**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview, the facility failed to follow the advance directive for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or DNR (A type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops) for two residents (Resident 7 and 39) of 16 sampled residents. Facility census was 38. Findings are: A. Record review of the facility policy titled Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) dated [DATE] revealed the purpose of the policy was to provide each resident the opportunity to make decisions related to medical care and to define a process to make resident decisions known. If cardiac arrest occurs, CPR must be initiated unless the resident has a valid DNR (Do Not Resuscitate-meaning the resident wish is that the facility staff do not perform CPR.) order on file that includes the medical order issued by a physician or other authorized non-physician practitioner; a valid Advance Direction on file that includes written instructions relating to the provision of healthcare when the individual is incapacitated. At the time of admission or re-admission, social services or designated staff member asks the resident/health care decision maker whether the resident has prepared an advance directive. The designated staff member will meet with the resident/health care decision maker to answer questions and determine if the resident/healthcare decision maker wishes to develop or amend advance directives. If an advance directive has been formulated, a copy will be scanned into OnBase (an electronic data storage for scanned documents). As necessary, physicians will be contacted for orders that reflect the resident's wishes. During the resident stay, advance directive orders are to be reviewed with the resident/healthcare decision maker at each care plan meeting to ensure no changes are needed. Document this discussion in the progress note-Care Conference Note. If a resident who has an advance directive informs a staff member that he or she has changed his or her decision, the resident's wishes for different measures will be followed and the physician will be contacted for updated orders. If the resident's medical condition or cognitive status changes, review the current advance directive orders with the resident and healthcare decision maker to determine if they wish to make changes. Physician's orders in response to resident's requests and/or advance directives regarding life-sustaining measures must be specific. Daily print a list of all advance directive orders and keep in a three-ring binder in an area easily accessible to nursing employees. When the electronic resident health record is available, the nurse may choose to access the code status on the dashboard of the resident's electronic health record. Record review of the admission record dated [DATE] revealed that under advance directive, Resident 7 was listed as a DNR. Record review of the Medication Administration Record (MAR) dated [DATE] revealed that under advance directive, Resident 7 was listed as a DNR. Record review of the Order Listing Report (which contained a list of all residents and their current code status) dated [DATE] revealed the code status listed for Resident 7 as DNR. Record review of the [NAME] Directive dated [DATE] for Resident 7 revealed Resident 7's choice to attempt resuscitation/CPR and to provide full treatment. The document was signed and dated by Resident 7 and the physician. Interview on [DATE] at 9:05 AM with the facility Director of Nursing (DON)-A revealed the process for obtaining an advance directive takes place during the admission process. DON-A revealed that Social Services (SS) is responsible for the admission process. DON-A also revealed that if SS is not available, the admissions process is completed by the facility's Business Office Director-A (BOD-A). DON-A revealed that if the advance directive is already in place, the form is discussed and verified with the resident or Power of Attorney ((POA: a legal document that allows someone else to act on your behalf if necessary). DON-A revealed that staff are aware of the current code status of each resident through the Order Listing Report printed every night shift containing a list of all residents and their current code status. Interview on [DATE] at 8:17 AM with Licensed Practical Nurse-E (LPN-E) revealed that if staff reported a non-responsive resident, LPN-E would check the resident code status on the nightly Order Listing Report and then assess the resident. Interview on [DATE] at 9:15 AM with BOD-A revealed that that SS was usually responsible for admissions and updating the code statuses during care conferences. The BOD-A revealed that the advance directive is part of the admission