Other·August 13, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 8/7/19. For Complaint CA00647850 regarding Quality of Care/Treatment, Resident Safety/Falls, a federal deficiency was identified (see F689). A Class "B" Citation was also issued for F689. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 33651, Health Facilities Evaluator Supervisor.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to prevent multiple falls for one of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE three sampled residents (Resident 1) when the facility: 1. failed to follow the physician's instructions to provide one to one (1:1, one caregiver to take care of one resident) caregiver for Resident 1 from 1/3/19 to 1/26/19; 2. failed to follow the physician's instruction to provide closely monitoring for the resident to prevent Resident 1's multiple falls; 3. failed to develop and/or implement residentcentered interventions to prevent recurred falls; 4. failed to do post fall assessment; the interdisciplinary team (IDT, heads from different department to discuss the care for residents) failed to discuss, addressed and provide proper interventions for Resident 1's multiple falls. 5. failed to turn on the tab alarm (a type of alarm attached to the bed or wheelchair and the resident's clothes to alert the staff when the resident attempted to get up from the bed or wheelchair. Tab alarm usage was one of the facility's intervention to prevent fall for Resident 1) when Resident 1 fell from the bed on 6/24/19. Resident 1 attempted to go to the bathroom without assist and fell. These failures resulted in Resident 1's seven falls, with two falls with compression fracture (break) of T11 (thoracic spine fracture) and rib fracture, and one fall with skin abrasion (skin tear). Findings: 1a. Review of Resident 1's admission record indicated Resident 1 was admitted on 12/19/18, and had the diagnoses of history of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE falling, unspecified dementia (a memory disorder with impair reasoning, personality change , decline in mental ability severe enough to affect daily live) without behavioral disturbance; age-related osteoporosis (medical condition that causes bones to become brittle and fragile) without current pathological fracture; Muscle wasting and atrophy (decrease in the mass of the muscle, wasting away of muscle) at both upper arms; abnormalities of gait (walking) and mobility; and Anxiety disorders (feelings of worry, unease or nervousness). Review of Resident 1's nurse's notes dated from 12/19/18 to 6/30/19 indicated Resident 1 had total seven falls in the facility since her admission. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/26/18, indicated Resident 1's cognitive skills for daily decision making was moderately impaired, required extensive assistance (staff provide weight-bearing support) for transfer, walking and toileting. The MDS also indicated Resident 1 was not steady and was only able to stabilize with staff assistance for surface to surface transfers. Review of Resident 1's "MORSE FALL SCALE" (fall risk assessment tool) dated 12/19/18 indicated Resident 1's fall risk score was 80 (a score of 45 and higher indicated high risk for fall). Review of Resident 1's fall risk care plan, dated 12/19/18, indicated she was at risk for falls due to history of previous falls, impaired balance, impaired safety awareness and use of antidepressants (medication capable of affecting the mind, emotions and behaviors). Some interventions on the care plan include FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE staff anticipate assistance needed for toileting or restlessness and assure commonly used items are within easy reach. Review of Resident 1's physician progress note dated 12/22/18 indicated Resident 1 " ...is impulsive and frequently tries to get out of bed unassisted." Review of Resident 1's nurse note dated 12/29/18 at 12:38 a.m., indicated staff heard a loud noise from Resident 1's room and found the resident was on the bathroom floor with her head pressed against the bathroom wall. The facility sent the resident to the acute hospital for evaluation. Review of the hospital discharge note dated 12/29/18 indicated Resident 1 had traumatic compression fracture on T11 due to the fall. Review of Resident 1's clinical record indicated there was no evidence that the nurse staff did post fall assessment for fall risk for the resident. There was no evidence the facility IDT discussed Resident 1's fall and what proper interventions