**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure a resident's environment remained as free of accidents and hazards as possible for 1 of 6 residents (CR #1) reviewed for accidents and hazards in that: - The facility failed to ensure the environment remained free of accident and hazards when CNA D and CNA W transferred CR #1 from her wheelchair to the bed on 2/2/25, and she sustained a laceration to her R leg requiring 15 sutures and 18 staples. An Immediate Jeopardy (IJ) was identified on 2/26/25. The IJ template was provided to the facility on 2/26/25 at 4:30pm. While the IJ was removed on 2/28/25 at 4:40pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm, with the potential for minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for serious injuries and hospitalization. Findings included: Record review of Resident CR#1's undated face sheet revealed she was an [AGE] year-old female originally admitted on [DATE], with the most recent admission being 2/2/25. She had diagnoses of muscle weakness, unsteadiness on feet, muscle wasting and atrophy (loss of muscle mass and strength,), end stage renal disease on dialysis (kidneys stopped filtering so a machine does it), reduced mobility, glaucoma (vision loss and blindness damaging the nerve in the back of the eye), lymphedema (swelling caused by buildup of lymph fluid in the body between skin and muscle), and cognitive communication deficit (difficulty communicating that's caused by a brain injury or other cognitive impairment). Record review of CR #1's admission MDS assessment dated [DATE] revealed a BIMS Score of 11 out of 15, which indicated moderately impaired cognition. She had impairment on one side of her lower extremities. According to the MDS, transfers were not attempted due to CR #1's medical condition or safety concerns. She was dependent on staff (helper does all of the effort and resident does none of the effort. Or the assistance of 2 or more helpers is required.) for ADL's. Record review of CR #1's Care Plan dated 12/26/24 revealed the resident sustained a skin tear to her R lower leg (Initiated: 2/2/25). The goal was to not have any infection to the skin tear through the review date (Initiated: 2/2/25, Target: 4/6/25). Interventions included the resident was transferred to the ED for eval/tx. Keflex (antibiotic) for 10 days. Monitor for s/s of infection and report any negative findings to the MD. The Care Plan also revealed CR #1 had an ADL self-care performance deficit r/t weakness that was initiated on 1/2/25. The goal was to improve the current level of function through the review date and was initiated on 1/2/25 with a target date of 4/6/25. According to the interventions, CR #1 required total assistance with transfers. Record review of CR #1's PT note from 1/31/25 revealed her precautions/contraindications were: High fall risk, HOYER pad in wc at all times. Record review of CR #1's Progress Note from 2/2/25 at 1:55pm by LVN B revealed, Resident was assessed with no new skin issues noted. VS are stable. Denies pain at this time. On call was notified of resident return. Resident alert and oriented and able to voice needs and concerns. Will continue to monitor. Record review of CR #1's Change in Condition Note from 2/2/25 at 2:10pm by LVN B revealed, Resident noted with a large skin tear to right outer LE. Pressure DS applied. Record review of CR #1's Progress Note from 2/2/25 at 2:10pm by LVN B revealed, CNA called this writer to resident room and noted resident in bed with a large skin to the right lower leg with moderate amount of bleeding. Resident denies pain at this time and appears in good spirit. Pressure DSG was applied to area. Both CNAs states that while attempting to transfer resident into bed that resident RLE got caught on the side of the bed resulting in skin tear. Resident states her leg got caught on side of bed while the aides was attempting to sit her on the on the bed . Record review of CR #1's hospital records from 2/2/25 at 4:10pm said the resident presented to the ED with a R leg laceration after getting it caught on a metal bed. According to the records, the resident had a leg laceration [tear or cut in the skin or underlying tissues] and partial skin avulsion [forceful tearing away of tissue or body parts, like skin, muscle, or bone], wound irrigated extensively, multilayer sutures placed along with staples . The laceration was 6.2 inches long and 0.78 inches deep. The resident received 15 sutures and 18 staples according to hospital records. Record review of CR #1's Physician's Orders revealed the following orders from MDS: - Cleanse skin tear one time only for 1 Day RLE with NS and apply pressure dsg. Ordered 2/2/25. - Monitor R Leg wound sight each shift. Ordered 2/2/25. - Remove staple and sutures in 14 days. Ordered 2/2/25. - Keflex (Cephalexin) 500 MG Oral Give 1 capsule by mouth. Ordered on 2/3/25. - Location of wound: Right lateral (outside) calf, skin tear PAIN CODE INTERVENTION, Every shift. Ordered 2/6/25. Record review of the facility's Provider Report from 2/2/25 revealed at about 2:15pm CR #1 arrived at the facility from home via family transportation. The SW grabbed a facility wheelchair, and the family transferred the resident from the family vehicle into the wheelchair and then rolled her into the facility. The family requested CR #1 be transferred into bed, so the SW asked CNA W to transfer CR #1 into bed. CNA W got CNA D to help her with the transfer. The CNAs raised the resident, pivoted her and sat her on the bed. When the aides lifted the resident's legs up on the bed, they noticed a skin tear to the outer portion of her lower leg. According to the Provider Report, The bed was inspected and though there were no jagged edges noted, there appeared to be blood on the side rail located on the base of the bed with a blunt opening. In an interview with CNA D on 2/26/25 at 9:04am she said CNA W asked her to come in and assist with putting CR #1 to bed. She said both CNAs transferred her into the bed. When they went to swing her legs into the bed, she saw blood on her hands. She asked CNA W if that was blood and she said yes, but they didn't see any blood on the w/c. Then they noticed blood on her leg. The blood on her gown was noticeable. In an interview with CR #1's family member on 2/26/25 at 10:21am she said they helped CR #1 into a wheelchair that she grabbed from the facility. She said they rolled CR #1 into the facility and spoke to the SW as soon as they entered the facility. Then they went back to the same room she was in before. She said CR #1 told her the aides were lifting her into the bed and she told them You're tearing my leg. Record review of pictures of CR #1's laceration to her R leg, received on 2/26/25 at 10:41am revealed a deep laceration in the shape of a C, exposing the subcutaneous (the deepest layer of your skin, made up mostly of fat cells and connective tissue) layer. In an interview with CR #1 on 2/26/25 at 10:51 a.m. she said her family member brought her into the facility and they spoke to someone at the nurse's station, but she did not remember who. She said 2 aides transferred her from the wheelchair into the bed. CR #1 said she yelled out and her