**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of online manufacturer guidance, and interview the facility failed to ensure equipment was maintained in a safe manner to prevent falls with injury for Resident #43 and Resident #50. The facility failed to provide adequate supervision and assistance to prevent Resident #48 from falls and eloping. Actual harm occurred on 02/03/23 when Resident #50 sustained a fall when the anti-rollbacks on his wheelchair were not properly functioning. The resident complained of severe pain for three days following the incident, with a decrease in functional mobility without any type of interventions. On 02/06/23 the resident was admitted to the hospital with a fractured right hip. Actual harm also occurred on 06/01/23 when Resident #43, who required staff assistance for personal care fell from a shower gurney after the rail of the gurney broke sustaining a fractured femur. Prior to the incident, there was no evidence the facility conducted any type of preventative maintenance or inspection of the shower gurneys. This affected three residents (#43, #48, and #50) of the six residents reviewed for falls. The facility census was 80. Findings include: 1. Record review for Resident #50 revealed the resident was admitted to the facility on [DATE]. Resident #50 had diagnoses including nondisplaced fracture of greater trochanter of right femur, chronic obstructive pulmonary disease, other seizures, paroxysmal atrial fibrillation, schizophrenia, ischemic cardiomyopathy, dementia with behavioral disturbance, secondary parkinsonism, hypertension, abnormal posture, dysphagia, aphasia, ataxia, need for assistance with personal care, cognitive communication deficit, and difficulty walking. Review of a facility fall investigation, dated 02/03/23, revealed Resident #50 was observed trying to scoot himself back in his wheelchair. When attempting to stand, the wheelchair rolled partially out from under him. The anti-rollback wheels did not lock when the resident stood to shift weight back in his chair. The resident was assessed to complain of some pain to the right leg area. Record review revealed there was no nursing progress note related to this incident on 02/03/23. Review of the facility Fall - Initial assessment, dated 02/03/23, revealed the resident complained of new pain to the right middle leg at a pain level rated a four out of 10 on a scale of one to 10. Review of the facility Fall - Follow-up assessment, dated 02/04/23, revealed the resident have a pain level of three out of ten with bruising noted to the right posterior leg and knee. Review of the facility Fall - Follow-up assessment, dated 02/05/23, revealed the resident had a pain level rated a four out of ten and was refusing to stand or apply weight to the right leg. Review of the facility Fall - Follow-up assessment, dated 02/06/23, revealed the resident was assessed to have a pain level rated a seven out of ten and was at the emergency room (ER) for hip pain. Review of the Medication Administration Record for 02/2023 revealed Resident #50 was documented to have been administered as needed Tylenol for pain once on 02/05/23 and twice on 02/06/23 which staff documented to be effective. Review of Resident #50's medical record revealed there were no comprehensive assessments of the resident's hip, range of motion/mobility status, changes in medical condition and/or notification to the physician prior to 02/06/23. Review of the nurse's progress note, dated 02/06/23, revealed Registered Nurse (RN) #173 received during report information that Resident #50 had fallen on 02/03/23 and had been complaining of pain since the fall. STNAs reported to RN #173 that Resident #50 had a substantial decrease in ADL's related to standing, ambulation, and transfers. RN #172 notified the physician at this time and new orders were received to obtain an x-ray of the knee and hip area. Review of the facility Work Order #1751, created on 02/06/23, revealed anti-rollbacks on wheelchair not functioning properly. On 02/07/23 the work order was updated to set to be completed. Review of the hospital progress note dated 02/06/23 revealed Resident #50 was admitted to the hospital on [DATE] after being found to have a right intertrochanteric hip fracture which required surgical repair while the resident was in the hospital. Review of the most recent annual MDS 3.0 assessment, dated 04/06/23, revealed Resident #50 had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03 out of 15. This resident was assessed to require extensive assistance from two staff members for transfers, toileting, and bed mobility and to require supervision with setup assistance only for eating. Review of the care plan, revised 06/14/23, revealed Resident #50 was at risk for falls. Interventions included maintenance to repair anti-rollbacks on 12/14/22 (after sustaining a fall with no injury on 12/14/22) and maintenance to check function of anti-rollbacks and repair as needed on 02/06/23. Interview with RN #173 on 06/27/23 at 9:00 A.M. revealed upon coming back to work after being off for four days facility STNA's reported Resident #50 had a decline