Inspection·November 20, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) failed to review and revise the fall risk care plan after a fall incident for one of four residents (Resident 1). This failure had the potential to result in Resident 1 experiencing further falls. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses including pathological fracture (broken bones caused by disease) in neoplastic disease, pelvis, unspecified B-cell lymphoma (a type of cancer), severe obesity due to excess calories, and neoplastic related fatigue (persistent feeling of exhaustion caused by cancer and its treatments). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 10/3/24, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment to test a person's cognition level) score was 14 (a score of 13-15 indicates the resident is cognitively intact). Review of Resident 1's Post Fall Evaluation, dated 10/15/24, indicated Resident 1 had an unwitnessed fall inside her bedroom. Review of Resident 1's fall risk care plan, revised 10/9/24, indicated the care plan was not reviewed and revised after the fall incident on 10/15/24 to prevent further falls. During a concurrent interview and record review on 10/28/24 at 10:33 a.m., with the Director of Nursing (DON), Resident 1's fall risk care plan was reviewed. The DON confirmed Resident 1 was a fall risk and had fallen in the facility. The DON further confirmed the fall risk care plan was not updated when Resident 1 fell on [DATE]. During a follow-up interview with the DON on 10/28/24 at 12:54 p.m., the DON confirmed that if a resident falls, the fall risk care plan should be updated. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person -Centered, revised March 2022, the P&P indicated, 11. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055210 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055210 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terraces at Los Altos Health Facility 373 Pine Lane Los Altos, CA 94022 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)