leg got caught on something on the bed. She said she was wearing a dress when it happened. She said she was out with her family that day and it did not happen before she got back to the facility. In an interview with CNA W on 2/26/25 at 11:10am she said they lined CR #1 up against the bed. They told her on the count of 3 they would transfer her. CNA W said CR #1 said she would help. She said CNA D was on the other side of the bed in case she fell off the other side. CNA W said after she transferred her onto the bed and went to lift her legs, there was blood everywhere. She said she did not see any on the wheelchair but saw some on the bed. CNA W said she did not see anything sticking out of the bed, but she saw something that was supposed to be covered because it looked rough. In an interview with LVN B on 2/26/25 at 11:50am she said she saw CR #1 in the hallway and was talking to her before she went into the room, and she did not have any blood or anything on her before the transfer. She said when the CNA told her to come to the room CR #1 was already lying in the bed and she had a laceration on her leg. LVN B said she saw blood on the floor in CR #1's room, and if it would have happened before she would have seen blood in the hallway. She said CR #1 had a bad skin tear, the worst she's ever seen. LVN B said she put a pressure dressing on it and sent CR #1 out via regular transport. She said the resident came back and she had sutures and staples. LVN B said CR #1 normally used a mechanical lift because she could not do anything. She said the CNAs should have looked at the [NAME] (worksheet that summarized patient information) or asked her how the resident transferred. In an interview with the SW on 2/26/25 at 12:06pm she said she was in her office when family stopped by her office and said CR #1 was back, so she went and got a wheelchair, and she notified the nurse. She said she did not notice any blood when the resident came in and the resident was not in any pain. The SW said she did not notice any blood on the floor as she was rolled to her room, in the hallway while she was waiting for her bed to be made, or any blood while she was in the room. The SW said she would have seen the laceration because it was visible. In an interview with the ADM on 2/26/25 at 1:15pm she said CR #1 had just got to the facility and family wanted her to be transferred to the bed. She said 2 aides transferred her into the bed and when the aides moved her legs they noticed the blood. The ADM said she did see the laceration and it looked bad, but she did not know if blood would have been seen dripping through the facility. In an observation with the ADM on 2/26/25 at 2:40pm, revealed the bed that was in CR #1's room was noted to have a ¼ grab bar attached to the side of the bed with a pipe sticking out without a cap on the end, making it rough and a potential hazard. The facility was asked if they had a policy on Accidents and Hazards, but they did not have one. Record review of the facility's policy and procedure on Safe Lifting and Movement of Residents (Revised October 2009) revealed in part: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety .medical condition will be incorporated into .decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff .shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident's mobility (degree of dependency. Resident's size. Weight-bearing ability. Cognitive status .Staff responsible for direct resident care will be trained in the use of manual .and mechanical lifting devices .Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary .Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings . An Immediate Jeopardy (IJ) was identified on 2/26/25. The IJ template was provided to the facility on 2/26/25 at 4:30pm. The Plan of Removal was accepted on 2/27/25 at 3:56pm. The plan of removal reflected the following: Name of Facility: {Facility} Date: February 26, 2025 Immediate action: What corrective actions have been implemented for the identified residents? A. On 02/02/2025 CR#1 involved in alleged deficient practice was discharged to the hospital due to a laceration sustained during a transfer from the wheelchair to the bed. B. On 02/02/2025 the incident involving CR#1 was reported to Health and Human Services. C. On 2/02/2025 at 4 pm the Administrator initiated the investigation, and blood was noted on the side of the bed frame on the square opening area. D. On 2/02/2025 CNA D was in-serviced on Referring to Resident POC for Transfer Instruction. E. On 2/02/2025 CNA W was in-serviced on Referring to Resident POC for Transfer Instruction. F. On 2/02/2025 at 5 pm the Maintenance Director conducted an inspection of all beds, and bed frames. Beds that were missing caps on the side of the bed frame were sealed with either a cap or tape. These open areas are generally utilized to attach side rails to the bed frame. G. On 2/02/2025 at 5:20 pm the Maintenance Director placed a tab in the open area identified on CR#1 bed and then aides changed the bed out per family request. H. On 02/03/2025 at 9:00 am the Administrator notified the Medical Director of the alleged deficient practice. I. The Corporate Clinical Service Director reviewed facility policy on 02/03/2025 regarding Safe Lifting and Movement of Residents and no revisions were deemed necessary. J. On 02/02/2025 at 10:09 pm resident CR#1 returned from the hospital with 18 staples and 8 sutures. K. On 2/03/2025 an audit of past incidents was conducted. Two incidents were identified and previously reported to Health and Human Services. Facility's Plan to ensure compliance quickly A. An in-service was initiated on 02/03/2025 by the Administrator and the Assistant Director of Nursing with the aides on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect. The aides were not allowed to return to work until they received this in-service. The completion date is 2/13/2025. B. On 02/03/2025 the Director of Rehab and the Assistant Director of Nursing completed a 100% checkoff on Resident Transfers with the certified nursing aides. The aides were not allowed to return to work until they received this in-service. The completion date is 2/13/2025. C. Newly hired nurses will be in-serviced by the Assistant Director of Nursing or designee on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect. D. On 2/06/2025 nursing staff were in-serviced by the Assistant Director of Nursing on Reporting Hazardous Equipment Immediately Including Removing Hazardous Equipment. E. The openings identified by Surveyor were covered and a facility wide audit conducted 2/26/2025. Areas of concern addressed immediately. Tape was applied to two Assist Bars that had openings. F. Ambassador Rounding Sheet that was implemented to monitor bed frames on 2/3/25 was updated 2/26/25 to include the monitoring of the Assist Bars. Ambassadors will also check vacant rooms. G. On 2/26/25 nurses were in-serviced by the Director of Nursing on referencing [NAME] prior to directing staff including C.N.A.s and staff from other departments on how to transfer residents. The Charge Nurse and Nurse Managers will update the [NAME] upon admissions and readmissions with any change(s) in status. H. On 2/27/25 nurses were in-serviced by Director of Nursing instructing Charge Nurses to assess new and readmitted residents to determine transfer status and to communicate findings to the C.N.A.