**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, fall investigation review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 5 of 7 (Resident #31, #50, #248, #498 and #501) sampled residents reviewed for falls and accidents. The facility failed to ensure processes were implemented to provide supervision and assistance to ensure the residents' environment was free of accident hazards. The facility failed to conduct thorough fall investigations to identify all contributing factors (root causes) and failed to implement appropriate interventions to ensure resident safety. Resident #498 was admitted on [DATE] and had 13 falls from [DATE] through [DATE]. On [DATE], Resident #498 sustained 3 falls, that resulted in a subdural hemorrhage, a C5 fracture (cervical neck fracture) and bilateral rib fractures. Resident #498 was sent to the emergency room (ER), was admitted to the hospital and discharged back to the facility on [DATE]. Resident #498 was a vulnerable Resident with memory impairment and abnormalities of gait and mobility. The facility's failure to provide supervision and ensure a safe environment free of accident hazards resulted in Immediate Jeopardy for Resident #498. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to use its resources effectively to attain and maintain the highest practicable well-being of vulnerable residents, to ensure systems and processes were implemented to provide supervision and assistance to ensure the resident environment was free of accident hazards. The Administrator was notified of the Immediate Jeopardy (IJ) for F-689 during the recertification/complaint investigation on [DATE] at 6:48 PM, in the Conference Room. The facility was cited at F-689, at a scope and severity of J which is Substandard Quality of Care. The Immediate Jeopardy existed from [DATE]-[DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 2:42 PM, with an alleged removal date of [DATE]. The Removal Plan was verified and validated onsite by the surveyors on [DATE] through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. The last day of the IJ was [DATE]. The IJ was removed on [DATE]. After the acceptable Removal Plan for F-689 was validated on [DATE], noncompliance remains for F-689 at a scope and severity of D. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, Falls, with a revision date of [DATE], revealed .The intent of this policy is to ensure the facility provides an environment that is as free from accident hazards, as possible, over which the facility has control to prevent avoidable falls .All residents will have a fall risk assessment on admission/readmission, quarterly, annually, and with a significant change of condition to identify risk for falls .A Comprehensive Care Plan will be implemented based on the resident's risk for falls with an individual goal and interventions specific to each resident to attempt to reduce the risk of avoidable falls .Care Plan Accidents goals and interventions will be revised as applicable .The Interdisciplinary Team (IDT) which includes the Director of Nursing (DON) or their designee reviews during the At-Risk Meeting .Falls may be reviewed at the facility Quality Assurance/Performance Improvement (QAPI) Committee . Review of the facility's policy titled, Accidents and Incidents, with a revision date of [DATE], revealed .The intent is to ensure the facility provides an environment that is as free from accidents and incidents that are avoidable, the facility investigates these occurrences with applicable documentation, and appropriate reporting is completed as applicable .The Nurse, Nurse Supervisor/Charge Nurse and /or the Department Director of Supervisor shall initiate and document the accident or incident . Review of the facility's document titled, Neuro Check Guidelines, dated [DATE], revealed .Witnessed Fall- No Head injury / did not Hit Their Head .Complete fall event in MatrixCare .Neuro checks not needed- follow provider orders .Continue charting on resident for 72 hours .Unwitnessed Fall or Witnessed Fall With Head Injury / Hit Their Head .Complete fall event in MatrixCare .Neuro checks every 15 minutes x [times] 4 (total of 1 hour) .Neuro checks every 30 minutes x 2 (total of 1 hour) .Neuro checks every 1 hour x 4 (total of 4 hours) .Neuro every 4 hours x 4 (total of 16 hours) .Resume routine charting for the remainder of the 72 hours post fall . 