FM)-A stated she got a call from (R1) around 7:00 a.m. complaining he had heavy chest pain and had been trying to reach staff and was told by staff the provider would be at the facility around 8:00 a.m. I was irritated and told them to call the doctor, how can you provide better service in that situation because clearly he was having a major heart attack!. During an interview on [DATE] at 1:24 p.m., NM-A stated on [DATE] around 8:00-8:30 a.m., she was informed FM-A was upset and at the nursing desk, so she went to talk with her. NM-A explained that was when she found out R1 had chest pain. When she asked LPN-A and LPN-B they informed her the physician had not been notified of R1's chest pain but his was added to the physician round list to be seen that morning, NM-A directed them to call the physician immediately because R1 had chest pain and could be a cardiac event which would need emergency intervention. In those cases we should call 911 and notify the physician after. During an interview on [DATE] at 10:13 a.m., nurse practitioner (NP)-A stated R1 was very in tune with his body and would ask questions about the healing process and about anything that happened during his stay health related. NP-A received a call from the facility at 8:26 a.m., R1 had been having chest pain since 5:30 a.m. I would expect the facility to call for chest pain, any word of chest pain. We were already behind [with emergency treatment]when they did call because they had not called at the onset of chest pain and I said to send him in immediately. R1 died last evening from complications, whether R1 died as a result of delayed treatment or surgery NP-A was unsure. NP-A stated R1 was planning to discharge home in the next couple of weeks when therapy was complete. During an interview on [DATE] at 1:38 p.m., administrator stated she expected the staff to notify the doctor for a change in condition and not wait until the provider is going to round on the resident, even if the provider is scheduled to come the next morning. Administrator stated after the incident occurred the facility began immediate actions to remedy the situation by providing education to all nursing staff, which included re-education on change of condition, signs and symptoms of cardiac conditions, a quiz that inquired of nurses what they considered a change of condition, and what do nurses do when a change of condition occurs along with a nurse meeting that was scheduled for next week to again review change of condition. Administrator and DON reviewed all residents by running a report and reviewing all other residents with recent changes in condition and identified no other at-risk residents. The facility Change in a Resident's Condition or Status policy revised February 2021 directed: -Our facility promptly notifies the resident, attending physician and resident representative of changes in the residents medical/mental condition and/or status. -significant change in resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: -will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions -impacts more than one area of the resident's health status -requires interdisciplinary review and /or review on to the care plan; and -ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider; including information prompted by the Interact SBAR Communication Form. 8. the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition of status. The facility Resident Examination and Assessment revised February 2014 directed the facility to examine and assess the resident for nay abnormalities in health status, which provides a basis for the care plan. Physical Exam included: -vital signs (blood pressure, pulse, respirations, and temperature) -cardiovascular (heart rate and rhythm, peripheral pulses, capillary refill) -respiratory (lung sounds, irregular or labored respirations, cough, sputum) -neurological (alertness and orientation, speech clarity) -genitourinary (urine clear or cloudy, presence of catheter) The past non-compliance IJ that began on [DATE] and was removed on [DATE] when it was verified the facility implemented the following: 1) re-education on change of condition with nurse management team prior to next shift 2) posters of signs/symptoms of cardiac episodes posted at nurses stations and reviewed with all staff 3) quiz for each nurse to take asking what do nurses do when a change of condition occurs, what is considered a change of condition 4) review of like residents and no one else was at-risk 5) nurse meeting scheduled for the week of [DATE] to reiterate presented education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to comprehensively assess, implement interventions, and provide timely notification for change in condition to a provider for 1 of 1 resident (R1) who was found unresponsive which delayed care resulting in death from acute respiratory distress. The facility's failures resulted in an immediate jeopardy for R1. The immediate jeopardy (IJ) began on 3/3/24, when licensed nursing staff failed to comprehensively assess and monitor R1 after being notified by several nursing assistants of R1's change in condition which included decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness. The Administrator and Director of Nursing were notified of the IJ on 3/7/24 at 5:25 p.m. The immediate jeopardy was removed on 3/8/24 at 2:40 p.m. but noncompliance remained at the lower scope and severity level 2 (D), which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses that included Parkinson's Disease, renal insufficiency, neurogenic bladder, seizure disorder or epilepsy, and muscle weakness. The MDS indicated R1 did not have cognitive impairment. R1 required substantial to maximum assistance with dressing upper body and toileting, dependent on staff for lower body, and use of a wheelchair for mobility. No oxygen use. R1's activities of