in ADL's since falling on 02/03/23 and was not wanting to eat or bear weight. RN #173 stated Resident #50 was ambulatory and fairly independent prior to his fall on 02/03/23. RN #23 further stated Resident #50 did not typically complain of pain and while being assessed by RN #173 the resident verbalized complaints of severe pain to his right hip and leg. RN #23 stated she notified the physician who ordered an x-ray which revealed a fracture, and the resident was sent to the hospital for evaluation and treatment. Interview with Resident #50 on 06/27/23 at 9:12 A.M. revealed the resident had fallen while attempting to stand and had to go to the hospital and have surgery. Resident #50 stated he had severe pain to the right hip and leg which he had verbalized to facility staff in the days following his fall. Interview with Director of Nursing on 06/29/23 at 9:00 A.M. verified Resident #50 had a fall on 02/03/23 and was sent out to hospital on [DATE] for evaluation and treatment for right hip fracture. 2. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypercapnia, anemia, dependence on supplemental oxygen, bipolar disorder, adult failure to thrive, schizoaffective disorder, contracture of left hand and elbow, muscle wasting, tremor, and muscle weakness. Review of a fall investigation, dated 06/01/23, revealed a State Tested Nursing Assistant (STNA) opened the door to the room of Resident #43 and informed the nurse the shower gurney had broken prior to the Hoyer lift transfer back into the bed and the resident had fallen on the floor. The STNA stated her, and her partner rolled resident on the gurney when the railing of the gurney snapped. Upon entering the room, the resident was observed lying on the floor and was yelling out in pain. The resident was assessed and found to have a hematoma to her right and left hands, bruising on the left side of her forehead, and was observed to yell out in pain every time her left leg was touched with a pain level of eight using the PAINAD pain scale. The physician was notified, and the resident was sent to the emergency room (ER) for evaluation. Review of the medical record for Resident #43 revealed no nurse's notes regarding the fall that occurred on 06/01/23. Review of the witness statement provided by STNA #133, dated 06/01/23, revealed she and STNA #5 showered Resident #43 on the shower gurney. When finished, the two STNAs took the resident back to her room to put her in bed. While getting the Hoyer lift ready for the transfer, the two STNAs rolled the resident toward them to get a Hoyer pad underneath her and the left side of the gurney came down and the resident fell. Review of the witness statement provided by STNA #5, dated 06/01/23, revealed Resident #43 was on the shower gurney and STNA #133 and STNA #5 were both on the side of the gurney they were rolling her towards when the gurney snapped, and the resident fell onto the floor on her left side. Review of the hospital progress note, dated 06/01/23, revealed this resident was diagnosed with a displaced intertrochanteric fracture of the left femur. Review of the care plan, revised 06/09/23, revealed the resident had a fall. An intervention (initiated 06/02/23) included staff education to inspect shower equipment prior to use. Review of the most recent significant change Minimum Data Set (MDS) assessment, dated 06/20/23, revealed Resident #43 was rarely/never understood. The assessment revealed the resident required extensive assistance from two staff members for bed mobility and toileting, required extensive assistance from one staff member for eating, and was dependent on two staff members for transfers. Interview with Maintenance Director (MD) #47 on 06/27/23 at 3:19 P.M. revealed the pipe on the shower gurney had broken during use with Resident #43. MD #47 was unsure if it was cracked before being used to shower Resident #43 as routine inspection and maintenance of the shower gurney had not been done prior to the residents fall. Maintenance Director #47 stated he was unsure of the recommendations for routine maintenance on the shower gurney but stated he would attempt to find them. Interview with Maintenance Crew employee #157 on 06/27/23 at 3:34 P.M. revealed the side rails of the shower gurney were up and the pin went through the PVC pipe on the shower gurney causing it to break and for the resident to fall. Maintenance Crew employee #157 stated prior to Resident #43's fall, there was not routine maintenance or inspection of the shower gurney, but following the incident staff were to inspect them monthly. Interview with the Director of Nursing (DON) on 06/29/23 at 8:51 A.M. verified there had not been routine maintenance or inspections of the facility shower gurneys prior to the fall experienced by Resident #43. The DON also verified the facility did not have a manual or policy for the shower gurney providing instructions on how to use, clean, or maintain the gurney in good, working condition. Review of the online guidance from Healthline Medical Products titled Recommendations from the manufacturer (https://www.healthlinemedical.com/instructions/healthline-medical-shower-gurney-maintenance/), not dated, revealed recommendations regarding gurney maintenance and use procedure revealed drop rails were not designed to hang on them and all joints of the shower gurney should be checked on a regular basis to make sure the pipes and fittings were secured. 3. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE]. Resident #48 had diagnoses including alcohol-induced persisting dementia, seizure disorder, chronic obstructive pulmonary disease, osteoarthritis, repeated falls, difficulty walking, unsteadiness on his feet and muscle weakness. Review of Resident #48's fall risk assessment completed on 12/20/22 revealed the resident was not indicated to have had any falls occurring in the previous 90 days. He was ambulatory with the use of assistive devices. He had diagnoses and the use of certain medications that increased his risk for falls. His overall score was nine, which did not indicate the need for any fall prevention interventions at that time. A review of Resident #48's nurses' progress notes revealed the resident had an unwitnessed fall on 01/04/23 at 7:45 P.M. The note indicated the resident was previously seen sitting in his wheelchair in the dining room watching a movie. Another resident had come to the nurses' station and informed the nurse that the resident had fallen. The nurse noted the resident was already back in his wheelchair when she was made known of the fall. She asked the resident if he had fallen and he reported to the nurse that he had. He was unable to provide any further description of the fall. A review of the facility's fall investigation for the fall occurring on 01/04/23 revealed the immediate action taken to prevent further falls from occurring included the use of Dycem to his wheelchair. Review of Resident #48's quarterly/significant change evaluation dated 05/03/23 revealed the resident's risk for elopement was assessed as part of the quarterly evaluation under the cognitive/ communication assessment of that evaluation. The resident's risk factors for elopement included being cognitively impaired, having the diagnosis of dementia, being able to ambulate independently with the use of a wheelchair, and being known to wander aimlessly. He was not known to have a history of eloping when at home, leaving the facility unsupervised, or leaving the facility without informing the facility staff. As a result of that assessment, he was not deemed to be at risk for elopement at that time. A review of a nurse's note dated 05/15/23 at 5:00 P.M. revealed the resident had a witnessed fall on that date. The note indicated the resident was in the dining room when staff witnessed the resident had slid out of his wheelchair onto his buttocks on the floor. The resident reported that he had slid out of his wheelchair. The intervention added was again to use Dycem to his wheelchair that had been previously ordered with his fall occurring on 01/04/23. A review of the facility's fall investigation for the fall occurring on 05/15/23 revealed the immediate action taken following the fall included providing staff education to ensure Dycem was in place to his wheelchair as was previously ordered. A review of Resident #48's physician's orders revealed an order, dated 05/15/23 for the use of Dycem to his wheelchair at all times. Review of Resident #48's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident rarely/ never made himself understood and was rarely/ never able to understand others. He had both short- and long-term memory impairment and his cognitive skills for daily decision making was severely impaired. He was not coded on the MDS as having had any behaviors during the seven-day assessment period and was not known to reject care or display any wandering behavior. He required a limited assist of one for transfers. He required supervision with set up help for ambulation in his room. Ambulation in hall only occurred once or twice, but he only required set up help for that when it did occur. He required supervision with the assist of one for locomotion on and off the unit. Balance issues were noted but he was able to stabilize without staff assistance. A wheelchair was the only mobility device used. The resident was identified as having had falls since his prior assessment. He had two or more falls without injury, one fall with injury that was not major injury, and one fall with major injury. A review of Resident #48's active care plans revealed he had a care plan in place for being at risk for falls related to dementia, weakness, unsteadiness on feet, difficulty walking, lack of coordination, and a history of falls. The care plan originated on 12/20/17 and was last revised on 06/14/23. The goals were to reduce the risk of serious injury in the event of a fall and for the resident to be free of falls. The interventions included ensuring his call light was within reach and to encourage the resident to use it for assistance as needed. That intervention was added to the care plan on 12/20/17. The interventions also included the use of Dycem (a tacky pad that could be placed on a seat of a chair to prevent sliding) to his wheelchair. That intervention