2. Review of the medical record revealed Resident #498 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Traumatic Subarachnoid Hemorrhage, End Stage Renal Disease (ESRD), Osteoporosis, Epistaxis, Malignant Neoplasms of Lymphoid, Hematopoietic, and related Tissues [group of cancers that affect blood cells and the tissues of the lymphatic system], Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Fibrosis, and Dementia. Review of the facility's Event Report dated [DATE], revealed Resident #498 had an unwitnessed fall at 10:35 AM. Resident #498's Fall Risk Score was 21 indicating the Resident was at a high fall risk. Staff documented following the Resident's fall that the Resident's pupils were 3 mm [millimeters] and Neuro Checks were completed as follows: Three (3) Neuro checks were performed every 15 minutes (not 4 every 15 minutes), Two (2) Neuro checks were performed every 30 minutes, One Neuro check was performed once for 1 hour (should have been every hour for 4 hours then every 4 hours times 4 for a total of 16 hours). Review of the Progress Note dated [DATE] at 6:25 PM, revealed Unwitnessed fall noted this shift. Resident confused and doesn't know why she was walking. No pain noted or reported . This was fall #1. Review of the Care Plan dated [DATE] revealed .Falls Resident at risk for falling R/T [related to] history of falls, impaired cognition, medications, ESRD, dementia, COPD, arthritis, pain, cancer, unsteady, poor safety awareness . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #498 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Resident #498 had 1 fall with no injury documented. Review of the progress note dated [DATE] at 2:30 PM, revealed Resident [#498] was seen crawling into the main hallway by CNA [Certified Nursing Assistant], resident refused to verbalize what occurred prior to CNA finding pt [patient] crawling on the floor, resident did not sustain any visible injuries and neuro [neurological] & cognitive sts [status] remain at baseline, no s/s [signs/symptoms] or c/o [complaint of] pain, resident was holding their chest and appeared to be SOB [short of breath], O2 [oxygen] sat [saturation] at time of incident was 84% [percentage symbol][normal oxygen sat is 95% - 100%], applied 1L [Liter] O2 and current sat. is 99% while on 1L O2 via [by way of] NC [nasal cannula], all other vitals at this time are WNL [within normal limits]. This was fall #2. Review of the progress note dated [DATE], revealed IDT [Interdisciplinary Team] Review: Resident [#498] sustained a fall without acute or latent injury on [DATE] Root Cause: [Named Resident #498] is at risk for falls related to impaired cognition and mobility per the comprehensive plan of care. Resident sustained fall on [DATE] without injury Intervention: Resident to be encouraged to remain in communal areas when possible. Discussed in AM clinical with no further recommendations offered at this time . Resident #498's BIMS score was 2, indicating severe cognitive impairment. The facility failed to complete neuro checks according to the neuro check guide after one hour following the unwitnessed fall on [DATE]. Vital signs were obtained at 2:30 PM and 2:45 PM. Neuro checks were completed every 15 minutes x 4 then stopped. Review of the facility's Event Report dated [DATE] at 10:40 PM, revealed Observed in the floor .[checked] Witnessed [fall] and did not hit her head . This was fall #3. The facility failed to identify this fall where Resident #498 was observed in the floor as an unwitnessed fall and no neuro checks were completed. The intervention implemented after this fall was a fall mat by the bed. Review of the progress note dated [DATE] revealed IDT Review: Resident sustained two falls without acute or latent injury on [DATE]. Resident #498 sustained two falls on [DATE] and the facility was unable to provide fall investigations for the 2 falls on the [DATE]. This was fall #4 and #5. Review of the Progress Note dated [DATE] at 1:44 PM, revealed Unwitnessed fall noted this shift. Resident confused and attempted to get out of bed. 5/10 pain reported . This was fall #6. Review of the care plan intervention for the Resident's falls dated [DATE], revealed, . fall mat to left side of bed . The facility failed to complete neuro checks according to the neuro check guide for this unwitnessed fall. Review of the facility's Event Report dated [DATE], revealed .unwitnessed fall .Fall Risk Assessment 17 High fall risk . Review of the progress note dated [DATE] at 12:39 AM, revealed Resident had an unwitnessed fall approximately 1900 [7:00 PM] in hallway 200. Vitals obtained were 96.9 [Temperature (T)], 134/78 [Blood Pressure (BP)], 82 [Pulse (P)], 98% [O2 sat] room air. Resident was on the fall [floor] with her head near the wall. Unsure if she hit her head. She was ambulating with the walker. Called DON [Director of Nursing] and reported the fall. Started neuro checks .Staff was able get resident to sit in the geri chair [a type of reclining chair] for just a little time before she climbed out and fell again about 19:45 [7:45 PM] .transferred resident [to the hospital] . This is fall #7. The facility failed to complete neuro checks according to the neuro check guide and failed to complete vital signs. Review of the progress note dated [DATE] at 