daily living (ADL) care plan dated 11/8/23, directed staff to monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Further focus on dehydration directed staff to monitor/document/record signs and symptoms that included but not limited to decreased or no urine output, concentrated urine, new onset confusion, dizziness on sitting/standing, fatigue/weakness, and dizziness. R1's urinary indwelling catheter focus dated 11/6/23, directed staff to monitor/document/report signs and symptoms of infection that included but was not limited to monitor/record/report blood-tinged urine, change in behavior, change in eating patterns. R1's Progress note dated 3/4/24 at 6:51 a.m., indicated that during rounds at 11:00 p.m. on 3/3/24, R1 was having labored breathing, cyanosis (blue) lips and hard to arouse. Vitals signs were way off blood pressure (BP)-81/47 (normal BP 120/80), P (pulse)-49 (normal pulse 60-100), T (temperature)-97.7 (normal temp 97-100), R-9, O2 (blood oxygen saturation)-78% (Normal O2 95-100%). The ambulance was called, and they left the building at 12:53 a.m. after unsuccessful attempt to raise R1's 02 above 89%. In review of R1's record, the last recorded set of vitals prior to 3/4/24 was documented on 2/6/24, almost one month ago. Her vitals were BP 110/70, P 85, T 97.6, R 18, and 02 93%. No other progress notes entries were made on 3/3/24 pertaining to R3's change of condition. During an interview on 3/6/24 at 10:29 a.m., nursing assistant (NA)-A stated she saw R1 in the dining room for lunch 3/2/24 and thought R1 looked good and had not noticed any changes. Emergency Medical Services (EMS) run report from 3/4/24 12:18 a.m. 1:25 a.m., indicated upon EMS arrival R1's O2 was in the low 20's on room air, R1 was unresponsive, was lying in a mid-upright position on the bed. Oxygen was applied at 12:33 a.m., high flow 02 per non-rebreather and an oropharyngeal airway placed. The patient is having periods of apnea, A strong sternal rub would get breathing started again. R1's emergency department summary dated 3/4/24, indicated R1 arrived in severe respiratory distress after being found around 12:30 a.m. in an altered state for level of consciousness. R1 had labs completed with a carbon dioxide (CO2) level of 81 mm (normal range 35-45). R1's Minnesota Documentation of Death worksheet identified the final disease or condition resulting in death was ACUTE RESPIRATORY FAILURE with the secondary significant condition contributing to death but not resulting in the underlying cause was listed as PARKINSON'S DISEASE, SEIZURE DISORDER. During a phone interview on 3/7/24 at 4:30 p.m., R1's family members (FM)-A, FM-B, and FM-C indicated they brought dinner to the facility to eat with R1 on 3/3/24. FM-C indicated that R1's sclera (white of eye) had been red and glossy and R1 looked dazed and drugged up. FM-A indicated that R1 had difficulty holding a cookie and took one bite of it. FM-A indicated that R1 did not seem like herself Sunday (3/3/24) and R1 usually enjoyed sweets, family meals and staying up late. R1 requested to go to bed and she usually sat in the recliner until 10:00 p.m. FM-A and FM-C indicated they had seen R1 hunched over to one side while on the toilet before R1 went to bed. FM-B indicated that FM-C had to point out to RN-A of the catheter having frank (bright red) cherry blood and sediment in it. FM-B stated that RN-A said, it's ok. During a phone interview on 3/7/24 at 8:30 a.m., NA-C indicated on 3/3/24 she worked the day shift and around 7:00 a.m. R1 had very little urine in her collection bag. NA-C did not think the urine was super dark at that time and did not notice any other changes. During an interview on 3/6/24 at 10:35 a.m., unit assistant (UA)-A stated on she worked the day shift on 3/3/24. UA-A explained R1 looked tired. R1 had told UA-A she did not feel good in general. R1 did not eat lunch but drank half a container of Ensure (vitamin enriched drink supplement). UA-A stated she told someone of R1's condition but could not recall if she told a nursing assistant or a nurse that R1 did not eat and was tired. During a phone interview on 3/7/24 at 11:21 a.m., NA-D indicated on 3/3/24 she worked the day shift and R1 did not look herself. R1 was pale, had a sore throat, did not talk, did not eat breakfast, and drank only half a container of Ensure. NA-D stated she told licensed practical nurse (LPN)-A of R1's symptoms. NA-D indicated (UA)-A sat with R1 for lunch, R1 did not eat anything then either and only consumed half of her Ensure. NA-D indicated when she emptied R1's catheter bag it only had 100-150 cc's of very dark, like an orange-brown color urine in it for the entire shift (normal 30 cc' s' per hour). NA-D stated she had notified LPN-A of her concerns for R1 at least three times that day. NA-D was aware LPN-A gave R1 a Covid test, however was unaware if LPN-A assessed R1 beyond the Covid test. During a phone interview on 3/7/24 at 1:52 p.m., LPN-A stated on 3/3/24 she worked the day shift. LPN-A stated NA-D felt that R1 was little slower to respond when completing tasks. R1 seemed fine when LPN-A gave R1 her scheduled medications in the morning. LPN-A attributed R1's slow response time to a newly scheduled pain medication (tramadol). LPN-A explained in response to NA-D concerns, she gave R1 a Covid test which showed negative results, however, did not complete any further assessments and did not take R1's vital signs. LPN-A stated she did not document NA's reported concern(s) and the negative Covid test results. During a phone interview on 3/7/24 at 10:34 a.m., Family member (FM)-A indicated that family was at the facility visiting R1 at 5:00 p.m. on 3/3/24 and R1 had one bite of bread for dinner. FM-A indicated R1's eyes were glazed over and R1 looked worse than normal. FM-A stated R1 was brought back to the room at 6:30 p.m., she wanted to lay in bed. FM-A