process and is captured on a form with an area labeled code status verification with resident or family and an area labeled advance directive note. The BOD-A revealed that when changes are made, the information is then relayed to DON-A. The BOD-A revealed that during the quarterly care conferences, the advance directive is also discussed to confirm the resident choice. Interview on [DATE] at 10:45 AM with Resident 7 revealed their Advance Directive choice is to be a full code (CPR). Interview on [DATE] at 1:11 PM with the Nursing Home Administrator (NHA) revealed DON-A interviewed Resident 7 on [DATE] in the afternoon and confirmed Resident 7's code status and choice was to be a full code. The NHA confirmed the resident choice to be full code was not documented in the resident record. The NHA confirmed that the resident record listed Resident 7 as a DNR. The Order Listing Report for all current Code Statuses revealed that Resident 7 Advance Directive order has not been revised since [DATE]. B. Record review of Resident 39's admission Record dated [DATE] revealed Resident 39 admitted into the facility on [DATE]. Record review of Resident 39's Minimum Data Set (MDS) (a mandatory comprehensive assessment tool used for care planning) dated [DATE] revealed Resident 39 had a Brief Interview for Mental Status (BIMS) (a brief screening tool that aids in detecting cognitive impairment) score of 13 (a score of 13 means the resident is cognitively intact). Record review of Resident 39's Progress Note dated [DATE] at 2:28 PM titled Advance Care Planning revealed the Resident states that the resident is a full code (wants CPR performed) and wishes to continue as such. Record review of Resident 39's Electronic Health Record revealed the document Transition Orders and Information for the Continuation of Patient Care (a summary of orders from the hospital provided to the facility) for Resident 39 dated [DATE] revealed the current Code Status for Resident 39 as Full Code. Record review of the Order Recap Report (a listing of all current and previous physician orders for a resident) dated [DATE] for Resident 39 revealed that Resident 39 had a physician's order dated [DATE] for CPR. Record review of Resident 39's Progress Note dated [DATE] at 2:45 PM revealed that at approximately 2:06 PM a physical therapist working with Resident 39 and had yelled out to the hallway that they needed help. The Nursing staff ran to the resident's room to find Resident 39 sitting on the toilet. Resident 39 was disorientated, weak, and unable to verbalize clear speech. The physical therapist was holding Resident 39's head up as the resident was leaning towards the wall. When the nurse arrived, a quick assessment was completed and resident's pupils were dilated and fixed. Resident 39 was unable to hold their hands or head up at that time. The Registered Nurse (RN) on duty was standing behind this nurse at time of assessment. The RN went to nurse's station to call 911 at 2:08 PM. Resident 39 began to convulse again. Resident 39's pupils were dilated to maximum size and the resident's eyes glossed over. Resident 39 appeared to have stopped breathing after seconds of seizure like activity. The 24 hour DNR report (Order Listing Report containing the code status for CPR or DNR for all facility residents) was checked and verified that Resident 39 was a DNR. Resident 39's sternum (center chest bone) was rubbed and the resident's name repeated loudly to gather a response. No response at that time. The resident's body continued to be limp. Lung sounds and heart sounds were assessed for several minutes with no response. Resident 39 was moved to the floor. The heart and lung sounds were assessed. No heart or lung sounds were heard for 5 minutes. Time of death at 2:14 PM. RN notified family, called the primary care provider on-call weekend services, and notified administrator. This nurse notified the Director of Nursing (DON). Interview on [DATE] at 8:53 AM with the facility DON-A revealed that at admission of a resident the social worker discusses advanced directives per a verbal discussion. DON-A revealed that the social worker verifies that the advance directive code status (the resident/resident family choice for CPR or DNR) is correct by visiting with the resident/family. The social worker discusses any discrepancy with them. DON-A revealed that when the resident/resident family wants to change the resident's code status the staff document the change in the resident record and request a physician order for the change. DON-A revealed that during the resident care plan meetings the facility will review the resident choice for CPR or DNR (code status) and request a new physician order when a change of code status is