to implement to prevent the future falls for Resident 1. During a telephone interview with licensed vocational nurse A (LVN A) on 7/29/19 at 10:42 a.m., she stated she worked with Resident 1 on 12/29/18 at night shift. LVN A stated Resident 1 had an unwitnessed fall in the bathroom and was sent out to hospital. LVN A stated Resident 1 was forgetful and confused "all the time" and intend to get up and go to the bathroom by herself. LVN A stated Resident 1 needed one staff assist for transfer and toileting. LVN A further stated that nurse staff should check Resident 1 frequently because Resident 1 went to bathroom by self without using call light for assist and unable to follow FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the instruction. During an interview with the director of nursing (DON) on 7/29/19 at 2:30 p.m., she stated there was no documentation indicating IDT discussed Resident 1's fall and what proper interventions to prevent the future falls. The DON stated there was no post fall assessment for Resident 1 for the fall on 12/29/18. The DON stated the nurse staff should have done a post fall assessment and IDT should have documented how IDT addressed Resident 1's fall with proper interventions to prevent future falls. 1b. Review of Resident 1's post fall assessment dated 2/3/19 indicated Resident 1 had a second unwitnessed fall on 2/3/19 at 4:15 p.m. and was sent out to the hospital to rule out head injury. The post fall assessment indicated Resident 1 fell when she transferred herself from the bed to the wheelchair and went to the toilet by herself. The hospital emergency department note dated 2/3/19 to 2/4/19 indicated Resident 1 had no fracture or injury from this fall. Review of Resident 1's clinical record indicated there was no care plan for this fall and there was no evidence the IDT addressed this fall. During an interview with the DON on 7/29/19 at 3:27 p.m., she stated the nurse staff should revise the care plan for Resident 1's fall on 2/3/19. The DON stated there was no evidence the IDT addressed this fall. 1c. Review of Resident 1's nurse note dated 4/1/19 at 3:05 a.m., indicated Resident 1 had an unwitnessed fall and was sent out to the hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of the hospital's Emergency Department note dated 4/1/19 indicated Resident 1 had left second rib fracture due to the fall. During an interview with the DON on 7/30/19 at 11:21 a.m., she reviewed Resident 1's clinical record and stated regarding Resident 1's fall, there was no post fall assessment for Resident 1's fall on 4/1/19; there was no evidence IDT addressed the fall; there was no documents indicated when the facility sent the resident to the hospital and when the resident returned to the facility; there was no evidence the nurse staff monitor Resident 1 post fall status on 4/3/19 for 72 hours following a fall per policy. The DON stated the facility should document these missing assessment and monitoring. 1d. Review of Resident 1's nurse note dated 6/24/19 indicated Resident 1 had an unwitnessed fall on 6/24/19 at 2:00 a.m. with skin abrasion on left upper arm. Nurse note indicated Resident 1 was found lying on the floor. Per resident, she sated "I need to go to the bathroom and I fell." Resident 1 was sent to the hospital for evaluation on 6/24/19 at 5:15 p.m. During a telephone interview with LVN B on 7/29/19 at 11:10 a.m., she stated she worked on 6/24/19 with Resident 1 when the resident fell. LVN B stated the staff heard Resident 1 yelled from the room and found the resident lying on the floor. LVN B stated the tab alarm was off when Resident 1 fell. LVN B stated staff "forgot" to turn the tab alarm on while Resident 1 was in bed. LVN B further stated, "Unfortunately, the tab alarm was not on and should be on." LVN B stated Resident 1 was very forgetful, confused and attempting to get out of bed and go to bathroom by self. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the DON on 7/29/19 at 12 p.m., she stated the facility should have bladder and bowel training for Resident 1 because most of the resident's falls were related to toileting. The facility should have IDT documentation regarding discussion for Resident 1's multiple falls, the cause of the fall, proper intervention to prevent future falls. The DON stated if "not document, means not done." The DON stated the facility should have proper and effective interventions for these falls. The DON sated there was no documented evidence indicating how often the staff monitored Resident 1. 