**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 6 of 8 residents (Resident #11, #14, #18, #52, #163, and #215) 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 appropriate fall investigations to identify all contributing factors (root causes) including the disabling of the courtyard door alarm on the 400 hall and failed to implement appropriate interventions to ensure resident safety. On [DATE] Resident #11, a vulnerable resident with memory impairment and abnormalities of gait and mobility, exited the building unsupervised and without staff knowledge after a staff member disabled the courtyard door alarm on the 400 hall. At approximately 11:15 AM, a staff member was looking out the window of a resident's room and saw Resident #11 outside and sitting on the ground in the courtyard. Resident #11 required 2 staff members to assist her off the ground and back into the building. Resident #11 was found 13 feet and 6 inches from the 400-hall courtyard door threshold. The temperature was documented by weatherspark.com to be 89 degrees Fahrenheit with severe thunderstorms watch in effect for [NAME] County ([NAME], Tennessee). The time span Resident #11 was outside could not be determined. The facility's failure to provide supervision and ensure a safe environment free of accidents hazards resulted in Immediate Jeopardy for Resident #11. Resident #14, a cognitively impaired resident at risk for falls, fell on [DATE], sustained a laceration to the left eye and was transferred to the emergency room for evaluation. The facility failed to complete a fall risk assessment for Resident #14 after the fall on [DATE]. The facility failed to ensure appropriate interventions were initiated, failed to obtain an x-ray, and failed to provide pain medication after Resident #18 fell on [DATE], resulting in a painful wrist fracture. Resident #52 fell on [DATE] and the facility was unable to provide a BIMS score on the event note, failed to complete neurological checks, and complete an updated fall risk assessment for Resident #52's fall on [DATE]. The facility was unable to provide a BIMS score on the event note and failed to complete neurological checks for Resident #52 after a fall on [DATE]. Resident #163, who was identified as at risk for falls, failed to have an appropriate care plan developed and implemented for fall preventions. Resident #163 fell on [DATE], sustained multiple skin tears, lacerations, and a head injury, and was transferred to a hospital, then transferred to a higher level of care hospital, and expired on [DATE] related to aspiration pneumonia. Resident #215 had a previous fall on [DATE], which resulted in a right hip fracture. The facility's investigation revealed Resident #215 had another fall on [DATE], with a root cause being the resident's meal tray was not set up within her reach. The [DATE] fall resulted in a left hip fracture. Residents #18, 163, and 215 had falls which resulted in fractures and a head injury, resulting in actual harm. Immediate Jeopardy (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 and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-689 during the recertification survey on [DATE] at 4:37 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which is Substandard Quality of Care. The Immediate Jeopardy began on [DATE] - [DATE], with [DATE] being the last day of the IJ. The facility's corrective actions were validated onsite by the surveyors on [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Immediate Jeopardy, was received on [DATE] at 10:39 AM with an alleged IJ removal date of [DATE]. The Removal Plan was verified and validated onsite by the surveyors on [DATE] through [DATE] by review of the in-service training records and audits, review of the facility's policy, review of new hire orientation packets, observations, and staff interviews. The last day of the IJ was [DATE]. After the acceptable Removal Plan for F-689 was validated on [DATE], noncompliance remains for F-689 at a scope and severity of G. The findings include: 1. Review of the facility policy titled Comprehensive Care Plan, dated [DATE], revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs .The comprehensive care plan shall describe, at a minimum .