expressed. Interview on [DATE] at 8:53 AM with the BOD-A revealed that the BOD initiates the resident admission process when social services is not able to be at the facility. BOD-A revealed that BOD-A has a conversation with the resident/family and asks what their wishes are for CPR or no CPR (DNR) and confirms that the orders from the doctor are the same as the resident/family wishes. BOD-A revealed that BOD-A uses the facility New admission Checklist for the admission process. The New admission Checklist has an advance directive line where BOD-A documents the resident/family response for their preference for CPR or DNR. BOD-A revealed if the resident/family preference does not match the physician order for CPR or DNR, BOD-A verifies with the resident/family and notifies the DON for the DON to follow-up with the physician for an order to match the resident/family wishes. BOD-A revealed that the resident code status preference is reviewed during the resident stay at each care plan meeting when resident/family are present. If the resident/family are not present at the care plan meeting social services will go to the resident room and review with the resident what the facility has as on file as their preference for CPR or no CPR. The social services will ask if this remains their preference. Record review of the facility provided Transition Orders and Information for the Continuation of Patient Care dated [DATE] revealed the current code status order as DNR/DNI. Record review of the medical record for Resident 39 revealed no documentation of a resident/resident family wish to change Resident 39's code status from CPR to DNR. Care Conference Notes (documentation of items discussed during resident care plan meetings) revealed no documentation of review of the resident code status. Interview on [DATE] at 2:12 PM with the Nursing Home Administrator confirmed that the facility had no documentation that Resident 39 or Resident 39's family had communicated that they requested to change the code status of Resident 39 from CPR to a DNR. Record review of the Abatement Statement for F678 Cardiopulmonary Resuscitation (CPR) dated [DATE] submitted by the Nursing Home Administrator on [DATE] at 4:54 PM revealed the following: -Education provided to the Health Information Manager not to scan any orders into charts unless it is noted by a Licensed Nurse. -Education to all licensed nurses, Director of Nurses, and Social Services Director by regional clinical services director Registered Nurse or Clinical Educator Registered Nurse utilizing advance directives/CPR policy to ensure resident whishes are documented in progress notes admission/re-admission and all orders are noted and placed into the electronic health record. Education will be provided to all licensed nurses currently in the building, new nurses, and all other licensed nurses prior to working their next shift. -Upon notification all residents' code status were printed from the order listing report. All resident advanced directives were produced. These two lists were compared to ensure that the code status preference for CPR choice matches. The facility is respecting the wishes of all residents and families regarding code status. -At the time of admission or re-admission, social services or designated staff member asks the resident/health care decision maker whether the resident has prepared an advance directive such as a living will, durable power of attorney for healthcare decisions. Resident wishes will be documented in the medical record progress notes. As necessary, physicians will be contacted for orders that reflect the resident's wishes. -Advance Directive orders are to be reviewed with the resident/healthcare decision maker at each care plan meeting to ensure no changes are needed. Document this decision in the Progress Note-Care Conference Note.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. Record review of the Good Samaritan Society (GSS) GSS [NAME] Village Incident by Incident Type Log, under slipped or fell, revealed Resident 26 had the following falls: 6/2/2022 at 9:00 PM, 7/25/2022 at 5:43 PM, 8/7/2022 at 11:55 PM, and 1/5/2023 at 5:40 AM. Record Review of Resident 26's Slipped or Fell #6437 Incident Report with a date of 7/25/2022 at 5:43 PM, revealed the resident had fallen in resident's room and was found sitting cross legged on the floor in the middle of the room. Resident 26 appeared to have a wet brief. Under the section, Predisposing Physiological Factors, revealed Resident 26 was confused, had gait imbalance, had weakness/fainted, had impaired memory, and was incontinent. Record Review of Resident 26's Slipped or Fell #6437 Incident Report with a date of 8/7/2022 at 11:55 PM, revealed the resident had been found sitting on resident's buttocks on the floor in the Solarium between a recliner and wheelchair (w/c). The alarm pad was put away on table by the recliner and was not sounding. The resident was wet. Under the section, Predisposing Physiological Factors, revealed Resident 26 was confused, and had weakness/fainted. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 6/2/2022 at 9:00 PM, revealed resident had a score of 13 and had a Category of medium risk, but the assessment was incomplete. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 7/25/2022 at 5:43 PM, revealed resident had a score of 17 and had a Category of high risk. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 8/8/2022 at 12:02 AM, revealed resident had a score of 18 and had a Category of high risk. Record review of Resident 26's Good Samaritan Society Fall Tool with a date of 1/5/2023 at 5:46 PM, revealed resident had a score of 11 and had a Category of low risk. Resident 26 had one or more falls between 3-12 months. Resident 26's cognition was moderately impaired, and had cognitive status problems of restlessness, reduced insight, confusion, poor memory, impulsive, and difficulty following instructions. Resident 26 had mobility/transfer problems of impaired balance or coordination, observed impulsive/risk-taking behaviors, and equipment/safety. The Fall Tool also reevaluated Resident 26 had incontinence problems. Record review of Resident 26's Minimum Data Set (MDS, a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 12/5/2022, section G revealed the resident required extensive assist, one-person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. It also revealed Resident 26 was not steady and was only able to stabilize with staff assistance for balance when going from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface to surface transfers. Further review of Resident 26's MDS under section H, revealed the resident was frequently incontinent of both urine and bowel and was not on a toileting program. Observation on 2/1/2023 at 9:30 AM in Resident 26's room revealed, the resident lying in bed with eyes closed. There was an alarm/position sensor pad underneath Resident 26, and the alarm box was hung on the top handle of the resident's nightstand. There was an alarm/motion sensor pad in Resident 26's wheelchair. Resident 26's call light cord was laying on the floor and the call light was hanging over the bottom bar of the resident's four wheeled walker (4 WW) that was on the right side of the nightstand and was not within the resident's reach. Observation on 2/2/2023 at 10:09 AM in Resident 26's room revealed, a narrow walkway upon entering the resident's room as Resident 26's roommate was sitting in a recliner to the left, there was a nightstand along the wall to the right, and an over the bed table along the right side of the recliner that made a narrow walk space. The roommate's call light cord was strung from the wall, down across the floor, and up over the bed table causing a potential tripping hazard. Resident 26 was observed lying in bed with an alarm pad in place under the resident and the alarm box hanging from the top handle from the nightstand. Resident 26 did not have a call light within reach as it was laying on the floor between the nightstand and a trashcan. Resident 26's over the bed table was parallel right next to the bed, resident's w/c was placed at the foot of the bed (right up against the bed). Observation on 2/6/2023 at 8:27 AM in Resident 26's room revealed, the resident lying in bed with eyes closed and a bed alarm pad in place under the resident. Resident 26's roommate was sitting in a recliner directly to the left upon entrance to the room. The roommate's over the bed table was to the right of the recliner and had made a narrow pathway to walk over to bed B (Resident 26's side) as the roommate's nightstand was catty corner from the recliner. Resident 26's roommate's call light cord was strung from the wall, across the floor, and up over the roommate's over-the-bed table. Observation in the commons area on 2/6/2023 at 1:08 PM, revealed Nursing Assistant-L (NA-L) had wheeled Resident 26 from the dining room to the commons area after lunch and had asked if the resident would wait for NA-L to come back and sat Resident 26 in a chair. Resident 26 had agreed. Observation in Resident 26's room on 2/6/2023 at 1:53 PM, revealed the education Coordinator (EC) entering Resident 26's room and had to move the resident's roommate's over the bed table to the right side of the room to make room make room, so EC could push Resident 26's w/c to the other side of the room. EC had put Resident 26 next to the bed, took the w/c peddles off, and said Maybe we should go to the