stated RN-A was notified of R1's red and clotty urine and RN-A stated they would follow-up the next day. During a phone interview on 3/7/24 at 11:11 a.m., NA-E indicated on 3/3/24, she worked the evening shift. NA-E stated during shift report NA-D reported R1 did not seem like herself, her eyes were red. R1 had stated she was not doing good. NA-E had checked on R1 at the beginning of her shift a little after 2:00 p.m. NA-E indicated at that time R1's lips were a darker purplish color and were like that throughout the entire shift. NA-E also explained when R1 talked she could barely hear her, and she wanted to go to bed early which was not normal. NA-E indicated that R1's urine output had been 150 cc' s' and was a really, really dark brown and looked like blood clots were in there. NA-E stated after dinner sometime and when R1 was in bed (could not recall time) it seemed like things had gotten progressively worse. as R1 had bloodshot eyes, was pale, and could not really move her eyes or talk. NA-E stated she immediately called registered nurse (RN)-A and RN-B to evaluate R1. NA-E indicated RN-A and RN-B came to R1's room, she did not see any vital signs taken, but the nurses told her they were normal. NA-E indicated she felt R1 should have gone to the hospital. During a phone interview on 3/7/24 at 12:21 p.m., RN-B indicated on 3/3/24 she worked the evening shift. RN-B stated a nursing assistant reported concerns about R1 so she went to R1's room; the room was dark during the assessment but she could see R1 had dark urine and red eyes. RN-B indicated RN-A took R1's vital signs and they looked stable. RN-B indicated they concluded R1 was fine aside from the dark urine and R1 did not need to be sent to the hospital. RN-B could not recall any of the vital sign values and did not document them and/or write a progress note. During a phone interview on 3/7/24 at 10:26 a.m., RN-A indicated on 3/3/24 he worked the evening shift. RN-A stated R1's family was at the facility around supper. R1's family had notified him they were concerned about the color of R1's urine and R1 was in pain. RN-A stated he explained to family R1 could not have any more pain medication until bedtime and he would have the concerns with the urine followed up tomorrow during the day (3/4/24). RN-A indicated he had checked R1's vital signs after R1 went to bed and they seemed normal and would pass it [concerns] on to the next shift to monitor. RN-A had also asked RN-B to evaluate R1. RN-A could not recall the time he took R1's vital signs, could not remember any of the vital sign values, and did not document and/or write a progress note about R1's condition. RN-A gave shift report to RN-C and stated, I shared what the family had said and told him [RN-C] as of now we are not concerned of anything and to just watch her. During a phone interview on 3/7/24 at 9:50 a.m., NA-F indicated he worked the overnight shift on 3/3/24. NA-F stated NA-E gave her shift report at 10:15 p.m. which included R1 was less responsive than normal, lethargic and urine was cola brown. NA-F did not go to R1's room until after 11:30 p.m. NA-F stated, immediately when I went to her room, I could tell she was in crisis. R1 had shallow breaths and R1's respirations were intermittent, and about 9 breaths per minute. R1 was unresponsive and not able to be aroused. She had virtually no urine in the collection bag. NA-F stated he took a full set of vital signs; R1's oxygen saturations were in the 70's (normal is 95-100%) and pulse was in the 40's (normal is 60-100 beats per minute). NA-F indicated that R1's head of bed had been elevated between 30 and 60 degrees. NA-F indicated he ran and told RN-C to call an ambulance. NA-F requested NA-G to sit with R1 and wait for the ambulance. NA-F indicated he completed vital signs only one time on R1 and was unaware if RN-C completed vital signs or an assessment. NA-F stated RN-C did not put oxygen on R1 and he gave emergency medical services (EMS) the medical history on R1. During a phone interview on 3/7/24 at 12:26 p.m., NA-G indicated she worked on the evening shift on 3/3/24. NA-G stated NA-F asked if she would sit with R1 or do rounds on the other residents. NA-G chose to sit with R1. NA-G stated when she got to the room R1 was unresponsive. NA-F had taken R1's vital signs, NA-F remembered R1's blood pressure was 81/47. R1 had the oximeter on her finger, it was not reading right. NA-G was concerned because R1's fingernails were blue. R1 did not have oxygen on, and no oxygen had ever been brought into the room. While they were waiting for the ambulance it seemed like R1 had hiccup things now and again. When EMS arrived, they put the oximeter on R1's ear and then NA-F switched places with her because NA-F said he knew R1 better. During a phone interview on 3/7/24 at 9:29 a.m., RN-C indicated he worked the overnight shift on 3/3/24. RN-C stated RN-A had only reported off R1 had coffee brown colored urine and low output but R1 had issues with urine output and catheter for some time. RN-C indicated he was notified of the change in R1 when NA-F was doing rounds. RN-C stated when he went into R1's room around 11:00 p.m., R1 was breathing differently and was not able to be aroused. RN-C stated he tried to arouse R1, but could not. RN-C called the on-call medical doctor, family, and EMS with update on R1. RN-C documented VS: blood pressure 81/47, pulse 49, respirations 9, oxygen 78%. During a phone interview on 3/6/24 at 12:10 p.m., EMS stated they received a call on 3/4/24 for respiratory distress on a resident at the facility. EMS stated when they arrived in R1's room, R1 did not have any oxygen on, and did not have the head of bed elevated more than 20-30 degrees. It didn't look like they had propped it up for anyone that couldn't breathe. EMS indicated initially a staff member was in the room but was unable to answer