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility's policy titled Neurological exam, dated [DATE], revealed .To provide a method to assure a uniform procedure for neurological assessments and to provide guidelines for observation and communication of neurological changes over a period of time .The facility shall initiate a neurological examination for individuals who have or may have experienced trauma to the head in order to capture any changes in a resident's neurological condition .a neurological examination shall be completed any time an individual has trauma to the head, either by a blow to the head or by falling and striking the head, regardless of whether they receive medical attention or not .Neuro assessments shall be performed for 72 hours or as ordered by the MD [Medical Doctor]/NP [Nurse Practitioner] . Review of the undated facility FALL PROCESS, revealed .OPEN EVENT NOTE UNDER PROCESS .OBTAIN WITNESS STATEMENTS .DOCUMENT IN THE EVENT NOTE WHY THEY FELL. GET TO THE ROOT CAUSE .ATTACH ALL REQUIRED DOCUMENTS IN THOS [THIS] PACKET .NEURO CHECKS INITIATED .FALL RISK ASSESSMENT UPDATED .MAKE SURE BIMS IS INCLUDED. IF NOT, THEN ADDRESS . Review of the facility's undated process titled EVENT NOTE PROCESS, revealed .MAKE SURE BIMS SCORE IS ON THE EVENT NOTE (SCORE HAS TO BE 13-15 TO BE ABLE TO EDUCATE THE RESIDENT) DO ROOT CAUSE ANALYSIS TO DETERMINE APPROPRIATE INTERVENTION AND PUT AN INSERVICE OUT WITH INTERVENTION IF NEEDED. COMPLETE FALL RISK - MAKE SURE TO ADD YOUR SCORE AND CALCULATE. START NEURO CHECKS - ON ALL UNOBSERVED FALLS AND THE RESIDENTS BIMS IS LESS THAN 13 OR IF GREATER THAN 13 AND THEY TELL YOU THEY HIT THEIR HEAD AND IF IT IS AN OBSERVED FALL AND THE RESIDENT HIT THEIR HEAD .UPDATE THE RESIDENT CARE NEEDS TO REFLECT THE FALL INTERVENTION IF IT AFFECTS THE C.N.A. CARE OF THE RESIDENT .COMPLETE ALL INVESTIGATION FORMS AND HAND IN TO THE APPOINTED PERSON .ATTACHED TO THE OCCURRENCE INVESTIGATION WORKSHEET OCCURRENCE AUDIT CHECKLIST .COMPLETE 72 HOUR DOCUMENTATION, EACH SHIFT, ON THE EVENT AND REFERENCE THE INTERVENTION. Review of the facility policy titled Fall Risk -- Fall Prevention, dated [DATE], revealed .A Resident that unintentionally comes to rest on the ground, floor or other lower level .when a resident is found on the floor, a fall is considered to have occurred .Each resident shall be assessed for fall risk and shall receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .1. The fall risk assessment shall be completed by a licensed nurse .After a fall .the fall risk assessment shall contain the following four components: a. Identify environmental hazards and individual risks, including the need for supervision. b. Evaluate and analyze hazards and risks. c. Implement interventions, including adequate supervision, consistent with a Resident 's needs, goals, plan of care and current standards of practice in order to reduce the risk of a fall d. Monitor for effectiveness of the interventions and modify the interventions as necessary in accordance with current standards of practice .An 'At risk for Fall' care plan may need to be created or updated for Residents upon admission/readmission to the facility, after a fall .to address items identified on the fall risk as needed .Resident with a BIMS [Brief Interview of Mental Status] score of 13 or greater may be educated on the use of the call light system and reminded to ask for assistance .intervention for consideration to reduce falls .related to the Residents individual fall risk factor and/or fall occurrence .routine rounding by staff .Placing a bedside mat on the floor next to the Resident's bed .Application of proper footwear .Refer to Residents to therapy department for screening .Assess and treat for pain as warranted . 2. Medical record review for Resident #11 revealed an admission date of [DATE], with diagnoses of Chronic ulcer of left ankle, Peripheral Vascular Disease, Alzheimer's Disease, Paranoid Schizophrenia, Hypothyroidism, Anxiety, Obsessive Compulsive Disorder, Insomnia, Abnormality of Gait and history of Repeated falls and Seizures. Resident #11's care plan dated [DATE], documented .has a self-care deficit R/T [related to] ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfer with interventions effective date [DATE] .Remind [Resident #11] to call for assistance before ambulation. Walk in room/out of room with assistance/device as needed. Requires SBA [Standby Assist] of 1 staff member for transfer and mobility. Exhibited wandering behavior with intervention to redirect when wandering is observed .provide diversional activities .prompt activity attendance to keep resident occupied . problems .at risk for falls r/t [related to] abnormal posture and gait unstable balance with interventions . Review of the Minimum Data Set (MDS) dated [DATE] and [DATE], revealed Resident #11 had a BIMS score of 14, required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene with 1 person assist, surface-to surface transfer (transfer between bed and chair or wheelchair) was not steady, and was only able to stabilize with staff assistance. Review of Resident #11's Fall Risk Assessment dated [DATE], documented a total score of 14 indicating moderate risk for falls. Review of the Physical Therapy (PT) Recertification Progress Note and Updated Therapy Plan beginning [DATE] revealed Resident #11, .lacks insight into condition and risk factors . Review of Resident #11's Fall Risk Assessment dated [DATE], documented