bathroom before you lay down. Resident 26 agreed and went to the bathroom. EC had said, Oh wait, where is our gait belt? Resident 26 had already stood up, using the grab bar. EC said, Oh too late. The w/c had not been locked and moved slightly backward during the self-transfer. Resident 26 voided. EC had asked Resident 26 to remain seated while EC located a gait belt and the resident agreed. EC located a gait belt on under three pillows that were on Resident 26's recliner. The gait belt had been placed on Resident 26 and EC had assisted cleaning the resident and pulled up her brief and pants. Resident 26 had reached back and held the left arm of the w/c with the resident's left hand and the w/c had moved slightly backward due to the w/c brakes not being locked during the transfer. Interview with EC on 2/6/2023 at 2:06 PM, confirmed the w/c breaks were not locked during two of Resident 26's transfers in the bathroom. EC had said EC would normally lock the w/c breaks before transferring a resident but didn't think about it. EC revealed that EC had not transferred Resident 26, Much. Interview NA-L on 2/6/2023 at 2:09 PM, revealed Resident 26 was to be toileted when they get the resident up out of bed, after lunch, and when they put her back to bed. NA-L had explained Resident 26 would normally skip breakfast. NA-L said Resident 26 would sometimes tell staff if the resident needs to go to the bathroom, but staff needed to check on the resident all the time to see if the resident's brief was soiled. Interview with the DON on 2/6/2023 at 2:41 PM, revealed the DON was who completed incident investigations. The DON felt the root cause analysis had been determined for Resident 26's fall incidents on 7/25/2022 and 8/7/2022, but nothing was mentioned about the resident being incontinent at the time of the fall. LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7, 12-006.09D7a and 12-006.09D7b. Based on observation, interview, and record review; the facility failed to ensure Resident 21 was provided supervision to prevent potential accidents with injury; failed to ensure the resident environment was free of accident hazards for Resident 3; and failed to identify causal factors and implement interventions to prevent falls and potential injury for Resident 26. This affected 3 of 5 sampled residents. The facility identified a census of 34 at the time of survey. Findings are: A. Review of Resident 21's quarterly MDS (Minimum Data Set-a comprehensive assessment used to develop a resident's care plan) dated 12/21/22 revealed an admission date of 11/16/21. Resident 21 had a BIMS (Brief Interview for Mental Status) score of 11 which indicated moderate cognitive impairment. Resident 21 required extensive assistance from staff for transfers and toilet use. Resident 21 had 2 or more falls since the prior assessment. Observation of Resident 21 on 2/01/2023 at 9:25 AM revealed Resident 21 was sitting in a wheelchair in their room calling out help me and rubbing their right shoulder; Resident 21's pillow and call light were on the floor in front of Resident 21's wheelchair. There were no staff in view. Continued observation revealed several staff members walked by Resident 21's room while Resident 21 was calling out for help, and no one entered the room to assist. Observation of Resident 21 on 2/02/2023 at 10:10 AM revealed Resident 21 was observed lying in bed yelling can I go to the bathroom please? NA-M (Nurse Aide) walked by the room and did not stop. Observation of Resident 21 on 2/02/2023 at 10:15 AM revealed Resident 21 was lying in bed and a family member entered the room and put the call light on shortly after entering the room. Observation of Resident 21's room on 2/2/23 at 11:30 AM revealed the call light did not have a clip on it so when it had been on the floor, the facility had failed to maintain it to make sure it stayed in place. Interview with Resident 21's family member on 2/01/23 at 10:35 AM revealed Resident 21 fell about 3 weeks ago and broke their arm. Resident 21's family member revealed Resident 21 was out in the lobby and got up unassisted and fell onto their right side. Resident 21's family member revealed they were not sure if Resident 21 was being monitored by staff when they fell or not. Residents 21's family member revealed they were not aware of what interventions the facility had put in place to prevent Resident 21 from falling again. Review of Resident 21's Progress Notes dated 11/16/21 to 2/2/23 revealed documentation Resident 21 had 17 falls since 12/6/21. There was documentation Resident 21 fell on 1/15/23 and was taken to the emergency room and found to have a fractured right arm; 1/5/23; 1/2/2023, 12/27/22, 12/25/22 and received a skin tear; 2 falls on 