5:42 PM, revealed While staff was attempting to assist resident, she quickly sat herself in the floor 'indian style' .Assisted with rising per one staff and much encouragement, res [Resident] quickly squatted in the floor . This is fall #8. Review of the Care plan intervention for the Resident's fall dated [DATE] revealed, .keep w/c [wheelchair] within reach at bedside .therapy eval [evaluation] for use of walker . Review of the progress note dated [DATE] at 2:06 PM, revealed resident [#498] continues on alert charting for monitoring falls resident had a fall on [DATE] no latent injury no neuro checks requested at this time no behaviors noted on this shift resident vitals remain WNL [within normal limits] . Interview revealed Resident #502 informed staff that Resident #498 was in the floor. Resident #502 no longer resided in the facility. See the Director of Nursing (DON) interview on [DATE] at 5:20 PM. This was an unwitnessed fall, and no neuro checks were completed. This was fall #9. Review of the facility's Event Report dated [DATE] at 11:53 AM, revealed resident [#498] was seated in dialysis chair in common area. Resident stood up and lost her balance and fell to floor, resident did not hit her head. Safely assisted resident back to chair, resident then attempted to get up again without assistance. Vitals taken BP 105/54, P 88, R 20, no injuries observed at this time .continue neuro checks .Witnessed . This was fall #10. Review of the Care plan intervention for the Resident's fall dated [DATE] revealed .sensory device to chair . The facility documented continue neuro checks but were unable to provide neuro check documentation. Review of the progress note dated [DATE], revealed Resident [#498] sent to hospital, resident had three unassisted falls that led to head injury, and other facial bruising with complaint of pain. Want to make sure resident has no underlying issues related to the falls . This was fall #11, #12, and #13. The facility failed to complete a fall investigation, vital signs, and neuro checks for the 3 falls on [DATE] for Resident #498. Review of the Emergency Documentation [Hospital #1], dated [DATE], revealed .Computed Tomography [CT scan] Head or Brain . Impression . subdural hemorrhage the anterior aspect of .4.1 mm [millimeters] .Discharge Diagnosis .Recurrent Falls; Subdural bleeding . Further review revealed Resident #498 was transferred from Hospital #1 to Hospital #2 on [DATE] to follow up with neurosurgery. Review of the [Named Hospital #2] History and Exam form dated [DATE], revealed .Patient diagnosed with SDH [Subarachnoid Hemorrhage], C [cervical]-5 fracture and bilateral rib fractures .Neurosurgery is following patient for SDH . Review of the [Named Hospital #2] Trauma Surgery Discharge Summary dated [DATE], revealed Additional Discharge Diagnoses . Subarachnoid Hematoma, Unspecified fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing, Other nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, and Multiple fractures of ribs, bilateral, subsequent encounter for fracture with routine healing. Review of the progress note dated [DATE] at 16:39, revealed Rtn [returned] to facility via EMS [Emergency Medical Services] on gurney; transferred to bed by EMS; tol [tolerated] well; resident alert and oriented to self; no s/s pain observed; c [cervical]-collar in place. No skin issues noted. LS [lung sounds] clear bilat [bilateral]; BS [bowel sugar] active X [times] 4 quads [quadrants]; no edema noted; will monitor. VSS [vital signs stable] . Review of the progress note dated [DATE] at 1:04 AM, revealed resident [#498] sustained unwitnessed fall and hit her head, no injuries noted but resident was bleeding from her nose. Vitals checked T-97.8, HR-74, R-16, BP-103/58, SP02-98% RA [room air] . EMS [Emergency Medical Services] arrived and safely transferred resident from bed to stretcher via assist x2. This was fall #14. Review of the Care Plan interventions for Resident 498's falls dated [DATE], revealed, .offer sensory sound device to assist in promoting restful sleep at hs [bedtime] . Review of the NP Progress Note dated [DATE], revealed Resident #498 was admitted to inpatient services at Hospital #1 from [DATE] - [DATE].seen today following readmission to the facility .She [Resident #498] presented to the hospital following and [an] unwitnessed fall with a nosebleed .She has a C5 c-spine fracture from another fall. She was admitted for acute blood loss anemia and anemia of chronic disease. She received one unit of PRBCs [packed red blood cells] . Review of the Care Plan dated [DATE], revealed .ADLs [Activities of daily living] Functional Status/Rehabilitation Potential .Resident has a self care deficit related to impaired physical functioning and medical conditions as evidenced by the need for staff assistance for adequate completion of ADL