questions [NA-G] and then another nursing assistant [NA-F] came to the room that provided answers. EMS stated R1's nursing assistant reported to EMS that the evening shift reported that R1 had not been acting like herself, had blue lips, and was sleepier. EMS state We had to bag (ambu bag-a technique used for encountering patients in respiratory distress using a bag, valve, and mask) her a few times and she was very agonal breathing (desperate gasping for air). A male nurse [RN-C] came to the room and produced paperwork for EMS and provided a secondary oxygen tank. EMS questioned and stated, if this would have been caught earlier would the outcome have been different? and nothing was mitigated to help the situation between calling the ambulance and us getting there. During an interview on 3/7/24 at 11:51 a.m., RN-D indicated that R1's oxygen saturations were scheduled to be checked weekly. RN-D indicated if oxygen saturations dropped below 90% on room air, they would initiate oxygen via the facility standing orders. Nurses were expected to start oxygen if the saturation was below 90% on room air. RN-D had an expectation that a full set of VS, lung sounds, and documentation would be done for any change of condition. During a phone interview on 3/7/24 at 1:36 p.m., medical director (MD)-A indicated nursing should follow the standing orders for oxygen if saturations are below normal. MD-A expected vital signs and assessments completed for any change of condition and a physician notified of the change. During an interview on 3/7/24 at 1:54 p.m., Administrator and Director of Nursing (DON) identified the facility had a standing order for oxygen. DON indicated being notified of R1 hospital transfer at 1:27 a.m. on 3/4/24. Administrator and DON expected a comprehensive assessment be completed and documented with any change of condition and the physician be notified. The facility Change in a Resident's Condition or Status policy revised February 2021 directed: -Our facility promptly notifies the resident, attending physician and resident representative of changes in the residents medical/mental condition and/or status. -significant change in resident's physical/emotional/mental condition 2. A significant change of condition is a major decline or improvement in the resident's status that: -will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions -impacts more than one area of the resident's health status -requires interdisciplinary review and /or review on to the care plan; and -ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider; including information prompted by the Interact SBAR Communication Form. 8. the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition of status. The facility Resident Examination and Assessment revised February 2014 directed the facility to examine and assess the resident for nay abnormalities in health status, which provides a basis for the care plan. Physical Exam included: -vital signs (blood pressure, pulse, respirations, and temperature) -cardiovascular (heart rate and rhythm, peripheral pulses, capillary refill) -respiratory (lung sounds, irregular or labored respirations, cough, sputum) -neurological (alertness and orientation, speech clarity) -genitourinary (urine clear or cloudy, presence of catheter) The facility Standing Orders for Skilled Nursing Facilities undated but signed by MD-A 11/14/22, directed: -initiate and titrate supplemental oxygen (02) from 1-4 liters per minute (L/min) via nasal cannula (NC) PRN for dyspnea, hypoxia (02 saturation less than (<) 90% or < 88% for chronic obstructive pulmonary disease (COPD) or acute angina to keep 02 saturations greater than (>) 90%; immediately update provider with nursing assessment. -care of indwelling catheter: do not irrigate, change catheter PRN for leaking or decreased urinary output using a similar-sized catheter. The immediate jeopardy that began on 3/3/24 was removed on 3/8/24 when it was verified the facility implemented the following: 1) The medical director reviewed the following policies Change in Resident's Condition, Charting and Documentation Policy, Oxygen Administration, and Resident Examination and Assessment. No revisions were necessary. Additional policies reviewed by the facility in conjunction with aforementioned included, Signs and Symptoms of Respiratory Distress, Signs and Symptoms of Hypercapnia (high C02 blood levels), and Oxygen Use. 2) The facility identified residents at increased risk of respiratory distress and reviewed each care plan to ensure appropriate interventions were in place. 3) Licensed staff were provided with education on implementation of oxygen, signs and symptoms of respiratory distress and hypercapnia, monitoring and assessing for change of condition, and physician notification. Licensed staff demonstrated competency in the education that they were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure safe mechanical lift transfers were completed along with following manufacturer guidelines on how to apply slings,harness, and checking strap before using them for 4 of 4 residents (R1, R2, R3, R4), who utilized a mechanical lift. This resulted in immediate jeopardy (IJ) for R1, R2, R3, R4 when staff were not implementing recent retraining resulting in residents sliding through the lift sling, pain and anxiety when transferred with the lift causing the likelihood for serious harm, impairment or death if they fell from the lift. The immediate jeopardy began on 10/6/23 when nursing assistant (NA)-F transferred R1, not in accordance with the care plan, which resulted in a fall from lift. This same practice resulted in a fall from a lift on 10/8/23 with R2. The immediate jeopardy was identified on 10/18/23, and the administrator and director of nursing were notified on 10/18/23 at 2:28 p.m. The immediate jeopardy was removed on 10/19/23, at 4:11 p.m. but