12/16/2022 at 7:28 AM and 5:30 PM; 12/13/22, 11/29/22; 8/3/2022 and was taken to the emergency room and found to have a bruised hip; 6/30/22; 5/16/2022 and was taken to the emergency room and found to have a fractured left wrist, 5/14/22; 2 falls on 5/10/2022 at 9:15 AM and 2:00 PM and was taken to the emergency room and found to have a urinary tract infection; 3/19/2022, and 12/6/2021. Review of Resident 21's Falls Tool assessments revealed the following results with the reason for the assessment listed including 18 falls: 1/17/2023 Falls Tool Return from Hospital High risk 20.0 1/15/2023 Falls Tool Fall or Found on Floor Medium risk 13.0 1/15/2023 Falls Tool Fall or Found on Floor High risk 16.0 1/5/2023 Falls Tool Fall or Found on Floor High risk 18.0 1/1/2023 Falls Tool Fall or Found on Floor High risk 18.0 12/25/2022 Falls Tool Fall or Found on Floor High risk 16.0 12/16/2022 Falls Tool Fall or Found on Floor High risk 19.0 12/16/2022 Falls Tool Fall or Found on Floor High risk 16.0 12/14/2022 Falls Tool Fall or Found on Floor High risk 20.0 12/13/2022 Falls Tool Fall or Found on Floor High risk 20.0 11/29/2022 Falls Tool Fall or Found on Floor High risk 20.0 8/3/2022 Falls Tool Fall or Found on Floor High risk 20.0 6/30/2022 Falls Tool Fall or Found on Floor High risk 20.0 5/25/2022 Falls Tool Return from Hospital High risk 20.0 5/16/2022 Falls Tool Fall or Found on Floor High risk 20.0 5/14/2022 Falls Tool Fall or Found on Floor High risk 16.0 5/10/2022 Falls Tool Fall or Found on Floor High risk 20.0 5/10/2022 Falls Tool Fall or Found on Floor High risk 20.0 3/23/2022 Falls Tool Return from Hospital High risk 16.0 3/19/2022 Falls Tool Fall or Found on Floor Medium risk 14.0 12/6/2021 Falls Tool Fall or Found on Floor Medium risk 14.0 11/16/2021 Falls Tool admission Low risk 8.0 Review of Resident 21's Care Plan dated 12/6/2021 revealed the following about Resident 21: -12/06/21, re-educated resident to call for assistance with transfers. Educate resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. -5/10/22, fall -5/10/22, lowered to floor -5/14/22, found on the floor. Educate/instruct resident and family on safe use of assistive devices. Review as indicated for significant changes in cognition, safety awareness and decision-making capacity. Educate Staff to check for cognition changes on rounds and positioning resident in bed to middle of bed. -5/16/22, found on floor. Call light bed alarm -5/19/22, resident moved to a room closer to the nurses' station for closer monitoring to help prevent further falls. -6/30/22, fall without injury -08/02/22, Staff reeducated on use and importance of sensor alarms to be plugged in and in use at all times when in bed -8/03/22, fall without injury. Immediate intervention: resident should have call light in reach at all times. Encourage resident to use call light to request assistance from staff. Resident should be encouraged to wait for staff to assist (them) with any needs to avoid further falls. Modify to maximize safety. Keep personal items such as tissues, water pitcher, cell phone, toiletries on over bed table within easy reach of resident and make sure that call light was within reach before exiting the room. Monitor resident every shift to ensure that sensor alarms to bed/wheelchair/recliner are in place and functioning properly. -11/30/22, fall without injury. Staff to ensure resident has (their) call light and anything else (they) request within reach prior to exiting room. Encourage resident to ask for assistance to reach items to help prevent further falls. Bed alarm used to alert staff to resident's movement and to assist staff in monitoring movement. Monitor resident every shift to ensure that sensor alarms to bed/wheelchair/recliner are in place and functioning properly. -12/13/22, fall without injury. Fall mat alarm was placed next to resident's bed. Concave mattress applied to bed as resident likes to sleep on the edge of the bed. Thin mattress will help prevent further falls or sliding out of bed. -12/14/22, fall without injury -12/16/22, fall without injury -12/16/22, found on floor with no injury -12/25/22, fall with skin tear to left elbow. Call light bed sensor changed. -1/01/23, found on floor in room. Remind staff to make sure resident has all (their) wants/needs beside (them) in bed with call light in reach prior to exiting (their) room after assisting (them). -1/05/23, fall in room -1/15/23, fall in lobby with MI (Major Injury). Interventions included: Audio monitor in room; to be on when in bed to alert staff to any movement. One staff member will be assigned per shift to check resident alarms. Staff will ensure the alarm was in place, turned on and functioning properly. Observation of the resident care