was added on 01/05/23. The care plan directed them to review information on past falls and attempt to determine the cause of falls. They were to record the possible root causes and to remove any potential causes if possible. The care plan was revised to include the intervention of educating staff to ensure proper placement of Dycem on 05/18/23. On 06/26/23 at 12:47 P.M., an observation of Resident #48 noted him to be lying in bed. His call light was on the floor under his bed and out of his reach. Further observation of Resident #48 on 06/27/23 at 10:29 A.M., noted him to be lying in bed with his call light still on the floor under his bed and out of reach. Findings were verified by LPN #135. On 06/27/23 at 10:48 A.M., an interview with LPN #135 revealed Resident #48 was at risk for falls. They typically laid him down after meals and one of the aides would have helped him to bed after breakfast. She reported his fall prevention interventions included ensuring his call light was in reach. She confirmed the resident did not have his call light in reach, as it was found under his bed on the floor. She retrieved it from the floor and secured it to the assist bar that was on the right side of his bed near his head. On 06/27/23 at 3:10 P.M., an interview with the DON confirmed Resident #48 has had multiple falls while in the facility. She confirmed the use of Dycem was added as a fall prevention intervention following the fall the resident had on 01/04/23. She also confirmed they provided education to staff to ensure the Dycem was in place in his wheelchair, after he fell again on 05/15/23. She acknowledged the fall on 05/15/23 could not be considered an unavoidable fall due to previously ordered fall prevention interventions not being in place that contributed to his fall. She also acknowledged the fall prevention intervention to ensure his call light was in reach was not implemented as per the plan of care when observations noted it to be under his bed and out of reach on 06/26/23 and again on 06/27/23. In addition, a review of Resident #48's active care plans that were reviewed/revised on 06/14/23 revealed he did not have any care plan in place for being at risk for elopement or for unsafe wandering. Further review of Resident #48's nurses' progress notes revealed a nurse's note dated 06/25/23 at 3:00 P.M. that indicated a door alarm was alarming. The alarm announced was identifying the alarm as coming from the courtyard door on the second floor. The nurse and an aide tried multiple times to silence the courtyard door but was unsuccessful in doing so. The aide informed another staff nurse working that floor who also tried multiple times to silence the alarm without success. A maintenance employee was called to report the problems they were having with an alarm sounding that could not be silenced. While awaiting a return phone call, the aide went to check other residents and found the short hall exit door to be the one alarming. She entered the code to that alarm and was able to get the alarm to stop alarming. The staff then started checking on the residents and found Resident #48 to be missing. A facility search was started, and the resident was found outside in his wheelchair by the dumpsters by one of the nurses working on the second floor and the aide assigned that unit. The resident was found alert and his skin was warm and dry. He was not found with any injuries and was not noted to be in any distress. Staff assisted him back into the facility and into bed without incident. A review of a nurse's note dated 06/25/23 at 3:30 P.M. revealed the facility's DON was notified of the door alarm situation and the resident exciting building. A new order for the use of a Wander guard alarm was given as well and placing the resident on 15-minute checks until further notice. A review of the facility's investigation for Resident #48's elopement on 06/25/23 revealed the incident description of the event was consistent with what was documented in the progress notes. The resident was not able to provide a description of the event. Predisposing physiological factors of the incident included him being confused and impaired memory. Predisposing situation factors included him being a wanderer. Two staff members (LPN #89 and STNA #25) were identified as being witnesses to the incident and provided statements. LPN #89's statement indicated the resident was found in the parking lot by the dumpster after exiting the back hallway door. STNA #25's statement indicated the resident was found outside the facility in the parking lot after exciting the facility unassisted. The facility's investigation indicated the DON was notified on 06/25/23 at 3:30 P.M. On 06/27/23 at 3:35 P.M., an interview with Maintenance Assistant #157 revealed he was the maintenance employee called by the facility staff when Resident #48 eloped from the facility on 06/25/23. He reported they informed him they had a door alarm going off that they could not get silenced. He recalled the concern was with an alarm on the second-floor courtyard door. He came into the facility to check it out. By the time he arrived, the alarm was