noncompliance remained at a lower scope and severity of an E with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: R1's Face Sheet identified R2 had diagnoses that included hemiplegia and hemiparesis (weakness one half of body) following cerebral infarction (stroke) affecting left non-dominant side. R1's quarterly Minimum Data Set (MDS) dated [DATE] identified R1 did not have cognitive impairment. R1's care plan dated 8/10/23 identified R1 required assist of two people with an EZ-Way stand and did not identify the lift harness size R1 required for transfers. Facility reported incident (FRI) dated 10/6/23, indicated nursing assistant (NA)-F did not follow R1's care plan that directed two assist for lift transfers; NA-F attempted to transfer R1 by herself. During the transfer R1 became weak and unable to support his weight; R1 had to be lowered to the floor. R1 did not sustain any injuries, the lift was removed from service, and NA-F was re-educated by nurse manager. R1's care plan dated 10/11/23, identified R1 required assist of two people with Hoyer (full body mechanical lift) with a sling size large. During interview on 10/17/23 at 11:32, R1 reported he was catapulted out of the standing lift on 10/6/23. He thought the machine was wobbly and dangerous. R1 explained he was going to be transferred from the toilet to his wheelchair. NA-F hooked him up to the lift and did not apply the lower leg strap. NA-F pushed the lift across his room to his wheelchair. As NA-F was lowering him to the chair, the back of his knees got caught on the chair and the knee stabilizer was not locked into place which caused his whole body to fall over. After the fall, R1 had knee pain, however did not report it because he had an important meeting to get to. R1 stated staff used two people most of the time, however sometimes they did not. After the fall, R1 was switched to a Hoyer, which caused him physical pain. R1 identified only some staff knew what they were doing, not all staff moved things out of the way before the transfer and was very concerned staff did not know how to safely operate the lift. During observation on 10/17/23 at 2:00 p.m., R1 was sitting in his wheelchair near the left side of the bed waiting to go to the bathroom. NA-A and NA-B were in his room with the Hoyer. NAs connected the sling loops to the crossbar of the lift. They did not wheel R1 closer to the bathroom so there would be less travel distance while R1 was suspended in the lift. When R1 was raised out of the wheelchair, NAs did not double check placement of the loops. While R1 was suspended in the air, NAs quickly maneuvered the lift around the side of the bed and rapidly pushed R1 into the bathroom that was approximately five feet away. The rapid movements caused R1 to jerk and sway back and forth in the sling. Throughout the process R1 cried out Jesus Christ!, OUCH! OUCH!, Fuck put me down!, Do something! Get me something different! and What the hell are you doing? At no point did NA's respond to R1's cries of discomfort and continued with the transfer to the toilet. Once on the toilet, NA-B was in front of R1 controlling the machine and NA-A was behind R1. R1 continued to voice pain and discomfort in his legs and genital area. NAs raised R1 off the toilet multiple times to get R1 seated on the toilet correctly. However, during these attempts NA-A was not holding the center handle on the back of the sling to guide R1 to an up-right position. The surveyor stopped further attempts by NA's and requested a nurse's presence related to unsafe transfer techniques and R1's reported discomfort. At 2:16 p.m. registered nurse (RN)-A entered R1's bathroom. R1 reported pain from the sling strap pushing on his thighs. R1 was raised off the toilet, NAs or RN-A did not verify sling placement was correct. Once suspended in the air, the sling was approximately 4 inches above his tail bone and approximately 4 inches over the top of R1's head. The sling placement caused R1's buttocks to sink down through the whole of the sling which resulted in the lower sling straps in-between R1's legs to tighten and R1's knees were pulled up towards his chest, pinching skin and genitalia. Staff pushed the lift across the room to the bed, however R1's wheelchair was in the way. Staff lifted the wheelchair up and over the lift. R1 continued to vocalize pain throughout the transfer. Staff lowered R1 to sit on his bed and NAs pulled up R1's pants and put the sling back under R1 and attached the sling to the lift. NA-A reported the the sling is fine here. When R1 was lifted off the bed to transfer to the wheelchair R1 was not centered in the middle of the sling. There was approximately two inches of sling on R1's left side with the rest of the sling on R1's right side. Throughout transfer R1 was screaming OUCH!!, his right hand was in a tight fist and shaking, he closed his eyes, and had facial grimacing. During interview on 10/18/23, at 10:33 a.m. NA-F recalled R1's fall on 10/6/23 when she attempted to transfer R1 alone from the toilet to his wheelchair with the EZ-stand. She raised R1 up because he was not standing straight and had left sided weakness and leaned more to the right. He can only can hang on to the machine with his right hand. When she raised him up she cinched the belly strap, however R1 would not allow her to put the leg strap on. She she pulled the EZ-stand from the bathroom and around his bed to where his wheelchair was located. NA-F stated she had not raised R1 high enough to get R1 into his wheelchair, his legs gave out, causing R1 to hang/dangle by the harness that was still connected to the lift. NA-F stated she then pulled the lift away from the wheelchair and lowered R1 to the floor. NA-F stated she did not follow the care plan to use two assist nor did she use the lift's calf strap. During interview on 10/20/23, at 10:20 a.m., family