(s) on duty. On 2/28/25 a monitoring visit was conducted to ensure the facility was following its POR. The visit revealed: Record review revealed on 2/2/25 CNA D was in-serviced on abuse and neglect and transfers by the ADM. The in-services given were about reporting abuse and how the resident had the right to be free from abuse and neglect and the importance of safety measures applied when transferring residents. Record review revealed on 2/2/25 CNA W was in-serviced on abuse and neglect and transfers by the ADM. The in-services were related to reporting abuse and how the resident had the right to be free from abuse and neglect and the importance of safety measures applied when transferring residents. Record review revealed on 2/2/25 the Maintenance Director conducted an inspection of all beds in the facility. The residents' lifts were also checked in all rooms. Record review revealed the following rooms had beds that were taped: 102D, 102W, 103D, 104D, 105W, 106D, 106W, 109D, 109W, 111D, 111W, 113D, 114W, 115W, 202D, 203D, 204D, 205D, 206W, 207W, 208D, 209W, 210D, 211D, 211W, 212D, 213D, 213W, 214W, 215W, 216D, 302D, 302W, 303D, 303W, 304D, 305D, 306W, 307W, 309D, 310D, 313D, 314D, 315W, 316D, 316W, 401W, 402W, 407D, 407W, 408D, 409D, 410W, 411D, 412D, 412W, 414W, 415D, 415W. Record review revealed on 2/3/25 an audit of past incidents was conducted and the 2 incidents that occurred were on [CR #2] on 1/14/25 and [Resident #73] on 1/25/25. Record review revealed on 2/3/25 in-services were given by the ADON and the ADM on safe transfers which included the policy of two-person transfers, safe lifting, and movement of residents. Record review revealed 35 members attended in person and 18 via phone. Record review revealed in-services were given on 2/3/25 by the ADON/ADM on referring to the POC for transfer instructions and was about ensuring staff referenced the POC to properly transfer a resident, and about requiring 2 people for transfers with a Hoyer transfer. There were 52 staff members who attended in person and 11 via phone. Record review revealed on 02/03/25 in-services were given by the ADM on ANE, and transfers. The in-services were about ensuring the resident had the right to be free from abuse and neglect, and to ensure treatment that was provided to residents when transferring, was according to the facility policy and protocol. There were 55 staff members who attended in person. Record review revealed on 2/3/25 in-services were given by the ADON on conducting transfers and newly admitted residents. The in-services were about ensuring new admits and readmits were not transferred prior to being assessed by a nurse, even if family made the request. There were 45 staff in-serviced in person and 18 via telephone. Record review revealed on 02/03/2025 in-services were given by the DOR and the ADON on Two Person Stand-Pivot Transfer Competencies and Mechanical/Hydraulic Lifts. There were 80 staff members signatures. Record review revealed on 2/3/25 the ADON gave a new hire orientation regarding transfers, POC and newly admitted residents. The in-services were about ensuring new admits and readmits were not transferred prior to being assessed by a nurse, even if family made the request. Also ensuring staff were referencing the POC to know how the resident transferred and making sure 2 people use the Hoyer lift. There were 8 staff members that were in-serviced in person. Record review revealed on 2/3/25 the ADM gave a new hire orientation on ANE. There were 8 staff members present. Record review revealed on 02/06/2025 the ADON gave in-services on reporting any hazardous equipment. The in-service explained that any equipment that did not look safe needed to be reported to the maintenance director/ADM or reported in the TELS system. All equipment that was defective should be taken out immediately for service. There were 49 staff members who attended in person and 7 via telephone. Record review of the facility wide audit conducted on 2/26/25, including the Assist Bars, revealed no concerns. Record review revealed the template of the ambassador rounding sheet that would be used to monitor bed frames, assist bars, and ensured the checklist was used for vacant rooms. Record review revealed on 2/26/25 the DON in-serviced the CNAs and Nurses on transfers and [NAME]'s. The in-services were about ensuring the safety of residents who required assistance and ensuring the CNAs used the [NAME] prior to transferring, and if they had questions, to ask the charge nurse. The in-services also talked about having a 1 person or 2 people assist, or total dependence on a Hoyer lift transfer. Record review revealed on 2/27/25 the DON in-serviced the nurses on the transfer status for admits/readmits. Nurses were to ensure assessments were completed on residents and readmissions prior to being transferred by any staff, and to educate CNA's on how to complete the transfer. There were 13 nurses who attended the in-service in person and 18 nurses who completed the in-service via telephone. In an interview on 2/28/25 at 1:15pm, LVN A said she was in-serviced on transferring, like assessing the resident's transfer status at admission, telling the aide what kind of transfer they were, and updating the task on the [NAME]. She said she was also in-serviced on CIC, for any change like today when a resident received an x-ray for pain. She was also in-serviced on ANE, and the different types of abuse were sexual, physical, mental, and misappropriation. She would report to the ADM (abuse coordinator). In an interview on 2/28/25 at 1:20pm, CNA C said she had in-services on transfers, and making sure the bed/wheelchair was locked, putting a gait belt on, having the resident put their hands on her shoulders, counting to 3, pivoting, and counting to 3 and then sitting. She said they in-serviced about never using a mechanical lift with just one person because an accident could happen. Also, they talked about looking on the [NAME] to see how the resident transferred. CNA C said if she saw any hazardous equipment she would report it. ANE was also in-serviced, and the different types of abuse were physical, verbal, mental, sexual, misappropriation. If she were ever to see ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 2:14pm, Med Aide E said they had in-services on transfers, which included always having 2 people when using the mechanical lift, looking on the [NAME] for the type of transfers, and using a gait belt. She said they were in-serviced on hazardous equipment, and they informed the nurse if they saw any, and placed the resident in a safe spot first. ANE was also in-serviced, and the types of abuse were physical, verbal, misappropriation, neglect, sexual, and mental. She said if she were to see any ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 2:38pm, CNA F said he had in-services about the mechanical lift and how it was a 2-person activity, and where to find information on transfers like the POC/[NAME]. He said if he came