care, weakness, impaired cognition from dementia, ESRD with dialysis, COPD with shortness of breath, rib fractures .C-Collar as ordered . Review of the quarterly MDS dated [DATE], revealed Resident #498 had a BIMS score of 00, which indicated severe cognitive impairment. No falls were documented on the assessment. Review of the Care Plan edited on [DATE], revealed .Pain .Resident has at risk for complaints of acute/chronic pain R/T [related to] ESRD with dialysis, cancer .rib fractures .Encourage resident to request pain medication PRN [as needed]. Observations in the resident's room on [DATE] at 4:26 PM and on [DATE] at 10:52 AM revealed no fall mat in Resident #498's room and Resident #498 was in a Broda chair (a type of reclining chair) in the hallway. During an interview on [DATE] at 2:13 PM, the Administrator was asked when she presented the Roster Matrix to the surveyor to verify the facility did not have any falls with major injuries. The Administrator stated, No. The Administrator was asked to verify the facility did not have any resident falls with fractures. The Administrator stated, No, we did not. During an interview on [DATE] at 11:03 AM, CNA E was asked if she worked with Resident #498. CNA E Stated, .yes, She [Resident #498] likes to crawl out of bed and lay on the floor. In March her face had bruising, and they said she fell. She had a C collar on. She tries to remove the collar. She was out [at the hospital] when I came back [back to work from being off], and she [the Resident] returned a few days later [to the facility] .She [Resident #498] is hard to redirect and yells at you, she will swing at you at times. She needs a fall mat, I tell them [staff] all the time because she likes to lie in floor. Never seen a fall mat in her room . During an interview on [DATE] at 1:54 PM, the Regional Nurse Consultant handed the surveyor the discharge summary and history and physical and stated, I cannot find a fall investigation for [DATE]. Observation in the resident's room on [DATE] at 10:08 AM, revealed no fall mat by Resident #498's bed. During a telephone interview on [DATE] at 7:15 AM, Licensed Practical Nurse (LPN D) was asked about Resident 498's fall which occurred on [DATE]. LPN D stated, . [named CNA U] came and told me what occurred. CNA [U] was helping another resident on the hall while she found [named Resident #498] on the floor. She didn't witness the fall. LPN D was asked if she had been reprimanded for not conducting a fall investigation. LPN D stated, I did not get written up .Someone did give me a call the next day and asked me what I did .I was on the phone with the on-call NP [Nurse Practitioner] the EMS arrived. I worked as agency then, but I have not worked there since. She [DON] asked me to come in early one night and I don't recall writing a statement . During an interview on [DATE] at 10:04 AM, CNA V was asked if there was a fall mat in Resident #498's room. CNA V stated, No Ma'am, no fall mat. During an interview on [DATE] at 5:20 PM, the DON was asked when and how often should neuro checks be initiated. The DON stated, For unwitnessed falls, after doing a complete assessment, notify provider, family, and follow through with orders . The DON was asked what was considered a fall with major injury. The DON stated, A fracture, a SDH [subdural Hemorrhage] is a major injury. The DON was asked when should neuro checks be done. The DON stated, It's nursing 101 you know to call family and provider, look at standard of care and best practices is neuro checks. It should be at least 3 days after the fall noted in the progress notes . The DON was asked who should start the fall investigation. The DON stated, The nurse should open it, and we review it in IDT [Interdisciplinary Team] Should be opened and started at point of the fall . The DON was asked who does fall risk assessments. The DON stated, [The] Nurse on the floor and at a minimum quarterly . The DON was asked who is responsible for witness statements. The DON stated, The DON and ADON [Assistant Director of Nursing]. The DON was asked why Resident #498 and #501 were not listed on the facility's matrix as falls with major injury (FMI). The DON stated, It was on there. The surveyor showed the DON the facility's matrix that did not reflect Resident #498 and #501's fall with major injury. The DON stated, Well, that was a mistake. The DON was asked which resident observed Resident #498 on the floor on [DATE]. The DON stated, [Named Resident #502] . The DON confirmed Resident #502 no longer resided in the facility. The DON was asked why there was no fall investigation for the falls that occurred on [DATE]. The DON stated, We did one investigation for all 3 falls that day .The third fall she went out because she hit her head that time . The DON was asked should a fall mat have been in room by the bed last week. The DON stated, Yes, it was not discontinued . The DON was asked should vital signs be taken with fall investigations. The DON stated, Vital Signs are fundamental nursing 101 .They charted WNL, Stable . The Vital signs were documented as stable, but the actual vital signs were not documented. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 3:00 PM. The ADON confirmed the neurological assessments were not completed per protocol and stated there should have been more than just one for an unwitnessed fall. 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Diabetes, Cellulitis Bilateral Legs, Edema, and Venous Insufficiency. Review of the annual MDS dated [DATE], revealed a BIMS score of 8, which indicated Resident #31 had moderate cognitive impairment. Resident #31 required maximum assistance of staff to perform activities of daily living (ADLs). Review of the facility's Event Report dated [DATE], revealed Resident #31 sustained an unwitnessed fall in the Resident's room. Staff performed a neuro check at 9:03 PM and at 9:15 PM. The facility failed to perform neuro checks according to the neuro check guide on Resident #31 after 9:15 PM. During an interview on [DATE] at 5:20 PM, the DON confirmed that neuro checks should be performed every 15 minutes for 1 hour, every 30 minutes x 4, every hour x 4, and every 8 hours x 2. 3. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses including Dementia, Diabetes, Peripheral Vascular Disease, and Hypertension.? Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #50 had severe cognitive impairment. Resident #50 required maximum staff assistance to perform toileting and bathing, and moderate staff assistance for transfers. Resident #50 had 1 fall since admission documented. Review of the facility's Event Report dated [DATE] at 5:46 PM, revealed Resident #50 sustained a witnessed fall in his room by the bedside table.Staff CNA [Certified Nursing Assistant] witnessed fall .Notes XXX[DATE] 5:54 PM .Resident had a witnessed fall and hit his head while attempting to get snacks off of his table . The facility failed to perform neuro checks according to the neuro check guide and obtain a witness statement from staff. 4. Review of the closed medical record revealed Resident #248 was admitted to the facility on [DATE], with diagnosis including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Dementia, Acute Kidney Failure, Psychotic and Mood Disturbance, and Anxiety. Resident #248 expired [DATE]. Review of Care Plan dated [DATE], revealed .Problem: Resident at risk for falling R/T [related to]: weakness, frequent falls, dementia, COPD [Chronic Obstructive Pulmonary Disease] with shortness of breath, tremor, bradycardia, medications .2 person assist with transfers .highlighted call light .encourage to be up in communal areas .non slip material to wheelchair .bilateral fall mats .bed in lowest position .Problem: Resident has impaired cognitive skills as evidenced by: Decision making problems, Short term memory problem, dementia, takes medications with potential for side effects . Review of the admission MDS assessment dated [DATE], revealed Resident #248 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #248 required maximal staff assistance for ADLs. Review of the Event Report dated [DATE], revealed .14:37 [2:47 PM] .unwitnessed fall w/o [without injury] .resident room .[Named Resident #248] Fall Risk Score Total:21 .high fall risk .Seen resident lying on foam fall mat left side of bed .Reminded resident to press call lights for needs and assistance XXX[DATE] Root Cause: .at risk for falls related to impaired cognition and impaired mobility . The facility failed to complete neuro checks after an unwitnessed fall according to the facility neuro check guide. Resident #248 had severe cognitive impairment so a reminder to press the call light for assistance was an inappropriate intervention. 5. Review of the medical record revealed Resident #501 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Fractured Rib, Diabetes, and Cerebral Infarction. Review of the admission MDS assessment dated [DATE], revealed Resident #501 had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #501 had 1 fall with no injury documented. Review of the progress note dated [DATE], revealed Fall event occurred, neuro checks in place no new injuries or concerns, redirected and encouraged to use call light and to keep bed at safe level, informed DON .Oncall Np [Nurse Practitioner], and RP family member, son .to make them aware of incident but no serious injury noted. Left voice mails with all appropriate contacts and encouraged son to know his dad is ok [okay] . Review of the facility's Event Report dated [DATE] at 1:49 AM, revealed .Fall unwitnessed .Neuro checks 11:00 PM, 11:15 PM, 11:30 PM, 11:45 PM, 12:15 AM, 12:45 AM, 1:15 AM, 2:15 AM, 2:15 AM, 3:15 AM, 4:35 AM .Fall Risk Score 16 High Fall Risk .