member (FM)-A indicated she had been aware three days after the 10/6/23 incident, however was not aware R1's care plan was not followed or that the leg strap had not been used for the standing lift. FM-A stated R1 had expressed extreme pain and discomfort while using the full body lift transfers and the straps would rub on his thighs during the transfer. FM-A expressed concerns staff did not have appropriate education and rushed too much during transfers. R2's Face Sheet identified R2 had diagnoses of dementia and osteoarthritis of bilateral knees R2's quarterly MDS dated [DATE], identified R2 had moderate cognitive impairment. R2's care plan dated 09/07/22, identified R2 required assist of two staff with use of EZ-stand for all transfers including toilet use with use of medium size sling. FRI dated 10/8/23, indicated NA-F had reported to the nurse R2 had slid out of the EZ-stand when she was transferring her. Nurse found R2 sitting on the bathroom floor with her back up against the toilet. NA-F did not follow R2's care plan that directed two staff assist. During an interview on 10/18/23, at 10:33 a.m. NA-F indicated she had never been a nursing assistant before and was hired at the facility to start on 8/21/23. NA-F indicated she had not been deemed competent by a nurse using the mechanical lift in the clinical setting. NA-F stated after R1's incident, she was educated by nurse manager (NM)-A and NM-B to use two person transfers and continued to work the rest of her shift. She then worked by herself on 10/7/23 and again on 10/8/23. NA-F indicated on 10/8/23 she had used and EZ Way stand to get R2 off the toilet, pulled R2 back away from the toilet and was providing peri care when R2 went limp and unresponsive, NA-F lowered R2 to the floor, disconnected the loops and left the room to get help. NA-F indicated R2 was supposed to be assist of two for EZ-stand transfer. During observation on 10/17/23 at 12:46 p.m., R2 was sitting in her wheelchair with a mesh lift sling placed underneath her. NA-C and NA-D positioned the lift and connected the sling loops to the lift. NAs raised R2 in the air and did not check loop placement before they lifted her. R2's sling was not centered causing R2 to lean to the left almost a side lying position. The sling was not placed down on R2's back causing R2's buttock to sink through the sling's hole. The sling position caused tension on the leg straps in-between her legs resulting in her knees being pulled up to her chest. NAs continued to move the lift away from the wheelchair without recognizing R2 sliding through the sling. The surveyor instructed NA's to stop immediately and readjust the sling. NA-D responded, What do you want me to do? It's a shower sling. NAs lowered R2 back into the wheelchair. As the NAs were adjusting the sling, R2 displayed facial grimacing while holding onto her right hip and yelled ouch, ouch, ouch. NA's did not respond to R2's pain. NA's again connected the loops, raised R2 up into the air, and did not check loop or sling placement. NA's quickly pushed and pulled R2 in the lift across the center of the room and around bathroom threshold going from carpet to tile. The momentum caused R2 to sway back and forth; NA-C was not consistently guiding the suspended sling with R2 nor tried to stop the swaying. NAs then lowered R2 to the toilet. NA-C and NA-D was unsure if they could leave R2 alone in the bathroom. They locked the lift breaks, and left the room with R2 still connected to the lift. Upon return to R2's bathroom, NA-D pulled the lift away from the toilet without double checking loop placement. NA-C was not watching nor assisting as NA-D maneuvered the lift around the corner of the bathroom into the bedroom and into her wheelchair. During interview on 10/17/23 at 1:15 p.m., R2 stated she had left hip pain when using the Hoyer from the pressure of the sling. R2 indicated the pain from the transfers was dependent on which staff it was. Some staff were more knowledgeable with lift transfers than others. R2 stated she was sometimes very fearful while being transferred in the lift and how staff were handling her. During interview on 10/20/23 at 10:20 a.m., FM-B indicated an awareness R2 had a fallen from the lift, however was not sure on how something like that could have happened. FM-B reported once she was present during a standing lift transfer and staff did not connect the calf strap, applied the harness, and told R2 to hang on. FM-B voiced concerns on staff's knowledge on lift safety. R3's discharge MDS dated [DATE], identified R3 did not have cognitive impairment. R3's care plan dated 5/6/22, instructed staff to use two assist with EZ-Way stand for toilet use and general transfer. During observation on 10/17/23 at 12:24 p.m., R3 was suspended in the air by the Hoyer over her bed; only NA-D was present. NA-D stated, I only had R3 lifted up like this because R3's back was in pain. NA-D lowered R3 so that she was partially supported by the bed but remained suspended by lift. NA-D locked the brakes of the lift and left the room to get help with transfer while being left in the lift. NA-D and NA-E re-entered the room, raised R3 up off the bed, did not check loop or sling placement. NA-E quickly pushed the lift approximately 3 feet over to the recliner while R3 freely swayed back and forth; NA-D was not providing guiding support. Once the lift was near the recliner, NA-E pushed lift legs against recliner base which had a wooden structure. This caused R3 to jostle abruptly without total control and support by NA-D. NA-D then guided R3 to a seated position. R3's care plan did not identify R3 required the Hoyer lift. During interview on 10/17/23 at 12:34 p.m., R3 recalled the fall from 7/25/23 and that she had experienced pain to her bottom because the impact was very hard. After the incident, she told FM-C who then reviewed the