area unit on 2/02/23 at 9:07 AM revealed Resident 21 was not located on the unit. As attempts were being made to locate Resident 21, the CB (Contract Beautician) was observed wheeling an unidentified resident down the hall of the resident care area unit. At 9:13 AM, NA-L (Nurse Aide) was inquired as to the location of Resident 21. NA-L called over their portable radio and asked if Resident 21 was in the bath house. An unidentified staff person came over the radio and said Resident 21 was in the beauty shop. At 9:15 AM Resident 21 was observed sitting in their wheelchair in the beauty shop which was located on an unoccupied and unstaffed unit. There were double fire doors at the entrance to the unit and one of them was closed. The beauty shop was observed behind the closed door. Resident 21 was observed sitting in their wheelchair in the beauty shop and no staff were present in the beauty shop or observed on the unit. Resident 21's right arm was in a cast, their back was to the door, and they were sitting by and facing the window which was across the beauty shop away from the door. There was an alarm box on their wheelchair connected to a cord that appeared to go underneath their bottom in the seat of their wheelchair. Resident 21 did not have any type of call device or call light and there was no call light observed in the beauty shop. There were 2 call boxes on the wall that had plugs in them and no cords and Resident 21's alarm box was not connected to the call box. There were no staff in the beauty shop and no staff observed on the unit. At 9:19 AM Resident 21 woke up and there were no staff in the beauty shop and no staff observed on the unit. At 9:21 AM, 14 minutes after the CB was observed on another unit with another resident, a staff person came into the beauty shop, and they identified themselves as the CB. Interview with the CB at that time revealed they were not aware and had not told by the facility Resident 21 could not be left unattended. The CB revealed the facility staff usually left the residents in the beauty shop and the CB let the residents sit by the window. The CB revealed it was a common practice for staff to bring residents to the beauty shop and leave the residents there even when the CB had more than one resident in the beauty shop. The CB revealed they had to leave the beauty shop to take another resident down to the resident care area unit and they left Resident 21 in the beauty shop unattended. The CB revealed a staff person had wheeled Resident 21 into the beauty shop and said here and left. The CB revealed they do it all the time. The CB revealed they already had another resident in the beauty shop at the time Resident 21 was brought to the beauty shop. The CB revealed they left the beauty shop to take the other resident out to the resident care area unit and they did not intend to be gone that long but they got stopped by someone and then they had to go to the office to get change. The CB revealed the facility did not train them about not leaving residents alone in the beauty shop and they had no knowledge that Resident 21 was at risk for falling. Observation of the beauty shop at that time revealed it was not visible from the dining room which was the closest area to the beauty shop and not visible from the resident care area unit. Resident 21 was also far enough away from any care areas to be heard if they yelled for help or if their alarm went off if they got up unattended. Interview with the MS (Maintenance Supervisor) on 2/02/23 at 11:10 AM revealed the alarm would have to be plugged into the box on the wall to be activated by the facility call system. The MS revealed if the alarm had a battery-operated alarm and the alarm box was on the chair, it was an audible alarm and not hooked into the call system so the resident would have to depend on staff to hear it and respond. Observation of Resident 21 on 02/02/23 at 12:00 PM revealed Resident 21 was resting in bed; there was an alarm box connected to a cable under Resident 21 and it was not connected to their call light box. Interview with the FA (Facility Administrator) on 2/02/23 at 1:40 PM revealed PT-J (Physical Therapist) and the SSD (Social Services Director) had offices on the same unit as the beauty shop and the FA believed the PT-J and the SSD would have responded if Resident 21's audible wheelchair alarm went off. The FA revealed they believed PT-J was in the therapy office charting during the time Resident 21 was unattended in the beauty shop. When the FA was notified no PT staff had been observed on the unit and the SSD door was observed closed, the FA said they tested the alarm, and it could be heard from the therapy room door 70 feet away. When the FA was inquired if PT-J and