[Named resident is at risk for falls .related to impaired mobility . The facility failed to complete neuro checks according to the facility neuro check guide. Review of the Care Plan dated [DATE] revealed Resident has a right rib fracture r/t to fall . 6. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on [DATE] at 2:42 PM. The surveyors validated the Removal Plan through review of the in-service training records and audits, review of the facility's policy, observations, and staff interviews. 1. Corrective Actions for identified resident(s) affected by the deficient practice. The facility failed to have a system in place to ensure the resident's environment remained as free of accidents and hazards as was possible and to ensure that the resident received adequate supervision to prevent accidents for resident #498. a. Resident #498 expired at the campus on [DATE]. b. On [DATE] at 22:42 resident was sent to the hospital after falling at the campus and obtaining a suspected head injury. Resident had documentation from the nurse in a nurse's note that the resident had 3 unassisted falls that led to head injury, facial bruising, and complaint of pain. The Director of Nursing (DON), nurse practitioner (NP), and the resident's family member were notified, and order was obtained to send to ER for evaluation. c. [DATE]: Resident was assessed at Vanderbilt hospital and was noted to have a 4mm subdural hematoma with no neurological changes, both pupils equal and reactive, and Glascow Coma Scale (GCS) was 14. Resident was confused, which is her baseline, and obeys commands. CT of the head showed small subdural hemorrhage with no visible acute infarct, contusion, hydrocephalus, or midline shift. d. [DATE]: Vanderbilt Discharge Summary shows that neurological exams remained stable throughout stay and she discharged from hospital to return to the campus. e. Resident returned to the campus at her baseline and returned to participation in her routine per her norm. f. [DATE]: upon the interdisciplinary teams (IDT) (Director of Nursing (DON), Assistant Director of Nursing (ADON), Social Services Director (SSD), and minimum data set coordinator (MDSC), review of records it was determined that the fall event(s) were not opened in the medical record in correlation with the assessment note. The DON and ADON immediately initiated an investigation that included interviews and education of nurses on completion of documentation. Through the investigation it was determined that each time the resident had a fall there was an intervention placed; however, the interventions did not get added into the plan of care. g. [DATE]: the Resident and her family opted to pursue hospice due to diagnosis of multiple myeloma, unrelated to fall and associated injuries from [DATE]. Hospice was initiated at this time and the resident stopped dialysis per her preference and end of life planning. Resident expired on [DATE] under the care of Hospice. 2. Identification of other residents who may be affected by the deficient practice and corrective actions that will be put in place to ensure the deficient practice does not reoccur. The facility took immediate action to ensure all residents are free from accident hazards and to ensure the residents receive adequate supervision to prevent accidents. a. [DATE]: All residents were reviewed by regional nurses and campus nurse leadership for fall risk and all resident care plans were reviewed for appropriate fall interventions. b. [DATE]: All falls since [DATE] were reviewed by regional nurses and campus clinical leadership to ensure that processes and procedures were followed per the plan of care and neuro checks were completed for unwitnessed falls and/or falls that resulted in the resident hitting their head. c. [DATE]: Resident rooms were rounded on by facility clinical leadership and regional nurses to ensure that fall interventions are in place. No concerns noted. d. All resident's that fall will be reviewed in clinical morning meeting by the members of the IDT (DON, ADON, MDS Coordinator (MDSC), and Social Services Director (SSD) to ensure that appropriate interventions are in place and care plans are updated. e. All residents that fall will be followed weekly in the campus At-Risk meeting to ensure interventions implemented are in place and effective. The IDT, in conjunction with the medical provider, who are reviewing weekly may make changes to the plan of care and interventions that are reviewed. 3. Measures put into place and systemic changes you will make to ensure that the deficient practice does not reoccur. a. All nurses will be re-educated on the Fall policy and completion of neurological checks for residents that have a fall and hit their head, or the fall was unwitnessed beginning 5[TRUNCATED]