a total score of 15 indicating moderate risk for falls. Review of the Nurse's Event note for Resident #11 dated [DATE] at 11:15 AM, revealed .Location .courtyard .Unobserved .no apparent injury .unobserved .see clinical note . Review of the facility's Clinical Note dated [DATE], at 14:54 (2:54) revealed, . [Resident #11] was found in the courtyard wandering around when they [staff] got to her resident was lying on the ground red and warm to the touch . Review of the Occurrence Investigation Interview for Resident #11 dated [DATE] at 11:15 AM, revealed, .Fall .courtyard .CNA [certified nursing assistant] saw resident from window . What did the Resident say? Unable to determine .How was the Resident positioned when you observed them? .on bottom .At the time of the occurrence, Resident was/had: (Check all that apply) .confusion, impulsive, Wearing Appropriate Footwear . Review of the facility's undated Interdisciplinary Team Occurrence Investigation Worksheet (provided by the facility related to the [DATE] fall) revealed .The root cause of the occurrence is Inappropriate Footwear .Intervention(s) put in place: encourage resident not wear 'crocs' when going outside .Behaviors that may have contributed to the fall .contributing factors .Agitation . Restlessness .Impulsive behaviors .Physical Function problems that may have contributed to the fall .gait disturbance, muscle weakness and loss of balance .Review the environment for possible contributing factors .Alarm not sound on door [alarm was disabled] .Review factors related to the resident for possible contributing factors .pain and fatigue . Review of the revised care plan for Resident #11 with the revision date of [DATE] revealed, problems .at risk for falls r/t [related to] abnormal posture and gait unstable balance with interventions updated [DATE], Actual fall. no apparent injuries. Review of an undated WITNESS STATEMENT conducted via telephone interview by the facility with CNA #3 regarding Resident #11's [DATE] fall, revealed .Date Incident Occurred [DATE] [[DATE] is the date written, however, the incident occurred on [DATE]] .observed resident [Resident #11] sitting on her bottom .[CNA #3] and another CNA [CNA #4] went outside and assisted the resident back in . A facility telephone interview on [DATE], related to Resident #11's [DATE] fall revealed CNA #4 stated . was in room [ROOM NUMBER] assisting with tray set when she [CNA #4] observed [Resident #11] sitting on her bottom approximately 5 feet from the door to enter the facility from the courtyard .she and another CNA [CNA #3] went outside and assisted the resident back in the facility and notified the nurse who assisted the resident . Review of the facility's WITNESS STATEMENT from the Social Service Director dated [DATE], revealed, .A resident [random resident] asked if he could go outside for some fresh air .I borrowed the alarm key to the courtyard from the nurse .unlocked the door .assisted resident [random resident] back inside .he [random resident] was in a wheelchair .I failed to get the key back from a nurse that triggers the exit alarm . Review of the facility's Addendum Note Clinical Note dated [DATE] at 8:48 AM, revealed, .CNA [CNA #4] saw resident [Resident #11] from the window of another room [room [ROOM NUMBER]] and went to get the resident from the courtyard. When they [CNAs] got to [Resident #11] resident was sitting on the ground, red and warm to the touch . Review of a Physicians Clinical Note dated [DATE], revealed, .apparently patient [Resident #11] fell back on [DATE] while she was out in the courtyard. I was asked to see the patient for a neurological evaluation .she has a history of memory impairment and seizure disorder. She also has peripheral vascular disease, insomnia, schizophrenia, conduct disorder, Alzheimer type dementia .when I saw her today she was awake, alert and slightly slow to respond .needs help walking , does not use walker .Neurological .oriented to place but not time or person .Assessment . History of Memory Loss .dementia .seizure disorder . anxiety .Plan .appears to have memory impairment at least orientation to person and time .appears to be able to stand but need assistance . Review of the NURSE'S EVENT NOTE dated [DATE] at 4:30 AM, revealed .Location Incident Occurred .Patient Room .bathroom .Unobserved Fall .Injury .Abrasion .left side of forehead .called to room by CNA, resident noted laying in the floor of her bathroom on her stomach with head turned to right side. 3 staff to get res [Resident #11] up .had on non skid socks and shoes was trying to get to the toilet and lost balance was incont [incontinent] of urine .STEPS IMPLEMENTED TO PREVENT RECURRENCE .visual sign to use call light for assist to bathroom . Review of the OCCURRENCE INVESTIGATION INTERVIEW dated [DATE] at 4:30 AM, revealed .What did the Resident say