fall on R3's personal camera in her bedroom. R3 explained she was very lucky staff were not pulling the lift away from the toilet like they normally did, she would have landed on the floor with bigger problems. R3 explained she was fearful for her own safety when being transferred in the mechanical lifts because of that fall and other experiences she has had while in the lifts. R3 explained there was two or three near miss falls in standing lift where staff have had to catch her before she fell to the floor. When she has been in the Hoyer, staff have left her alone dangling in the air in her room. When staff push her around in the lifts they rush, and do not seem to pay attention. R3 found it very necessary to check loop placement herself because staff were always in a hurry and rushing. FRI dated 7/26/23, indicated on 7/25/23, R3 was assisted from the toilet using EZ-Way stand with assist of two NA's. Upon lifting R3 to a standing position, right side of EZ stand strap slipped from the hook and R3 was abruptly lowered to the toilet seat. The 7/25/23, video footage of the incident was reviewed and identified R3 was seated on the toilet attached to the lift with two staff present. The driver of the lift unlocked the lift breaks and started to raise R3 off the toilet, at about midpoint it was evident the right harness loops were not inside the hooks, rather rested on top. Staff assisting did not identify the loops were not correctly placed and continued to raise R3. As R3 was nearing a full standing position the loops slid off the top of the hook causing R3 to suddenly drop back down to the toilet. During interview on 10/18/23 at 11:40 a.m., FM-C reported reviewing the video footage and notifying the director of nursing (DON) on 7/26/23 of a fall. FM-C explained the video camera was put into R3's room because there had been ongoing safety concerns with the way staff were operating the mechanical lifts. During interview on 10/20/23 at 8:06 a.m., NA-I indicated she was present for the R3's incident on 7/25/23, with NA-H. NA-I stated neither of them checked the loops prior to raising R3 off the toilet and loops slipped off the hook. She was thankful R3 was still over the toilet otherwise R3 would have fallen to the floor. NA-I stated R3's calf strap was also not applied and should have been. NA-I explained she had thought the calf strap was supposed to be applied however, when she was trained nobody else was using them, so she did not think it was necessary. During interview on 10/19/23 at 4:12 p.m., DON indicated she was notified of R3's incident with the lift on 7/26/23, not by staff but by FM-C. The investigation identified the top loop of the harness was not appropriately applied and was not all the way under the safety latch. DON was not aware of the calf strap was not applied. DON reported NA-H and NA-I had verbal coaching that included not reporting the incident and safe patient handling. Additionally both received Just In Time training which included reading and signing information about mechanical lift safety. DON stated a return demonstration for ensure competency was not provided or completed for any staff following the incident. R4's Face Sheet identified R4 had diagnoses of hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left non-dominate side and a history of falls. R4's quarterly MDS dated [DATE], identified R4 had significant cognitive impairment. R4's care plan dated 8/25/2020, instructed staff to transfer R4 with a Hoyer with two assist and medium size sling for all transfers. During observation on 10/18/23 at 12:15 p.m., R4 was seated in his wheelchair with NA-E and NA-C present preparing for a transfer with a Hoyer. NA-E attached loops of sling to lift stating here we are going up while NA-C was adjusting window blinds and out of reach of R4. NA-E did not stop to check loop placement. NA-E continued to lift R4 up and pull the lift backwards away from the wheelchair and NA-C moved the wheelchair across the room. At the same time NA-E continued to push and maneuver the lift towards R4's bed and because of the lack of guidance by NA-C, R4 spun in a circular motion while suspended in the air. R4 was grasping and shaking the upper lift straps crying out OH MY GOD! NAs did not intervene or respond to R4's discomfort or dangers of R4 grabbing the straps. Once the lift and R4 were to the bed NA-C guided R4 to a lying position on the bed. During interview on 10/19/23 at 3:38 p.m., NA-A and NA-J indicated they had never had to complete return demonstrations as part of mechanical lift training before. During interview on 10/20/23 at 8:06 a.m., NA-I indicated mechanical lift training was completed after R1 and R2's falls however, the training did not include return demonstration to ensure competency. During interview on 10/20/23 at 1:21 p.m., NA-L indicated she was a student nursing assistant, another certified NA had determined she was competent to operate the lifts. During interview on 10/20/23 at 8:03 a.m., NA-M indicated she was a student nursing assistant, another certified NA had determined she was competent to operate the lifts. During interview on 10/20/23 at 8:38 a.m., NA-R indicated the lift education that was presented on 10/9-10/10/23 were forms and paperwork to read. There was no return demonstration on lift operation completed. During an interview on 10/18/23, nurse manager (NM)-B indicated after the lift incidents on 10/6/23 and 10/8/23, there was lift education required, however it did not include testing for competency. During interview on 10/17/23 at 4:46 p.m., DON indicated following R2's fall on 10/8/23, NA-F was immediately removed from the floor and sent home. On 10/9/23 training was initiated for both types of lifts. Staff were trained on lift positioning, transferring, safety, how to put the person in, and the whole competency checklist from EZ-Way. However, staff