across hazardous equipment he would stop and get the nurse and maintenance. CNA F said if a resident was re-admitting after 1 day and he had not worked with the resident before, he would look on the [NAME] to see how to transfer the resident. In an interview with LVN G on 2/28/25 at 2:55pm he said he had in-services on transfers and how there was a book now that was updated as admission/readmissions came in and stated how the resident's transferred. He said he also was in-serviced on ANE, and the different types of abuse were physical, financial, neglect, sexual, mental. He said if he were to see ANE he would report it to the ADM (abuse coordinator). LVN G said he was also in-serviced on mechanical lifts and needing 2 people at all times. He said to find how a resident transferred, you would look at the [NAME]. He said if the bed had something wrong with it, he would get a new bed before transferring a resident and report it to maintenance. In an interview on 2/28/25 at 3:02 p.m., LVN H said she received in-services on transfers and having to assess new admits to determine the safest way to transfer, then she informed the CNA and put it in the transfer book. She said staff could find the transfer status of a resident on the [NAME]. She also received in-services on ANE. The different types of abuse were sexual, physical, neglect, misappropriation, and mental. She said if she were to see ANE she would report it to the ADM (abuse coordinator). She said if she saw faulty equipment she would report it to maintenance and take it out of rotation. In an interview on 2/28/25 at 3:07pm, Med Aide I said she received in-services on ANE, and the different types of abuse were physical, mental, verbal, neglect, misappropriation, and sexual. She said if she were to see ANE she would report it to the ADM (abuse coordinator). She said she also received in-services on transfers and how mechanical lifts required 2 people, ensuring the mechanical lift did not hit someone, using the right size mechanical lift pad, asking the nurse how to transfer the resident, looking at [NAME], and using a gait belt. In an interview on 2/28/25 at 3:12pm, CNA J said she was in-serviced on transfers and how the transfer status was on the POC/[NAME], always using 2 people for mechanical lifts, always explaining to the resident what was going on, and always using a mechanical lift mat. The CNA said she also received in-services on ANE, and the different types of abuse were verbal, physical, mental, sexual, and misappropriation. She said if she were to see ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 3:21pm, RN K said she received in-services on transfers and about how the admitting nurse was going to determine the resident's transfer status, updated the [NAME], and told the CNA what the transfer status was. She said she also received in-services on mechanical lifts and how 2 people always had to be used, and making sure the right sling was used. ANE was also in-serviced, and the types of abuse were physical, verbal, misappropriation, neglect, and sexual. She said if she ever saw ANE she would report it to the ADM (abuse coordinator). In an interview on 2/28/25 at 3:27pm, CNA L said she received in-services on transfers and if a resident was a 2 person transfer then they had to use 2 people or they could use a mechanical lift. She also received in-services on the use of a gait belt, and how the admission nurse would have to assess the resident before anyone could transfer the resident, and the transfer status would be entered into the transfer book and in the system. She said she was also in-serviced on ANE, and the types of abuse were verbal, physical, sexual, and neglect. She said if she saw any ANE she would report it to the ADM (abuse coordinator). In an observation on 2/28/25 at 3:43pm, revealed CNA M and CNA F performed a mechanical lift transfer. The CNAs strapped the resident in and gave instructions to the resident regarding the lift. They ensured the lift was locked prior to the transfer of the resident. The CNAs placed the lift mat underneath the resident. Then they clipped the mat to the lift and informed the resident that the mechanical lift would be moving up. The CNAs lifted the resident slowly while 1 used the remote and 1 guided the resident. The resident did not hit anything and was placed into his chair smoothly. In an observation on 2/28/25 at 4:03pm, revealed CNA J and CNA N performed a 2 person transfer from wheelchair to bed. The CNAs started off with the bed being low for transfer and they applied a gait belt to the resident. There was constant communication between the resident and staff to ensure the resident was safe during the process. The resident was asked to put her hands on CNA J's shoulder for her comfort during the transfer. On the count of 3 the 2 CNAs picked up the resident from the gait belt, pivoted and sat her down on the bed. Once the resident was sitting on the edge of the bed, CNA J swung the resident's legs over onto the bed. In an interview on 2/28/25 at 4:10pm, the ADM said she expected staff to follow the plan of care/[NAME] and reference that first. She said CNA D and CNA W should have looked at the POC/[NAME] or spoke to the nurse before transferring CR #1. She said if the aides did not know the transfer status of the resident there was a risk for injury to the resident. In an interview on 2/28/25 at 4:31pm, the DON said they had in-services on transfers and how the nurses would assess residents when admitting them and determine their transfer status, and then enter the transfer status on the [NAME] and inform the CNAs and other staff. She said they also had in-services on ANE and the types of abuse. An Immediate Jeopardy (IJ) was identified on 2/26/25. The IJ template was provided to the facility on 2/26/25 at 4:30pm. While the Administrator was notified the IJ was removed on 2/28/25 at 4:18pm, the facility remained out of compliance at a severity of no actual harm with the potential for minimal harm, that is not immediate jeopardy with a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (CR #1) of 4 residents reviewed for respiratory care. The facility failed to ensure CR #1, who was on continuous oxygen, was provided with sufficient oxygen while out of the facility at an MD appointment on [DATE]. CR #1 was transported to the hospital from the MD appointment. An Immediate Jeopardy (IJ) was identified as past noncompliance on [DATE]. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began on [DATE]. This failure could place residents who received oxygen therapy at risk of respiratory complications, hospitalization and/or death. The findings included: Record review of CR #1's admission Record dated [DATE] revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), heart failure, pleural effusion (a collection of fluid around your lungs), dementia, chronic kidney disease, and fluid overload. Record review of CR #1's discharge assessment-return anticipated MDS dated [DATE] revealed his cognitive skills for daily decision making was moderately impaired. He required assistance from staff with ADL care. His MDS did not indicate he was on oxygen. Record review of CR #1's care plan revealed he was on oxygen therapy. Interventions were to have oxygen via nasal cannula at 2-3 L per minute continuously, and to observe for signs and symptoms of respiratory distress and report to MD prn: respirations, pulse oximetry (noninvasive method for monitoring blood oxygen saturation), increased heart rate, restlessness, diaphoresis (excessive and abnormal sweating), headaches, lethargy, confusion, atelectasis (the collapse of a lung or part of a lung), hemoptysis (when you cough up blood from your lungs), cough, pleuritic (two large, thin layers of tissue that separate your lungs from your chest wall) pain, accessory muscle usage, and skin color, date initiated [DATE]. Record review of CR #1's physician's orders revealed an order for O2 at 2-3 L/minute via nasal cannula continuously every shift, order date [DATE]. Record review of CR #1's O2 saturation revealed it was at 95% out of 100% on [DATE] at 7:12 a.m. on room air. Record review of CR #1's nursing note dated [DATE] at 8:00 a.m. written by LVN D reflected in part, Res up in w/c in dining room eating breakfast. O2 on via n/c at this time. Res aware of doctor appt today and dressed and rdy per staff. Will monitor Record review of CR #1's nursing note dated [DATE] at 8:44 a.m. written by LVN D reflected in part, Res up in w/c alert and responsive. Resp even and unlabored. No distress noted. Appetite good. Will monitor. Record review of CR #1's nursing note dated [DATE] at 10:30 a.m. written by LVN D reflected in part, Res transported to doctor appt at this time. Record review of CR #1's MD progress note dated [DATE] written by MD R reflected in part, On exam pt is seen on home oxygen which was provided by his nursing home. On arrival pt was found to have an O2 saturation of 86% and during the visit developed cyanosis (medical term for when your skin, lips or nails turn blue due to a lack of oxygen in your blood) around his mouth and fingertips. Pt's [family member] reported that this has happened in the past and required prompt change in O2 tanks. Pt's oxygen tank was found to be empty and he was rapidly switched to another tank. Pt's O2 saturation at that time was found to be 72%, and EMS was called. Eventually O2 saturation improved to 92% and all other vitals remained stable and patient was taken to [Hospital Name] ER . Plan . 2. Acute hypoxemic respiratory failure Notes: Pt presented with cyanosis and dyspnea (shortness of breath) after O2 ran out of portable tank. Pt's tank was replaced and cyanosis resolved with replacement of supplemental O2, pt was sent to ER for further evaluation and treatment. Pt advised on importance of securing O2 and dangers of drops in oxygen . Record review of CR #1's hospital record dated [DATE] at 1:25 p.m. reflected in part, Patient is a [AGE] year old with past medical history CHF (progressive heart disease that affects pumping action of the heart muscles), hypertension (high blood pressure), hyperlipidemia (high cholesterol), diabetes who was brought in by EMS with complaints of shortness of breath, chest pain. Patient states that he began having symptoms a few hours ago. Patient states that he has chest pressure rated an 8 out of 10 not worsened or relieved by anything. Patient reportedly with a new diagnosis of CHF but has not been able to get a prescription for home oxygen. Patient denies other significant symptoms at this time. Patient was noticed by nephrology (medical specialty that focuses on the study of the kidneys) staff to be cyanotic which prompted EMS call. EMS states that the patient was hemodynamically stable (patient's vital signs-like heart rate, blood pressure, and oxygen saturation-are within normal ranges) throughout transport, placed on nonrebreather (a medical device used to deliver high concentrations of oxygen to patients in emergency situations) with 100% saturation throughout transport .Primary impression: Acute hypoxic respiratory failure . Secondary Impression: anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), elevated troponin (a protein, a complex chemical molecule, found in certain types of muscle in your body), hyperkalemia (high potassium), pleural effusion, pneumonia (a lung infection that can be caused by bacteria, viruses, or fungi), and thrombocytopenia (low blood platelet count). Record review of CR #1's hospital record dated [DATE] at 12:52 a.m. reflected in part, .Patient was at nephrology appointment and noted to be hypoxic did not have his oxygen, he is on 3 L nasal cannula at his nursing home, he was transported not on oxygen. Patient exhibited shortness of breath and chest pain radiating 8/10 but resolved once oxygen was placed . called [family member] for collateral information . In an interview on [DATE] at 11:15 a.m. LVN D said CR #1 had an appointment after breakfast (on [DATE]). She said she put a new oxygen tank on him, he went out to his appointment and the tank ran out of oxygen. She said he was on 2-3 L of continuous oxygen, and it should have lasted around 6-8 hours. She said she did not think he would run out. She said after the incident, the facility conducted an in-service to ensure the oxygen tank was new and full before the patient went out of the facility. She said since the incident, she would send an extra oxygen tank with the driver if the resident was out of the building for a while. In a telephone interview on [DATE] at 11:39 a.m. CR #1's family member said the MD office informed her his oxygen tank was empty. She said she was unsure if the oxygen tank was working or not. She said he could have had a stroke or died without his oxygen. In an interview on [DATE] at 12:22 p.m. the Corporate DON said 2 L of continuous oxygen should last approximately 4-5 hours. She said it would last a shorter timeframe if the resident was on a higher Liter. She said when a resident went out to an appointment, facility staff put on a new tank when they left and that should be enough for the allotted time. She said residents were not typically out of the building for longer than 4-5 hours. If residents were out longer than 4-5 hours, they could send an extra tank of oxygen with them. In an interview on [DATE] at 12:34 p.m. the Talent and Learning Director said she was previously the respiratory therapist at the facility years ago. She said the facility used E cylinder tanks for portable oxygen and each tank held 2000 psi (a commonly used E cylinder can hold nearly 680 liters of oxygen when filled to 2,000 psi). She said the length of time the oxygen lasted was based on the liter flow. She said if a resident was on 2 L the portable tank could last from 4-5 hours. She said the tank should be changed at 4 hours when it reached the red area, with 500 psi remaining. She said when she was the respiratory therapist, she ensured to calculate how long the resident would be out of the facility, call the MD office and ask about oxygen availability, and determine what mode of transportation was used. She said if the resident was on 2 L she would send an extra tank with the van in case of an emergency. In a follow up interview on [DATE] at 1:15 pm LVN D said she put a new, full oxygen tank on CR #1 at breakfast time around 7:30 a.m.