the SSD had been notified Resident 21 was in the beauty shop unattended and they needed to monitor Resident 21 and listen for their alarm the FA said no. The DON was also present and replied no to the same question. The FA revealed they felt that someone would have responded. When the FA was inquired if the unit the beauty shop was located on was staffed, the FA revealed therapy and social services was down that hall but there were no residents residing on that unit and no staff were scheduled to work on that unit and monitor it. When the FA was notified since PT-J and the SSD were not notified Resident 21 was in the beauty shop unattended and they were to stay on that unit to monitor Resident 21, they could have left the unit, could have been on the telephone, or could have been working with a resident without knowing Resident 21 was unattended in the beauty shop; the FA confirmed PT-J and the SSD did not know Resident 21 was in the beauty shop and could not have been depended upon to monitor Resident 21 or respond if Resident 21 got up unassisted and activated the alarm or called out for assistance. Observation of the unit the beauty shop was located on 2/02/23 at 1:49 PM revealed the therapy room was down the hall then around the corner down another hall and the charting office was across the therapy room. The distance from the beauty shop door (the actual distance from the location in the beauty shop was unable to be measured as the door was locked) was 135 feet 9 1/2 inches from the therapy office charting desk to the beauty shop door. The distance from the beauty shop door to the SSD door was 127 feet 11 inches. (A football field is 300 feet long from goal line to goal line). There were no staff observed in the therapy room and the SSD office door was closed. Interview with the SSD on 2/2/23 at 1:52 PM revealed they were unaware Resident 21 had been in the beauty shop on 2/2/23 and they had not been requested to monitor Resident 21. Observation of the facility therapy room on 2/06/23 at 8:44 AM revealed PT-P was in the office which was across the therapy room, and they said PT-J was not working that day. When inquired if the office was where PT-J would have been charting in on Thursday, PT-P revealed that it was. Interview with PT-J on 2/06/23 at 8:55 AM revealed the facility staff or CB did not notify them Resident 21 was in the beauty shop on 2/2/23 and that they needed to monitor Resident 21. PT-J revealed once in a while if the CB saw PT-J walking by the beauty shop they would ask them to watch, but it was not a routine thing or something they did consistently and they did not recall they had said anything to PT-J on 2/2/23 about Resident 21 being in the beauty shop and that Resident 21 required monitoring. B. Observation of Resident 21 on 2/01/2023 at 9:25 AM revealed Resident 21 was sitting in a wheelchair in their room calling out help me and rubbing their right shoulder; Resident 21's pillow and call light were on the floor in front of Resident 21's wheelchair. There were no staff in view. Continued observation revealed several staff members walked by Resident 21's room while Resident 21 was calling out for help, and no one entered the room to assist. Observation of Resident 21 on 2/02/2023 at 10:10 AM revealed Resident 21 was observed lying in bed yelling can I go to the bathroom please? NA-M walked by the room and did not stop. Observation of Resident 21 on 2/02/2023 at 10:15 AM revealed Resident 21 was lying in bed and a family member entered the room and put the call light on shortly after entering the room. On 02/02/23 at 3:15 PM the abatement plan was received from the facility administrator and the IJ was abated at this time and lowered to an E. There was documentation the facility educated the CB not to leave residents alone in the beauty shop; call cords were placed in the beauty shop; and the remainder of the facility staff were educated not to ignore resident requests for assistance and would continue to be educated as they reported for duty. C. Observation of Resident 3's room on 2/02/23 at 9:07 AM revealed Resident 3 was not in their room. There was an oxygen concentrator (a machine used to deliver oxygen to a resident) in the room that was on. Interview with the FA (Facility Administrator) on 2/06/23 at 4:06 PM confirmed the facility staff were not supposed to leave the oxygen concentrators running when they were not in use. The FA called the MS (Maintenance Supervisor) on the phone, and they confirmed the facility staff were expected to shut the concentrators off when the residents were not in their rooms. Review of the facility policy Oxygen Administration dated 6/29/22 revealed the following: turn off oxygen when not in use, if appropriate.