did not do return demonstration for knowledge check. In a subsequent interview on 10/18/23 at 1:10 p.m., DON indicated staff should not be locking brakes on the mechanical lifts in the facility, staff should not leave residents unattended while hooked up to any mechanical lift, and all staff should follow manufactures recommendation for all mechanical lifts. During interview on 10/20/23 at 2:45 p.m. Administrator stated expectation was all mechanical lifts were used in accordance to facility policy and residents should not be left unattended attached to mechanical lifts. During interview on 10/18/23 at 9:35 a.m., EZ-Way lift representative (LR)-A indicated its important for staff to complete strap safety checks prior to transfers and in accordance to manufacturer's recommendations. The foot plate and the shin pad were to be positioned according to resident needs. LR-A stated We don't want spinning people in the air staff should be guiding. LR-A indicated the base of toileting (hygiene) slings are to be positioned at the pants and we do not want sliding or significant leaning. If residents are leaner's staff should be using a different style sling. LR-A indicated residents could fall out of lifts if staff were to use wrong size slings, if the sling position was crooked or misplaced, using the wrong loop, or if there was a uneven surface such as moving over carpet. Checking and double checking the safety loops and positioning was a very important factor in safety with mechanical lifts. EZ Way smart lift (full body Hoyer lift) operators instructions dated 6/14/23 identified the wheels of the EZ Way Smart Lift should never be locked when lifting or lowering a resident. Prior to lifting a resident staff are to make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars. Upon lifting the resident continue the upward motion until there is tension on the sling legs, making sure all the loops on the sling are securely hooked on the hanger bars. For patients who have soft or delicate skin, care must be taken to ensure the sling is smoothed out along the thigh. When transferring from chair, wheelchair or toilet when placing the sling staff are to place the excess sling length over the left thigh and repeat on the right side. This procedure will ensure the sling is under the patients tail bone and behind his/her back, with the patients weight evenly distributed on the sling. It is important the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of neck). While using the handles located on the back of the sling, position the resident so he/she can properly align to be lowered onto the chair, toilet or wheelchair. Staff are to stand behind the patient and hold onto the center handle located on the back of the sling. When the patient is nearly seated pull up on the center handle to ensure the patient will be seated in a upright position. EZ Way Smart Stand lift (sit to stand lift) operators instructions dated 6/14/23 identify *WARNING* For safe operation of the EZ Way Smart stand the stand must be used by trained personnel in accordance with the operators manual, video and training checklist to avoid injury to patient. The harness should be placed around the upper body of the patient so the sides of the harness are between the patients torso and arm resting two to three inches below the underarm. Use shin pad Strap: If a caregiver deems it necessary to keep a patients shins or feet on the foot plate, secure the shin strap around the patients legs. Prior to raising the patient caregivers are to verify the loops are properly hooked inside the pigtail at the end of the EZ Way smart stand arms and safety catch is in place, blocking the strap from exiting through the pigtail. When patient is being raised, simultaneously tighten the safety strap buckled around their torso. Facility Mechanical lift policy dated 7/2017 titled lifting machine, using a mechanical identified The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. c. Sit-to-stand lifts. 4. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Steps in the Procedure 1. Before using a lifting device, assess the resident's current condition, including: a. Physical: b. Cognitive/Emotional: 2. Measure the resident for proper sling size and purpose, according to manufacturer's instructions. a. Clear an unobstructed path for the lift machine; c. Position the lift near the receiving surface; and d. Place the lift at the correct height. 10. Place the sling under the resident. Visually check the size to ensure it is not too large or too small. 12. Attach sling straps to sling bar, according to manufacturer's instructions. a. Make sure the sling is securely attached to the clips and that it is properly balanced. b. Check to make sure the resident's head, neck and back are supported. c. Before resident is lifted, double check the security of the sling attachment. 13. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. 14. Check the resident's comfort level by asking or observing for signs of pinching or pulling of the skin. 15. Slowly lift the resident. Only lift as high as necessary to complete the transfer. 16. Gently support the resident as he or she is moved, but do NOT support any weight. The immediate jeopardy that was identified on 10/18/23, was removed on 10/19/23, at 4:11 p.m. when it was verified the facility implemented the following corrective actions: -Reviewed manufacture's recommendation in conjunction with their mechanical lift transfer policies and procedures. -Re-educated staff on appropriate positioning of the slings/harnesses and checking placement of the loops on slings/harnesses according to manufacturer's recommendations -Completed a return demonstration that ensured all staff who utilize the mechanical lift could complete safe transfers in accordance with facility policy and manufacturer guidelines for a safe transfer.