- 8:00 a.m. She said he left the building for his appointment between 9:30 a.m. - 10:00 a.m. She said she glanced at the oxygen tank when he left the building, and it was a little less than full. She said he was on the oxygen tank for approximately 1 ½ hours when he left the facility. She said no one told her how to ensure the resident had enough oxygen while out of the facility, or how to calculate how much oxygen the resident would need while out of the facility. In a telephone interview on [DATE] at 8:31 a.m. CR #1's Clinic Staff said the first and only time CR #1 was seen in their office was on [DATE]. She said his appointment was scheduled for 11:30 a.m. She said he was in a w/c with an O2 tank, but it was out of oxygen, it was low. She said his O2 saturation was 86% on arrival. She said his O2 tank was found to be empty, and the office rapidly switched the tank. She said CR #1 looked tired and sick, but he was at the MD office for a hospital follow up. She said the nursing facility did not call beforehand to see if the office had oxygen on hand. In an interview on [DATE] at 11:06 a.m. the Administrator said on the day of his MD appt staff put an oxygen tank on CR #1 around 9:30 a.m. She said the same day they were notified he was sent to the hospital from the MD office due to blue tinge on his hand. She said he was sent to the MD's office with a full tank, and they were uncertain when the oxygen ran out due to the uncertain timeline and not being there. She said the resident could be at risk of not receiving the adequate amount of oxygen to support his needs. She said the facility could have anticipated some of the resident's needs but could also glean that the receiving entity would have emergency support. She said the facility should do what they could to provide support to the resident on their end. She said after the incident the facility instituted best practice for worst case scenario and in-serviced nurses on [DATE] to send residents out with 2 tanks and ensure drivers returned any remaining tanks. She said the new procedure was to ensure safety measures were in place. In a follow up interview on [DATE] at 12:44 p.m. LVN D said she sent CR #1 to his appointment with 1 portable O2 tank (the one in use). She said she did not know if the MD office had oxygen on hand and said the resident could be at risk of desaturating if he ran out of oxygen (Respiratory desaturation, known as hypoxemia in medical terms, is when you have low blood oxygen saturation.) In an interview on [DATE] at 1:06 p.m. RN S said she would ensure the resident had a full tank of oxygen if sent out of the facility. She said the tanks typically lasted around 3-4 hours on 2 L. She said 3 L would last a shorter time. She said she had to know the driving distance, where they were going and how long they would be gone. She said she would send the resident with an extra tank or two. In an interview on [DATE] at approximately 2:07 p.m. LVN C said she would send an extra O2 tank with a patient who went out of the facility. Record review of the facility's in-service entitled, O2 Management for outside appointments dated [DATE] conducted by the previous DON and provided to nurses and CNAs reflected in part, when residents are going out for outside appointments always check O2 tank to ensure it is full or place a brand-new tank when transportation arrives to pick up resident. Always send 1 extra O2 tank with resident to appointment and have transportation to bring both tanks back upon residents return. The in-service had 34 signatures. Record review of the facility's Oxygen Administration policy dated [DATE] reflected in part, The purpose of this procedure is to provide guidelines for safe oxygen administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to ensure treatment and care was provided to CR #1 for approximately 4 hours after she had a change in condition with sudden onset of mental status and neurological deficits on 10/02/24 at approximately 12:37 p.m. CR #1 was not transported to the ER until approximately 4:39 p.m. where she passed away on 10/15/24. -The facility failed to monitor CR #1 after having a change in condition on 10/02/24 for approximately 4 hours. An IJ was identified on 01/24/25. The IJ template was provided to the facility on [DATE] at 5:34 p.m. While the IJ was removed on 01/26/25, the facility remained out of compliance at a scope of pattern and severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). These failures could place residents at risk of not receiving necessary medical care, hospitalization, and death. The findings included: Record review of CR #1's admission Record, dated 01/24/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included encephalopathy (disease of the brain), unspecified, muscle weakness, paroxysmal atrial fibrillation (type of irregular heart beat that comes and goes), and cognitive communication deficit. Record review of CR #1's Quarterly MDS Assessment, dated 09/12/24, revealed a BIMS score of 3, indicating severe cognitive impairment. Further review revealed resident was dependent (the assistance of 2 or more helpers was required for the resident to complete the activity) with showering and required substantial/maximal assistance (helper does more than half the effort) with toileting and lower body dressing. Record review of CR #1's MAR dated, 10/01/2024-10/31/4, revealed an order for Xarelto tablet 10 mg, 1 tablet by mouth in the evening related to angina pectoris (chest pain or pressure), unspecified. Further review revealed the resident spit out her medication on 10/01/24 and refused the medication on 10/02/24. Record review of CR #1's care plan, last review date completed 09/20/24, revealed the resident had altered cardiovascular status r/t atrial fibrillation, a communication problem r/t hearing deficit, and an ADL self-care performance deficit r/t weakness. Record review of CR #1's progress notes written by Nurse B, dated 10/02/24 at 12:37 p.m., revealed a reported change in condition of Stroke/CVA/TIA/new neurological signs and Other change in condition. Mental status noted altered level of consciousness (hyperalert, drowsy but easily aroused. Functional status noted swallowing difficulty. Neurological status evaluation noted Altered level of consciousness (hyperalert, drowsy but easily aroused. Further review read in part .Nursing observations, evaluation, and recommendations are: Resident sudden onset of mental status, neuro deficits. Resident is usually alert and aggressive from time to time with an adequate appetite. Usually responds with words or nodding of the head .Primary Care Provider responded with the following feedback: A. Recommendations: Send to ER for further evaluation and treatment of neurological Granchanges [sic] .Blood pressure, pulse, respiration rate, pulse oximetry, and blood glucose were taken. No additional vital signs were noted after this time. Record review of CR #1's progress notes, dated 10/02/24 at 17:09 p.m. (4:09 p.m.), read in part .Resident was picked up by transfer service to be taken to [hospital]. Record review of CR #1's hospital records, dated 10/02/24, read in part .clinically suspect patient had a CVA .The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life