already silenced. He was informed the alarm that was going off was from the other door at the end of the hall and not the courtyard door as was being announced overhead. He indicated the courtyard door and the short hall exit door had the same code announcement and the overhead message would refer to them both as the courtyard door, even if it was the one at the end of the hall. He was informed a resident had gotten out when he arrived and was found at the bottom of the ramp by the facility's dumpsters. He confirmed by checking his phone that he received the call at 3:12 P.M. and he was in the facility by 3:30 P.M. in which the resident was already back in the facility. On 06/27/23 at 406 P.M., an interview with the DON revealed she was called about the elopement by Resident #48 on 06/25/23 at 3:28 P.M. The staff informed her of what had happened. It was reported to her that the nurse and the aides were in other residents' rooms. They then heard an alarm go off for the courtyard door. The overhead announcement indicated it was the courtyard door. The staff told her they looked outside but did not see any residents out there. They could not get the alarm to silence and called maintenance to come in to check it out. The staff realized the courtyard door was not flashing and it was the exit door at the end of the short hall that was flashing instead. They checked the residents and found Resident #48 to be missing. They went outside and found the resident at the end of the ramp near the dumpsters. On 06/27/23 at 4:10 P.M., an observation of the courtyard door on the 2nd floor revealed it led to the facility's designated smoking area. The alarm system on the courtyard door allowed the door to be immediately opened by turning the doorknob but would sound an audible alarm if the door was opened without entering the code into a keypad. The keypad alarm box on the wall would flash red if that was the door alarming in addition to an overhead announcement that identified the courtyard door as the door alarm that had been activated. The short hall exit door was checked and noted to have a delayed egress of 15 seconds before that door could be opened. A constant audible alarm sounded when the door's bar was pushed on until the door opened and then a different sounding alarm would go off accompanied by an overhead announcement. The courtyard door and the exit door at the end of the short hall both led to the same ramp that led down to the facility's side parking lot where the dumpsters were. The ramp was made of decking material and had a long, gentle slope with handrails on both sides. The side parking lot had a black tar pavement with a raised curb that enclosed it on the back end and the side. It led to the front parking lot where a steep driveway went down into the road the facility sat on. On 06/27/23 at 4:13 P.M., further interview with the DON revealed the alarm company had told them they could not program the alarm system to differentiate between the courtyard door and the short hall exit door, due to their proximity to one another. She indicated, when she was called, Resident #48 had already been found and brought back into the facility. She suspected he was not out there very long between the time the alarm sounded and when he was found. On 06/28/23 at 8:51 A.M., an interview with LPN #89 revealed she was one of the two nurses working on the second floor on 06/25/23 when Resident #48 eloped. She was the nurse assigned the long hall and not the short hall where the resident resided. She stated the overhead message indicated the courtyard door was alarming and they could not get it to stop. She confirmed the called maintenance to come in to check the alarm out and did not realize it was another door other than the courtyard door that was going off. STNA #25 noticed the keypad at the end of the short hall exit door did not look right. She punched in the code and the door alarm silenced. They realized at that point that someone could have gone through that door and not the courtyard as was originally thought. She and the aide went out into the courtyard when the door alarm first went off and did not see any residents out there. She was not sure if they exit door at the end of the short hall was sounding for the full 15 seconds, when the door was pushed on and before it released. She was down the long hall at the time and did not hear it alarming until the announcement was made overhead for the courtyard door. She was not sure where the nurse or the aide that was working the short hall was at that time or if they heard the short hall exit door alarm before being opened. They did a head count when they realized the exit door at the end of the short hall was the one sounding and noticed Resident #48 was missing. She and the aide went outside to look for the resident and he was noted to come out from behind the dumpsters still sitting in his wheelchair. She suspected he was only out there for five to seven minutes between the time the courtyard door alarm sounded and being found in the side parking lot. This deficiency represents non-compliance investigated under Complaint Number OH00143456.