happened .I don't know .How was Resident positioned when you observed them? .laying in floor on her stomach with head turned to the right .Other comments: .does not wait or call for assistance . Describe any noncompliance issues or impaired safety awareness of the Resident .getting up by herself w/out [without] assistance . Review of the undated INTERDISCIPLINARY TEAM OCCURRENCE INVESTIGATION WORKSHEET, for the [DATE] fall, revealed .The root cause of the occurrence is: Ambulating to restroom without assistance .Intervention(s) put in place .Visual cue placed in Resident room to call for assistance with toileting . Observations on [DATE] at 11:06 AM, revealed Resident #11 sitting in her room in a recliner chair with eyes closed, fully dressed in socks and croc shoes on her feet. A reddened area was observed above Resident #11's left eye, from a fall she had in the bathroom on [DATE]. During an interview on [DATE] at 4:00 PM the Social Worker Director (SSD) was asked about Resident #11 wandering outside to the courtyard unsupervised on [DATE]. The SSD stated, .it was on a Saturday [[DATE]] .I came in that day and I took another resident outside to the courtyard who was in a wheelchair just to get some fresh air .I unlocked the courtyard door [off the 400 hall] when I brought the resident back in, I cut the door alarm off, took the resident back to his room and was talking with other residents and I forgot to cut the alarm back on .I was in another resident room it was at least 15 min .I was coming down the hall and they were bringing Resident #11 back in from outside .No one else knew that the alarm was dislodged .No one knew she was out there and she was in the courtyard by herself. I forgot to turn the alarm back on and she had wandered outside, and no one knew it . The SSD stated .she [Resident #11] was sitting on her bottom when they found her .It was hot that day. This was reported to the state and was investigated .I felt so bad .I am so glad that they saw her .I felt bad because I forgot to turn that alarm back on .and it was so hot that day . The SSD was asked did she see anyone else in the courtyard when she was bringing another resident back inside the building. The SSD stated no. The SSD was asked if Resident #11 was allowed to go into the courtyard by herself. The SSD stated .no, she is never outside alone .someone is always with her .she loves to be outside .she is never outside in the courtyard by herself, the staff only takes her out because when she goes out she does not want to come back in and she would not let the staff know when she needed to come back in .she would have never been outside unattended because she has a lot of mental diagnoses and cognition not good .I forgot to cut the alarm back on .no one knew until she was found .it was my fault I forgot to engage the door alarm . During an interview on [DATE] at 4:30 PM, CNA #3 was asked about Resident #11 being found in the courtyard unsupervised. CNA #3 stated .I was passing a lunch tray to a resident in room [ROOM NUMBER], as I was placing the tray on the table, the blinds were open, and I noticed Resident #11 was outside in the courtyard sitting on the ground. I ran to get her yelling for assistance from CNA #4 . [Resident #11] was sitting on the ground .I remember it was really hot that day .she [Resident #11] was sweating a lot . CNA #3 was asked if she heard the door alarm sounding. CNA #3 stated .No I did not hear an alarm . CNA #3 was asked if Resident #11 was outside alone. CNA #3 stated .there was no one else outside with [Resident #11] .she was on the ground when I saw her through the window .it took 2 of us to get her up .it was so hot that day .she was anxious, red and flushed .I was not [Resident #11's] CNA that day but have worked with her and she does not go into the courtyard alone .she loves to be outside and we have a hard time bring her back in . CNA #3 was asked if she wrote a statement about Resident #11 being outside on the ground, unsupervised the day the incident occurred. CNA #3 stated .I was thinking I needed to write a statement, but no one asked me until 7/3 [[DATE]] that Monday [2 days later] I was called, and I gave statement over the phone . CNA #3 was asked if the Administrator came to the building after the incident to take her statement. CNA #3 stated .No .if she did, she did not talk to me I was not called or talk to till Monday . During a telephone interview on [DATE] at 4:00 PM, Licensed Practical Nurse (LPN) #5 was asked about Resident #11 being found in the courtyard on the ground and unsupervised. LPN #5 stated .Resident #11 was my assigned resident. It was my first shift working at the facility on 7/1 .I saw resident [Resident #11] going down the hall, she was a little unsteady .I asked if she was OK to be walking the halls and the CNA said yes .I was passing my medications