threatening deterioration in the patient's condition during their evaluation in the ED .MRI brain wo IV contrast, result date 10/03/24 .impression small acute nonhemorrhagic (not causing or associated) bilateral (two-sided) cerebral hemispheric (symmetrical halves of the cerebrum (largest part of the brain) and cerebral infarcts (ischemic stroke), the distribution of which suggests embolic etiology (cause of an embolic stoke) . Record review of CR #1's hospital Discharge summary, dated [DATE], read in part .presented with AMS and found to have acute CVA .pt passed at 16:06 (4:06 p.m.) . During an interview on 01/24/25 at 10:38 a.m., Nurse B said anytime there was an order to send the resident out to the hospital the doctor would let the facility know if they needed to be sent out regular transport or 911. She said due to the resident's dementia, she was not very verbal, but she could communicate in her own way. She said on 10/02/24 CNA B noticed resident CR #1 was not really wanting to eat and drink and would pocket food in her mouth. She said her vital signs remained perfect, stable. She said she would squeeze her hands. She said she had altered mental status and had to have her food taken out of her mouth. She said resident CR #1 gripped both of her hands, followed her fingers, and pupils were normal, it was more that she was nonverbal and pocketing her food. She said the change in condition occurred approximately between 12:00 p.m. and 1:00 p.m. She said the NP gave the order for the resident to be sent out via regular transport. She said she called the transportation company at approximately 1 p.m. She said the transport company told her it would be 1 ½ to 2 hours when the resident would be picked up. She said she notified NP, and she said it was okay. She said come end of her shift, 2:00 p.m., she gave a report to the oncoming nurse, Nurse C, and told her about the situation and that if the transportation company did not show up by 3:00 p.m. to follow-up with them and the NP. She said she did not suspect resident was having a stroke and on the change in condition form she marked stroke/CVA/TIA/new neurological signs and other change in condition and listed altered mental status. She said she was just referring to the altered mental status. She said she remembered asking the ADON about what she should mark because she felt the resident was not having a stroke and she said the ADON said to select it and to note altered mental status. She said if there was a place to click neurological symptoms, she would have just clicked neurological symptoms. She said her shift ended at 2: 00 p.m. and she was not aware of what happened after she left. She said the only signs the resident presented with was altered mental status, non-verbal, and pocketing food. She said CR #1's baseline was that one could ask her yes and no questions and she would answer, she would jibber jabber (speech that is or appears to be nonsense) and would always drink water when offered. She said when she left work, resident CR #1 was still at the facility. During an interview on 01/24/25 at 11:22 a.m., CNA B said CR #1 had dementia but would regularly greet her. She said on the morning of 10/02/24, CR #1 was kind of quiet but alert. She said the resident would look at her when she entered her room and then would look at the ceiling but would not speak. She said at breakfast she fed her, and she ate well. She said at lunch she was the same but not as alert. She said she would ask her if she was okay, but she would not speak and would only look at her and around the room. She said for lunch the resident would close her lips like she did not want to eat. She said the resident opened up her mouth and she fed her a spoonful of food. She said she thought she was chewing her food, but she was pocketing her food. She said she told the resident to swallow her food, but she would not. She said she massaged her cheeks and told her to swallow her food, but she spit it out. She said she told another CNA to tell Nurse B and Nurse B came in the room and took over. She said Nurse B checked her vitals and the resident followed her finger. She said the resident was still at the facility when her shift was over at 2:00 p.m. During an interview on 01/24/25 at 1:03 p.m., the DON said she remembered the staff came to her and asked her to look at CR #1. She said she did not know how she normally presented and when asked they told her that she was normally aggressive but recently had been declining as in not eating as much, not being aggressive, and was being treated for an UTI. She said she knew with UTI residents that their mental status could be altered. She said CR #1 was responding, would open her eyes, would follow her, so she told the Nurse B to call the doctor to see what recommendations they suggest. She said Nurse B made the call to the doctor. She said she does not remember if the NP saw the resident earlier that morning but thinks she may have. She said Nurse B told her it was okay to send the resident to the hospital. She said Nurse B did not specify if it was a non-emergent or emergent transport. She said she remembered everything was stable and vital signs were within normal limits. She said she looked at CR #1's chart and saw he was sent out at 5 p.m. She said she did not go back and check on the resident during the time period in between because it was her understanding CR #1 was being sent out to the hospital and she was not notified that the resident was still in the building. She said she is not included in shift reports from one nurse to the other. She said Nurse C never mentioned anything to her about the resident. She said she did not suspect resident was having a stroke. She said days prior to 10/02/24, she was not eating, or her normal self, and it was not a sudden change. She said they had already told the doctor that the resident was eating less. On 01/24/25 at 2:36 p.m., a telephone call made to CNA C, but call went unanswered. Left a voicemail requesting a return phone call. On 01/24/25 at 2:39 p.m., a text message was sent to CNA C requesting she call. During an interview on 01/24/25 at 3:19 p.m., NP said she did not recall the conversation on 10/02/24. She said per her notes, later in the day nurse sent CR #1 out due to acute altered mental status, was not responding to stimuli, was sent to ED. She said she also documented resident was a high risk for rehospitalization. She said she did not see the patient when she had her change in condition so she did not know if it should have been a regular or 911 transport. She said based on her professional opinion, patient not responding to stimuli or is weak, it is usually 911. She said she doubts CR #1 would have been a resident the facility would have sent out regular transport. She said she should have gone out 911 based on their documentation and hers. She said if she had been asked specifically, she would have said to send out 911. She said she did not receive any other follow-ups from the facility about transportation. During a follow-up interview on 01/24/25 at 5:04 p.m., DON she said she knows the transportation company would have done a set of vitals when