1e. Review of Resident 1's nurse's notes from 12/19/18 to 6/30/19 indicated Resident 1 had seven falls in the facility since her admission in December 2018. These seven falls occurred on 12/29/18, 2/3/19, 2/5/19, 3/17/19, 3/31/19, 4/1/19, and 6/24/19. There was no documented evidence that the facility IDT discussed and addressed these falls, what proper interventions the facility should implement to prevent these falls. Review of Resident 1's physician's notes dated 12/28/18 indicated Resident 1 was impulsive and frequently tried to get out of bed unassisted. Review of Resident 1's physician's note dated on 1/3/19 indicated Resident 1 " ...was impulsive and at high risk fall risk ...requiring 1:1 caregiver support ...continue close supervision for repeated falls ..." Review of Resident 1's physician's note dated on 1/26/19 indicated Resident 1 " ... " ...was impulsive and at high risk fall risk ..." The physician's note indicated the resident's 1:1 supervision for fall prevention had since discontinued. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's physician's note dated 2/4/19 indicated Resident 1 needed " ...very close monitoring as patient forgets to call for help when getting out of bed ..." Review of Resident 1's physician's note dated 2/12/19 indicated Resident 1 " ...needed 24hour supervision for safety optimally and even with that likely to fall again ..." due to multiple factors and poor safety awareness. Review of Resident 1's physician's note dated 3/21/19, 4/20/19, 5/16/19 and 7/11/19 indicated Resident 1 " ...need very close monitoring as patient forgets to call for help when getting out of bed ..." due to impulsivity and underlying cognitive issue. Review of Resident 1's clinical record indicated there was no evidence the facility followed the physician's instruction to provide 1:1 caregiver for Resident 1 from 1/3/19 to 1/26/19; there was no evidence the facility provide close monitoring for the resident to prevent Resident 1's multiple falls. Review of Resident 1's sitter schedule in January 2019 indicated Resident 1 was scheduled to have a sitter to be with Resident 1 from 1/1/19 to 1/3/19 for 24 hours per day (from 7 a.m. to next day 7 a.m.); from 1/4/19 to 1/14/19 for 12 hours per day (from 7 p.m. to 7 a.m.). Review of Resident 1's nurse's note dated from 1/1/19 to 1/16/19 indicated nurse staff documented Resident 1 had a sitter accompanied during evening shift (8 hours per shift) on 1/1/19, 1/2/19, 1/3/19, 1/6/19, 1/7/19, 1/11/19 and 1/14/19. There was no documented evidence indicated the facility provided the sitter service to Resident 1 for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rest of the scheduled sitter days. During a telephone interview with the DON on 8/2/19 at 1:17 p.m., the DON stated per facility billing record that the facility hired a sitter (caregiver) to take care of Resident 1 on 1/3/19 for 24 hours and on 1/4/19 for 12 hours. The sitter's service ended on 1/15/19. The DON stated there was no documented evidence for each sitter service day regarding when and how the sitter took care of Resident 1 from 1/3/19 to 1/15/19. The DON stated there was no evidence the facility followed the physician's instructions regarding closely monitor Resident 1 due to multiple falls. Review of the facility's revised policy and procedure, "Fall-Clinical Protocol" dated April 2013, indicated " ...If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance) ...The staff and physician will monitor and document the individual's response to interventions intended to reduce failing or the consequences of falling." Review of the facility's revised policy and procedure, "Falls and Fall Risk, managing" dated December 2007, indicated " ...If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant." Review of the facility's policy and procedure, "Assessing Falls and Their Causes" dated October 2010, indicated " ...Resident must be assessed in a timely manner for potential FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055210 (X3) DATE SURVEY COMPLETED 08/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE TERRACES AT LOS ALTOS HEALTH FACILITY 373 Pine Ln Los Altos, CA 94022 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cause of falls." Review of the facility's revised policy and procedure, "FALLS" dated 7/27/17, indicated the nurse staff should chart residents' post fall status for 72 hours following a fall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S0O111 Facility ID: CA070000010 If continuation sheet 10 of 10