when I heard the CNAs yelling that Resident #11 was outside lying on the ground. I don't know how she got outside .I heard that a resident wanted to water the flowers and when he came back in, they forgot to set the alarm back .I'm really not sure. I did not hear a door alarming at all . I did not see her [Resident #11] go out of the door and do not know how long she had been outside .I was called on Monday 7/3 [[DATE]] and asked if I could come in [to work] on 7/4 [[DATE]] .the Administrator wanted me to make corrections to the documentation that she [Resident #11] was found on her bottom and not lying on her back .I didn't know [Resident #11] had gone outside. I assisted the 2 CNAs bring her [Resident #11] back in and I took her vital signs and gave her some water at the desk . During a telephone interview on [DATE] at 4:19 PM, CNA #4 was asked about Resident #11 being in the courtyard unsupervised. CNA #4 stated .I was assigned to Resident #11 that day .I was giving a shower [to another resident]. It was close to time for the trays to come out. As I was coming out of the shower room I heard and saw CNA #3 running and shouting [Resident #11] was outside in the courtyard on the ground .I started running with her .it was hot outside .[Resident #11] was on the ground and we had to help her up and we got her inside and sat her at the nursing station for the nurse to check her out because she was flushed .[Resident #11] walks the hall and sits at the nursing station .I don't know who let her out, she does not go by outside by herself never .I did not hear the door alarms .no one knows for sure how long she was outside . During an interview on [DATE] at 5:56 PM, the Administrator was asked about Resident #11 being outside, unsupervised and being found on the ground. The Administrator stated, .the event notes and charting was not completed .I asked the nurse to come and make changes to the documentation .I came up to the facility that day of incident but did not get all the statements . The Administrator was asked what Resident #11 had stated happened. The Administrator stated, .[Resident #11] can recall some things and sometimes cannot tell what happened .[Resident #11] has psychosis, it depends on her mental status that day .[Resident #11] goes out to the courtyard with the Activity Director but [Resident #11] has been out there before by herself she likes the flowers . The Administrator was asked should Resident #11 have been in the courtyard unsupervised at any time. The Administrator stated No. During an interview on [DATE] at 9:51 AM, CNA #3 was asked if the Administrator had requested a demonstration of the incident of Resident #11 being found outside on the ground, unsupervised. CNA #3 stated No, the Administrator did not talk to me the day of the incident. I was called on [DATE]rd about a statement for this incident .I did not demonstrate how she was found to the Administrator . During an interview and observations on [DATE] at 2:55 PM, with Resident #11 and the Director of Nursing (DON) in Resident #11's room, the DON was asked where the visual cue reminder was to remind Resident #11 to use call light for assistance when toileting. The DON looked around the room, opened the bathroom door and a red sign was posted on the inside bathroom door that read, Prior to getting up from toilet Please use call light to call for assistance. Resident #11 was asked, would you know to read the sign on the inside of the door. Resident #11 did not answer. Resident #11 was asked, do you know how to use the call light when you have to use the bathroom? Resident #11 stated, .I don't know . Resident #11 was asked do you know what a call light is? Resident #11 stated .no, I don't know . Resident #11 was asked, did you hurt your head when you fell? Resident #11 stated .I guess it's right here [pointing to left side of head 1-inch red spot noted above eyebrow] . Resident #11 could not demonstrate the use of the call light and was unable to confirm she knew to call the nurse for assistance when she needed to get up. The DON stated .I did not put the sign up .I wasn't aware it was on the inside of the door .the Administrator put it up . The DON stated .Resident #11 will go to the bathroom on her own and call us if she needs help . The DON was asked if the intervention was appropriate to have visual cues inside the bathroom door. The DON stated, .it's just to remind her to call us .I will put the sign on the outside of the door . During an interview on [DATE] at 9:18 AM, the Director of Rehab was asked about Resident #11's therapy evaluations. The Director of Rehab stated, .[Resident #11] has been on our case load because of treatments to a chronic ulcer to the left ankle .she receives treatment 3 times a week .requires verbal cueing to follow directions and tactile [grab under arm to guide]. I talked with [Resident #11] after the fall, and she did not remember .She needs supervision with ambulation when outside because of her gait .it is very unsteady .she shuffles when she walks and ambulates with very slow movement .