they arrived. She said she does not know why it took them so long to arrive at the facility to pick the resident up. During a follow-up interview on 01/25/25 at 9:39 a.m., Nurse B said she told the NP she felt CR #1 was having altered mental status, was responding to stimuli, gave her vital signs which were all stable, when attempted to be fed she was holding food in her mouth, CNA encouraged chewing movements, but resident just spit the food out. She said when she would call out resident's name, she would not make any sounds or acknowledgements and would only look at the person who was speaking to her. She would turn her head look at her but did not make any noises. She was blinking when she looked at her. She said the NP said as long as CR #1's vital signs were normal they could use regular transport. She said she took the resident's vital signs approximately 2 additional times but did not document. During an interview on 01/25/25 at 10:09 a.m., EMS Representative said they received a call from the facility on 10/02/24 at 13:12:32 (1:12 p.m.) and picked up at 16:39:11 (4:39 p.m.). He said it was called in as ER altered mental status and vitals showed she was stable. Record review of the facility's Charge Nurse job description, dated 2023, read in part .The primary purpose of your job position is to provide direct nursing care to the residents .to ensure that the highest degree of quality care is maintained at all times . Record review of the facility's Change in a Resident's Condition or Status policy, revised 2016, did not include sending a resident 911 versus regular transport. The Administrator was notified on 01/24/25 at 5:34 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 01/25/25 at 12:31 p.m.: [] Plan of Removal [] submits the following Plan of Removal for the alleged failure to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. By submitting this plan of removal [] does not admit to the accuracy of the alleged deficient practice. What corrective actions have been implemented for the identified residents? A. On 10/02/2024 resident CR#1 involved in alleged deficient practice was discharged to the hospital. B. On 01/24/2025 at 6:00 pm the Administrator notified the Medical Director of the alleged deficient practice. C. Nurse Managers completed a 100% assessment of all residents residing in the facility for changes in condition on 01/24/2025, and none were identified. D. On 1/24/2025 LVN B was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the Emergency Room. The facility audited the change in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician 1/24/2025, no concerns were identified. E. On 1/24/2025 LVN C was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the Emergency Room. F. The Corporate Clinical Service Director reviewed facility policy on 01/24/2025 regarding change in condition and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was completed on 1/24/2025 by the Corporate Clinical Service Director with the Director of Nursing on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. B. The Director of Nursing completed an in-service on 1/25/2025 with the licensed nursing staff on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Licensed nurses will not be allowed to return to work until they receive this in-service. C. Newly hired nurses will be in-serviced by the Director of Nursing or designee on changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. D. The Director of Nursing or designee completed an in-service on 1/25/2025 with the licensed nursing on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Licensed nurses will not be allowed to return to work until they receive this in-service. a. Use non-emergency transport for stable residents requiring evaluation or treatment for non-urgent conditions, such as worsening chronic symptoms or mild infections. b. Call 911 for life-threatening emergencies or rapidly deteriorating conditions, such as chest pain, severe respiratory distress, unresponsiveness, or suspected trauma. Always assess vital signs, consult facility protocols or providers as needed, and document the decision-making process thoroughly to ensure appropriate and timely care. E. On 1/25/2025 CNA's received in-services on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. CNAs will not be able to work until they have completed this in-service. F. Newly hired CNA's will be in-serviced by the Director of Nursing or designee on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. How will the system be monitored to ensure compliance? A. The 24-hour report will be reviewed daily by the Director of Nursing or designee to audit nurse documentation in progress notes of change in conditions and the documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Discrepancies noted during reviews will be immediately corrected by contacting the attending physician of the change of condition and completing documentation in the patient's progress note. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. The review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 01/24/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. On 01/25/25-01/26/25, surveyor monitoring confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Record review revealed on 01/24/25, the facility completed an assessment for all residents in the facility for changes in conditions, and none were identified. Record review revealed on 01/24/25, Nurse B was in-serviced on recognizing a change in condition and monitoring while awaiting transport to the emergency room. Record review revealed on 01/24/25 the facility audited changes in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician. Record review revealed on 01/24/25, Nurse C was in-serviced on recognizing a change in condition and monitoring while awaiting transport to the emergency room. Record review revealed on 01/24/25, the DON was in-serviced on managing and monitoring changes in resident condition. Record review revealed in-service was completed on 01/24/25 with the DON on Managing and Monitoring Changes in Resident Condition. Record review revealed on 01/25/24, in-service was completed with 40 licensed nursing staff on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Record review revealed, on 01/24/24 in-service was completed with 40 nurses on the ongoing monitoring and assessing of residents scheduled for transport to the hospital. Record review revealed, on 01/24/25 in-service was completed with 40 CNAs and 7 MAs on recognizing a change in condition and who to notify. Interviews were conducted from 01/25/25 to 01/26/25 with staff from all shifts: DON, 2 RNs, 7 LVNs, and 9 CNAs. Licensed Nursing staff verbalized an understanding on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility, the ongoing monitoring and assessing of residents scheduled for transport to the hospital and recognizing a change in condition and monitoring while awaiting transport to the emergency room. CNAs verbalized an understanding on recognizing a change in condition and who to notify The Administrator was notified the Immediate Jeopardy was removed on 01/26/2025 at 11:36 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.