[Resident #11] is very high risk for falls because of her gait . The Director of Rehab was asked about Resident #11 wearing crocs being the root cause of the fall on [DATE]. The Director of Rehab stated, .I don't think wearing the crocs shoes had anything to do with the fall being a root cause because [Resident #11] wears crocs everyday .inside or outside she is very unsteady with ambulation because of the shuffling of her feet and unsteady gait .she needs supervision . The Director of Rehab was asked should Resident #11 be outside ambulating unsupervised she stated .definitely not . During a telephone interview on [DATE] at 2:00 PM, the Medical Director stated, . [Resident #11] definitely has some mental impairments with her memory .her walking is very unstable .definitely should not have been outside unsupervised . During an interview on [DATE] at 4:00 PM, the Regional Nurse Consultant (RNC) was asked if Resident #11's fall interventions and root causes for falls on [DATE] and [DATE] were appropriate. The RNC stated .the interventions and root causes are discussed when a fall occurs .we should monitor and follow up to see if the interventions are effective .the root causes are determined when a fall occurs what caused the fall and should be discussed in the fall meetings .I am directing the staff to call me personally when there is a fall so we can implement the appropriate interventions .before now this was not being done and we have some work to do with our falls . The RNC confirmed the root cause .wearing crocs shoes when outside for Resident #11 should have been reevaluated and monitored due to Resident #11 was wearing croc shoes on the [DATE] fall in the bathroom and gait was unsteady. 3. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses of Parkinson's Disease, Dementia, Anxiety, Hypothyroidism, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #14 had a BIMS score of 1, which indicated severe cognitive impairment, and required limited assistance from staff for ambulation. Review of the Care Plan dated [DATE], and revised on [DATE], revealed Resident #14 had .Dementia .Interventions .Shoes will have non-skid soles and fit well .Parkinson's .Interventions . Modify environment as needed .Provide rest periods as needed .Observe for lack of coordination .Self care deficit R/T [Related To] ambulation .Remind [Named Resident] to call for assistance before ambulation .At Risk For Falls .Offer to be placed in bed prior to becoming impulsive . Review of an Event Note dated [DATE], revealed Resident #14 had an observed fall on [DATE], sustained a laceration of the left eye, was transferred to the emergency room for evaluation and returned to the facility. The facility failed to conduct a Fall Risk Assessment after Resident #14's fall on [DATE], in accordance with facility policy. During an interview on [DATE] at 4:06 PM, LPN #1 confirmed he was at Nurse's Station #1 on [DATE], and observed Resident #14 walking back and forth down the 400 Hall, walking independently with no difficulty, until she lost her balance and fell, and hit her head and injured her left eye. LPN #1 was asked what his immediate intervention was after the fall. LPN #1 stated, .assessed the resident, completed a neuro check, and called the ambulance. During an interview on [DATE] at 9:52 AM, the Assistant Director of Nursing confirmed a Fall Risk Assessment was not completed after Resident #14's fall on [DATE], and should have been. 4. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses of Dementia, Malnutrition, Depression, Anxiety, Compression Fracture Lumbar, and Obsessive-Compulsive Disorder. Review of the Clinical Notes Report dated [DATE] at 10:32 PM, revealed Resident was witnessed by this nurse grabbing hand rails on 100 hallway and sat down on the floor using the hand rail for assistance, this nurse asked if she needed any help and she stated yeah get me up from here so I helped her up and walked with her to her room where she laid down, resident did not hit head and denied any pain or discomfort at the time. Review of Resident #18's [DATE] Care Plan revealed, XXX[DATE] Actual Fall .No apparent injury; Intervention: Staff IN-Service to offer frequent rest periods when witnessing ambulation . Review of the Clinical Notes Report dated [DATE] at 4:59 PM, revealed Post fall wound assessment completed. Resident's cognition appears slowed from her baseline. Left side weakness with eyes appearing to not track with equally while following objects. Baseline ROM [range of motion] in BUE [bilateral upper extremities] and BLE [bilateral lower extremities] within resident basel[TRUNCATED]